Background to this inspection
Updated
3 May 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 15 and 16 March 2018 and was unannounced.
The inspection team comprised two adult social care inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give key information about the service, what the service does well and improvements they plan to make. We reviewed the PIR and other information we had about the service including statutory notifications. Notifications are information about specific events that the service is legally required to send us.
Some people at the service may not be able to tell us about their experiences. We used a number of different methods such as undertaking observations to help us understand people’s experiences of the home. As part of our observations we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the needs of people who could not speak with us.
During the inspection we spoke with 11 people living at the home, five relatives and seven staff members, this included senior staff, and the registered manager. We also spoke with four visiting health professionals. We reviewed six people’s care and support records, a selection of medicines records and four staff files. We also looked at records relating to the management of the service such as incident and accident records, meeting minutes, recruitment and training records, policies, audits and complaints.
Updated
3 May 2018
The inspection of Combe Lea Community Resource Centre took place on 15 and 16 March 2018 and was unannounced. When the service was last inspected in October 2016 four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified.
During this inspection we checked that the provider was meeting the legal requirements of the regulations they had breached. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Combe Lea Community Resource Centre, on our website at www.cqc.org.uk.
Combe Lea Community Resource Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Combe Lea Community Resource Centre provides care and accommodation for up to 30 people. On the days of the inspection 30 people were living at the home. The home was over two floors, with access to all floors either via stairs or the lift. All bedrooms have en-suite facilities. Gardeners Row was on the first floor and was a unit for people living with dementia. Willow on the second floor was for older people who were physically frail.
At the last inspection the service was rated as Requires Improvement. At this inspection we found that improvements had been made within the service. All of the four previous breaches had now been met.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The provider had failed to take action required following a fire service inspection. The provider had not made improvements needed to the fire systems at the service. The registered manager had notified the provider who had placed it on the corporate risk register. We have notified the fire brigade of this.
People were protected from the risk of infection because staff followed the correct procedures in respect of laundry and avoiding cross infection. However, we noted the laundry baskets were broken and identified this as a potential risk. The provider sent evidence that new baskets had been ordered following the inspection.
The service had received an award after being nominated by a person’s relative. The provider had a video clip of the relative talking about the service on their website. People and their relatives were complimentary about staff. We observed staff interacting with people with warmth and kindness. It was evident staff knew people, their histories and preferences. People’s independence was promoted where possible and staff protected and respected peoples’ dignity.
Care plans were person centred and gave staff clear information about people’s likes and dislikes. We observed staff ensuring everybody received attention and were supported to do things they liked.
Staff were confident about identifying and reporting any suspected abuse and the provider’s procedures were followed if any concerns were identified.
People had clear risk assessments to guide staff how to keep them safe and staff followed this guidance. People had clear assessments in place to ensure their health needs, nutrition and skin condition was monitored. Staff liaised with health professionals to maintain peoples’ wellbeing and to address any new health concerns.
Staff were trained, experienced and supervised. There were enough staff to meet people’s care needs and they carried out their tasks with kindness and discretion. Staff supported people in line with the Mental Capacity Act 2005.
People received their medicines in the way they preferred to take them and medicines were stored and disposed of safely.
People, their relatives and staff were positive about the registered manager and told us they were visible and approachable.
The registered manager had implemented a comprehensive governance system which had identified areas of the service which needed improvement. Where improvements needed had been identified these were followed up and checked by the registered manager.