Coumes Brook Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People said they felt safe living at Coumes Brook and were involved in making decisions about their safety. People were safeguarded from abuse and avoidable harm. Risks to people were managed well. The provider learned lessons when things had gone wrong and took immediate action to manage risks. We saw evidence of thorough investigations being carried out and of lessons learned and embedded into practice. Overall, the provider followed safe recruitment processes and made sure there were enough suitable staff. People were supported to receive their medicines safely. However, documentation in relation to some medicines required improvement. People were protected from the risk of infection, as staff followed safe infection prevention and control practices. The home environment and equipment was kept clean and safe.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they could tell staff about things that concerned them. They were confident that changes would happen if they did. One relative said, “The management are brilliant at listening and addressing any issues. They are very responsive to any of our concerns regarding [Relative].

Staff knew how to report accidents or incidents. The registered manager reviewed incidents and shared feedback with the team for further action and learning.

There was a process in place to monitor incidents, accidents, and near misses. Staff recognised incidents and reported them appropriately, and managers investigated incidents and shared lessons learned. Senior staff maintained a record of accidents and incidents and reviewed regularly to look at patterns and trends.

People and relatives told us they were involved in discussions about their care needs and felt safe. One relative told us their family member had 'absolutely thrived' since been at Coumes Brook.

Staff told us they were given information on how to support people who were new to the service and that care plans were frequently updated when needs changed.

We saw the provider had successfully worked with partners and had been involved in discussions with them about people's care needs. One health professional said, “The staff at Coumes Brook are quick to phone if they think someone is in pain or restless and needs a review. They have a close relationship with the district nurses and the staff at the surgery."

The provider had processes in place to ensure safe system, pathways and transitions were maintained. This included an initial needs assessment at the start of a service being provided.

People and their relatives told us they were happy with the service and felt safe around the staff. One person said, "I definitely feel safe here. The staff are wonderful and very helpful."

Staff received training on how to recognise and report abuse and knew the processes to be followed to keep people safe. All were confident any issues raised with the registered manager or provider would be fully investigated to make sure people were protected. One staff said, “People are definitely well cared for and safe. If I did have any concerns I would report it straight away and I know the manager would sort it out.”

During the site visit we saw kind and respectful interactions between people and staff. Staff were seen to offer people choices and seek consent before supporting. The atmosphere in the home felt warm and open and this was reflected in comments from people and relatives.

There were systems in place to protect people from abuse, including policies, procedures and training for staff. The provider confirmed during a recent review of incident information they had identified an incident that had not been reported to the local authority safeguarding team as required. The provider had completed a thorough review of their systems to Investigate and report allegations of abuse. Records confirmed the incident had been investigated thoroughly and action had been taken by the registered manager to reduce the risk of repeat events. We found the management team and care staff had reflected on what went wrong, what the possible implications for people of what they had done were, and what they would do differently. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. People can only be deprived of their liberty when this is in their best interests and legally authorised under the MCA. In care homes this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). There were effective systems in place to ensure the appropriate authorisation had been sought where people were deprived of their liberty.

People and their relatives told us they felt safe and were supported to understand and manage risks. People were involved in the assessment of their needs and the management of their risks where able. People believed staff would respond to their needs quickly and efficiently, especially if they were in pain, discomfort, or distress.

Staff promoted people's safety and independence. People’s care plans were regularly reviewed and in response to any change in needs.

It was clear from our observations that staff had developed good relationships with people. Staff we spoke with had a good understanding of people’s needs. We saw how staff were anticipating people’s needs and identifying triggers and redirecting, preventing people experiencing emotional distress and or increased anxieties. For example, we saw how staff took time to explain to people what they were doing and allowed people time to process information.

People's risks were assessed at regular intervals or as their needs changed. Care plans informed staff how to provide care that mitigated these known risks. Staff were kept up to date with changes in people's care during handovers and team meetings. Staff completed regular checks on the premises and equipment to ensure people's safety. This included checks by external contractors on gas, electrical and fire safety.

People said they felt safe in the environment and had all the equipment they needed.

Staff reported there were systems to check the environment and equipment in the service. No concerns had been raised about the safety of the environment by staff.

During our inspection we conducted a tour of the premises and found it was clean, tidy and free of any unpleasant odours. There were systems in place to reduce the risk and spread of infection. People’s individual needs were met by the adaptation, design, and decoration of the premises. People had a variety of spaces in which they could spend their time, and their bedrooms were personalised.

Risks relating to the physical environment had been identified and the necessary remedial actions were completed to ensure people’s safety. Environmental risk assessments considered all aspects of the home, both internally and externally to ensure people lived freely within a safe environment. The provider undertook regular health and safety checks of the premises. Safety systems and equipment used at the service were maintained and serviced at regular intervals to make sure these remained in good order and safe for use. People had individual personal evacuation plans in place to guide staff in the event of a fire.

People said they liked the staff supporting them and support was available in a timely way. One person said, “I get on well with staff as I can talk to them. The staff are very good and carefully chosen and get involved in the best of ways.”

Staff raised no concerns about staffing levels.

We observed people being supported appropriately by staff in a timely manner throughout our visit. Our observations showed there were enough staff to safely meet people’s needs and respond to their requests. Staff were visible and available in communal areas and people did not wait long for their support. Staff supported people at their own pace and treated people kindly and with respect.

We looked at the recruitment information for 3 staff members. Records confirmed a range of checks including application, interview, and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. However, we found gaps in recruitment records. The registered manager was responsive to the concerns raised and immediate action was taken for the records identified and a review of other records was to be completed. Staff were well trained and competent in their jobs. Staff received training, which enabled them to feel confident in meeting people’s needs and identify changes in people’s health.

People confirmed that the home was clean and tidy with a homely feel.

Staff said they had received appropriate training in infection prevention and control and were aware of safe hygiene practices.

The environment was safe, clean and well cared for. PPE was available throughout the building and easily accessible for staff. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There was an infection control lead in the service and there were good systems in place to monitor routine cleaning. Staff received training in infection control and had access to personal protective equipment.

Infection control audits were completed on a regular basis to ensure the safety of the layout and hygiene of the premises. The provider’s infection prevention and control policy was up to date.

People confirmed they received their medicines in a timely and safe manner. People were supported by staff who followed systems and processes to administer, record and store medicines safely.

Staff told us they received training and competency assessments to ensure they were safely administering medicines. Training records confirmed this.

Overall medicines were managed safely. However, documentation required improvement. For example, body map documentation was not always in place. Some people were prescribed medicines on an 'as and when' required basis, but protocols in place to ensure safe administration, lacked detail and we found room temperatures were not always recorded consistently. The provider responded immediately during and after the inspection to address these concerns.