Coombes Wood House

Updated 24 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by one inspector 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.

Service and service type

Coombes Wood House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked for a provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service and 16 relatives about their experience of the care provided. We spoke with nine members of staff including the registered manager, deputy manager, senior care workers, care workers, housekeeping staff and the cook.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We received feedback via email from a further seven staff members. We received feedback from two professionals who regularly visited the service.

Updated 24 June 2022

About the service

Coombes Wood House is a care home without nursing and is registered to provide accommodation and support for up to 39 older people. Coombes Wood House provides care for people living with dementia, physical disabilities and mental health conditions. At the time of the inspection there were 38 people living there.

People's experience of using this service and what we found

People were happy at the service and spoke positively about the care they received. Relatives praised staff for the support they provided.

Risks to people were effectively assessed and monitored. Medicines were managed safely. Staffing levels were monitored to ensure people were supported safely. People were safeguarded from abuse. Effective infection prevention and control systems were in place.

Staff received regular training, supervision and appraisal. Staff all spoke positively about their experience working at Coombe Wood House, especially praising the registered manager and deputy manager.

People received effective support with eating and drinking. Staff worked well with external professionals to ensure people received the support they needed. Health professionals praised the staff for positive outcomes when supporting people with complex needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.

People received personalised support based on their assessed needs and preferences. A range of activities took place and people were supported to maintain their relationships and interests. The provider had a complaints procedure in place.

The registered manager and provider maintained good governance systems. Monitoring of activities for individuals, re-positioning and food and fluids required a more robust system but this was put in place during the inspection and staff were knowledgeable about what to do. Feedback was regularly sought and acted on. People, relatives and staff spoke positively about the culture and values of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 16 March 2021 and this is the first inspection. The last rating for the service under the previous provider was Requires Improvement, published on 7 August 2019.

We also looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.