Archived: Comberton Nursing Home

Updated 29 September 2015

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 2 June 2015 and was unannounced. The inspection team comprised of two inspectors.

We looked at the information we already had about this provider. The provider sent us their Provider Information Return (PIR) when we asked for it. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at information sent to us by people anonymously. We took this information into account when we planned the inspection.

Providers are required to notify the Care Quality Commission about specific events and incidents that occur including serious injuries to people receiving care and any safeguarding matters. These are called notifications and help us to plan our inspection. We contacted other organisations such as the commissioners and safeguarding team for information. We spoke with 11 people who lived at the home, two relatives, the registered manager, two nurses, the cook and three care staff. We looked at the care records of four people, the medicine records for six people, staffing rotas, staff training records, complaint records, the providers audits of the quality of the service, accident/ incident records and staff recruitment processes. We also carried out observations of people’s care.

Updated 29 September 2015

We inspected this home on 2 June 2015. This was an unannounced inspection. Comberton Nursing Home provides accommodation for up to 36 people who require residential and nursing care. There were 34 people living at the home when we visited.

The home had a registered manager, who was present during the visit to the home. 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.

At our previous inspection of this care home in April 2014 the provider was not meeting the requirements of the law in relation to infection control standards. The provider sent us an action plan to tell us the improvements they were going to make. During this inspection in June 2015 we looked to see if these improvements had been made. We saw that improvements had been made so that people lived in a clean environment and the equipment they needed had been replaced.

People and their relatives told us that they felt safe and staff knew what to do to keep them safe from the risk of harm or abuse.

Risks to people’s health and care had been identified. Staff knew how to help reduce risks to people from falling or pressure sores because plans were in place to guide them.

There had been concerns about the numbers of staff available to meet people’s needs. The provider had addressed this by increasing the staffing levels and people reported they now had the support they needed.

Staff had been trained to support people’s needs but at times staff did not apply their training to their practice. Staff had received an induction and had access to regular supervision to support them in their caring role.

Staff understood the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). However the provider had not fully ensured they followed the correct procedures where people lacked the capacity to take their medicines.

People had appropriate support to eat and drink. The risk of weight loss was known and monitored to ensure people had the right support. People had access to health professionals to maintain their health. The monitoring of people’s health needs was not consistent to ensure issues were identified.

People were able to make decisions about how they wanted their care provided. Some people told us that they were very happy at the home and were happy with the care provided. Where people were unable to express their preferences some staff demonstrated a lack of thought and consideration for people’s needs. We found there could be more emphasis on respecting people’s belongings and protecting their dignity.

People told us there had been a lack of activities organised but we found that the provider had employed a new activities coordinator and further organised activities were planned.

Although systems were in place for people and their relatives to raise their concerns or complaints, the recording of and response to people’s concerns was not evident.

The provider had plans to increase the management structure by employing a deputy manager. The registered manager told us the biggest challenge to the service was recruiting nursing staff. She had interim agency nurses supporting her. There were systems in place to monitor the quality of the service provided. However these were not effective and did not enable the registered manager to account for actions taken in response to people’s needs.