OSJCT Coombe End Court

OSJCT Coombe End Court provides care and accommodation for up to 60 people, some of whom live with dementia. Accommodation is provided on two floors accessed by stairs and a lift. People have their own rooms with en-suite facilities and access to communal areas. A garden is accessed from the ground floor. At the time of the inspection there were 51 people living at the service.

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

At our last inspection we found shortfalls in governance systems which placed people at risk of harm. We served a Warning Notice for a breach of Regulation 17 (Good governance). This inspection was carried out to check the provider had made the required improvements. We found they had carried out the work needed to meet the Warning Notice.

The provider had reviewed night security arrangements to make sure processes were effective and robust. Management had an improved oversight of night care security check forms to make sure checks were being carried out when needed. Systems were in place to make sure people’s names were added and removed from records as appropriate.

Risk management monitoring records had been completed contemporaneously. For example, people’s re-positioning records were completed when people were moved. When people had falls, any required observation checks had been completed and recorded as required.

At our last inspection we were somewhat assured by cleanliness as we observed on day one of our inspection areas of the home that were not clean. At this inspection we observed the home was clean on both days of our site visits. We did, however, note one area of the home had an odour which was present on both days. The registered manager told us this had been identified by the provider and a new carpet was being sourced.

Staff were wearing personal protective equipment (PPE) as needed and there was a good supply available in the home. Staff were testing as per the government guidance for COVID-19. Where any positive cases for people or staff were identified the registered manager liaised with local health protection agencies to take necessary action.

People were able to have visits from relatives and/or friends. Visitors were asked to wear PPE as needed.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 April 2022) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We 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 COVID-19 and other infection outbreaks effectively.

Recommendations

We have made one recommendation for a review of internal door locks.

Follow up

We will meet with the provider and continue to monitor information we receive about the service, which will help inform when we next inspect.

OSJCT Coombe End Court provides care and accommodation for up to 60 people, some of whom live with dementia. Accommodation is provided on two floors accessed by stairs and a lift. People have their own rooms with en-suite facilities and access to communal areas. A garden is accessed from the ground floor. At the time of the inspection there were 50 people living at the service.

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

Systems in place to monitor risks to people were not robust and staff were not recording their actions contemporaneously. Night care security arrangements had been increased to hourly, but we observed shortfalls to these arrangements which placed people at risk of harm. The provider told us they were carrying out a night care whole service review at all of their homes in the organisation. The findings would be shared across the organisations so lessons could be learned, and more effective arrangements put into place.

On our first day of inspection we observed there were areas of the home that required maintenance and needed a clean. Cleaning records had not been completed in one area of the home for four days. We observed some bins were broken and in one toilet not available. On our second day of inspection these shortfalls had been addressed and a different cleaning system had been put in place for kitchen areas.

During our inspection we received a whistleblowing concern about low staffing numbers. We reviewed staffing and found some evidence to substantiate that concern. People and staff told us there were not enough staff at all times. Agency staff were being used but at times there were none available which placed permanent staff under strain. Whilst care was being delivered, it took longer than usual. The provider was actively recruiting and trying to attract new staff to the home.

People had their medicines as prescribed and there were safe management systems in place. Staff had been trained to administer medicines and were observed to be following safe practice. We observed healthcare professionals visiting during our inspection and were told they visited people regularly where needed.

People and staff were testing for COVID-19 following the government guidance. Any visitors to the home had to complete a Lateral flow test prior to entry. All professional visitors had to demonstrate they had been vaccinated for COVID-19 and all staff had also been vaccinated.

Visiting was being supported both indoors and outdoors. Relatives spoke to us about being essential care givers which meant they could visit at any time even during outbreaks of COVID-19. Visitors had to wear personal protective equipment (PPE) which was supplied by the home. We observed staff were wearing the appropriate PPE at all times during our inspection.

Staff had been trained on working safely during COVID-19 and told us they had plenty of PPE available throughout the pandemic. Staff told us they felt supported and had systems in place to support their well-being.

There was a registered manager in post. Feedback about them from relatives and staff was positive and appreciative of their management approach. The registered manager told us they had good support from the provider and their peers.

Quality monitoring was in place and a full range of audits were being completed for all areas. Whilst the monitoring was being carried out it had not identified all of the shortfalls we found during the inspection.

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

Rating at last inspection

The last rating for this service was good (published 17 February 2020).

Why we inspected

The inspection was prompted in part by notification about a person using the service who had died. This inspection did not examine the circumstances of the incident as this was still being investigated by the provider and other agencies. This inspection reviewed the wider safety arrangements for people at night.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We 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 COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for OSJCT Coombe End Court on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified one breach in relation to management oversight and governance at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

OSJCT Coombe End Court is a care home providing personal care to 51 people aged 65 and over at the time of the inspection. The service can support up to 60 people. The building is purpose built over two floors, one of which specialises in providing care to people living with dementia.

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

People said they felt safe living in the home and staff supported people to manage the risks they faced. People received support to take the medicines they had been prescribed.

There were enough staff to provide the care that people needed.

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

People were supported to choose meals they enjoyed, and staff helped people to eat and drink where required.

People were able to access the health services they needed.

Staff received suitable training to give them the skills to meet people’s needs. The registered manager provided good support for staff to be able to do their job effectively.

People received care from kind and committed staff. Staff respected people’s privacy and dignity. People were positive about the care they received and about the quality of staff.

People knew how to raise any complaints about the service. The registered manager investigated complaints and took action to make improvements where needed.

People had been supported to develop care plans that were specific to them. These plans were regularly reviewed with people to keep them up to date.

The service was well-led, with a registered manager. People felt the management team had a good understanding of any issues in the home.

The quality of the service was regularly assessed, and action taken to make improvements where needed.

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

Rating at last inspection

The last rating for this service was good (published 20 February 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

At the last inspection in January 2017 the service was rated Requires Improvement. Following this inspection, the provider agreed to complete regular action plans to show what they were doing to improve the ratings in key questions of Safe, Effective, Responsive and Well Led.

OSJCT Coombe End Court 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.

At OSJCT Coombe End Court up to 60 people can be accommodated in one adapted building. There is a unit on the ground floor which supports people living with dementia.

A registered manager was 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.’

Quality Assurance processes were in place. An overarching improvement plan was in place with action plans on how shortfalls were to be met. The registered manager monitored the quality of the service and looked for continuous improvements. Healthcare professionals told us the staff made “great efforts to engage with the local community.”

Care plans were person centred for some people and included their preferences regarding people’s preferred first name and staff were aware of people’s likes and dislikes. “This is me” profiles in bedroom were brief but informative. Life stories were in place for some people. These needed to be further developed particularly for people living with dementia as they helped in developing person centred plans.

Where people used repetitive behaviours to gain staff support we observed an inconsistent approach. Care plans were not developed on how staff were to consistently approach these situations. A professional said for people with misperceived situations some staff need to “validate how people feel” and to be accepting of this. The registered manager said some staff “need reminding, we will do some workshops and refresh the back to basics training.”

There were people who expressed their anxiety and frustrations through verbal and physically aggressive behaviours. Care plans and risk assessments were in place on how to respond to triggers identified. Staff told us they used distraction techniques and where care was refused people were given time to accept support. We observed staff use different techniques to support people when difficult behaviours were presented.

Mental capacity assessments were completed for care and treatment to live at the home. Some capacity assessments did not reflect the DoLS applications. For example a capacity assessment was not completed for people whose medicines were administered by the staff. Also staff had not recorded if the Court appointed deputy was consulted about best interest decisions such as using pressure mats in bedrooms.

People were empowered to make day to day decisions. Staff were knowledgeable about the Mental Capacity Act, people’s varying levels of capacity and had an awareness of Deprivation of Liberty Safeguards (DoLS). Applications to the supervisory body were made for continuous supervision and the least restrictive options were used which meant people were able to move freely around the property.

Although we saw staff were available and spent time with people in Pearl unit, relatives and some professionals raised concerns about staffing levels. All people commented that the staff were very good, but that staff time is task focused. The registered manager told us the staffing levels were appropriate to the dependency needs of people. Staff told us that changes in staffing hours meant people benefitted from consistent staff.

People were supported to access health professionals when needed and staff worked closely with people's GP’s to ensure their health and well-being was monitored. Nurse practitioners were undertaking routine visits and GP’s covered more urgent treatment. Staff told us the process had become longer as nurse practitioners had to consult with the GP before prescribing or changing treatment plans.

People said they felt safe and relatives felt their family members were safe living at the home. Staff had attended training in safeguarding of adults procedures, which included the types of abuse and about reporting allegations of abuse. Staff knew how to identify the types of abuse and to report their concerns.

Systems were in place to identify and manage potential harm. Risk assessments were devised and reviewed regularly to support people to take risks safely. Some people had been identified at risk of falls, choking and malnutrition. The staff were aware of individual risks and the actions needed to minimise the risk of harm. For example, pressure mattresses for people at risk of pressure ulcers and 72 hour observations following a fall.

Accidents and incidents were reported and analysed for patterns and trends. Reflective meetings took place to ensure there was learning to reduce repeated occurrences. Robust systems of recording and auditing incidents were in place; for example, incident reports were linked to the care plan.

People received their medicines safely. Medicine administration records (MAR) sheets were signed to indicate when medicines were administered. Where people were prescribed medicines with specific instructions for administration we saw these instructions were followed.

People received effective care from staff who had the skills and knowledge to support them and meet their needs. Staff attended training set as mandatory by the provider. Staff had an opportunity to meet with their line manager as needed to discuss their performance, concerns and training needs.

People’s dietary requirements were catered for. A whiteboard in the kitchen listed people’s dietary needs such as intolerance, textured diets and date of birth to celebrate birthdays. The chef told us they were made aware of people’s food preferences. We saw staff show people the choices of food available and to support some people to maintain their independence adapted cutlery and crockery was used.

Staff interact with people in a positive manner. Records showed that staff treated people cared for in bed with compassion. For example, nicotine patches were prescribe and Reike (a technique based on the principle that that energy can be channelled by means of touch, to activate the person’s natural healing processes and restore physical and emotional well-being). The rights of people were respected and staff gave us examples on how they respected people’s privacy and dignity.

Arrangements were in place for external entertainers to visit the home and internal activities. People were able to pursue interests and there were opportunities for them to join group activities and to have one to one time with the activities coordinators. Resident and Relatives meetings were taking place and we were told how suggestions were acted upon.

The team worked well together, they mentored and supported each other. Staff said there had been improvements since the appointment of the current registered manager.

People feel confident to approach staff irrespective of their role with complaints. They are confident their concerns will be taken seriously.

We made a recommendation about the deployment of staff.

Coombe End Court provides accommodation for up to 60 older people. The accommodation is arranged into three separate units over two floors. The unit on the ground floor supports people living with dementia. The home is run by The Orders of St John Care Trust, a national provider of care.

A registered manager was in post and was recently appointed. 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.

People were at risk from unsafe medicine systems. People were not always having their medicines at their prescribed times. Prescribed medicines were not always in stock which meant doses were missed for some people. Staff signed the medication administration records (MAR) charts but from the stock checks conducted it was clear that some medicines had not been administered. For other people the staff had not signed the MAR charts but had administered the medicines. Protocols were not in place for all medicines prescribed to be taken when required (PRN). This meant staff were not given guidance on when to administer these medicines which included the maximum doses that the PRN’s could be administered.

People living at the service, relatives and staff said there were staff shortages. They said there was heavy reliance on agency staff. The registered manager said recruitment of staff was a priority and that consistent agency staff was used. These agency staff were included in team meetings and handovers to provide consistency. People were sympathetic about staff shortages but wanted the organisation to employ consistent staff to deliver their personal care.

While risk assessments were in place for people with a history of falls and action plans listed the preventative steps to be taken, we found that staff had not reported all falls. We also found the reports of the falls were not clearly documented.

Care plans lacked detail and were not always updated to reflect people’s changing needs. Information was duplicated and at times inconsistent with each other. The people we spoke with were not aware of having a care plan or about review meetings where their needs were discussed.

Quality assurance systems were in place and while shortfalls were identified with the standards of care, actions plans were not always actioned. Internal audits were in place to assess the effectiveness of systems but there were inconsistencies in the areas assessed.

People told us they felt safe with the staff. The people who needed assistance from staff said the staff knew how to use equipment which protected them from harm. Moving and handling risk assessment gave staff guidance on how to assist people with mobility needs. The number of staff and the equipment needed to support the person was included in the risk assessment. Malnutrition Universal Screening Tool (MUST) were used to assess the potential of people to develop malnutrition. Where people were at risk of malnutrition the action plans depended on their weight which included monitoring of food and fluids intake with supplements prescribed and enriched diets served. For people at risk of pressure sores there was equipment used and regular repositioning to relieve pressure points.

People had access to GP and healthcare specialists for their ongoing health needs. People had regular check-ups with optician, dentists and chiropodists and staff organised the appointments.

People told us the staff were caring. They told us there were forums where they were able to raise issues and to make suggestions. Staff were aware of people’s likes and dislikes and had insight into the needs of people living with dementia. Members of staff were eager to promote consistency to people from a stable staff team. The people we spoke with were confident to approach the registered manager with complaints. They said the registered manager investigated their complaints and acted upon the issues raised.

The specialist dementia unit and the foyer of the property were refurbished and adapted for people living with dementia. There were places of interest for people to encounter while they walked around the unit. We saw there were snacks and fresh fruit available to people in baskets to imitate fruit stands. Door entry systems into the unit were not used during the day which meant people had the freedom to walk around the ground floor. The ground floor lounge was adapted into a coffee and refreshments and movie area. Home baked cakes were available to people and their relatives at all times and we saw people enter the lounge and help themselves to cakes. We also saw relatives and people sit in this lounge make refreshments to have with cakes.

We undertook this focused inspection to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for OSJCT Coombe End Court on our website at www.cqc.org.uk. We could not improve the rating for 'is the service effective?' from requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

Members of staff knew the actions they must take for people at potential risk of falls, pressure ulcers and from malnutrition. However, members of staff needed to be more aware of the action plans for people who at times needed additional support with moving and handling. For example when to use hoists. Senior staff were knowledgeable about risk management. However, fluid intake intervention records lacked the daily target intake for each person and were not always totalled at the end of the day. This meant the staff were not aware of the people who were not having sufficient fluids and a potential sign of deteriorating health.

People were helped to make day to day decisions and members of staff were knowledgeable about the principles of the Mental Capacity Act 2005 (MCA). People’s capacity to make specific decisions was assessed. However, MCA were not completed for some intimate procedures and we observed the zimmer frame was removed from the side of one person sitting at the table. This meant there was potential for restricting one person’s liberty as the person had to depend on the staff to leave the table.

People said they felt safe and the staff made them feel secure. Members of staff we spoke with had a good understanding of safeguarding of vulnerable adults from abuse and the expectations placed on them to report abuse. They knew that it was their duty to report their suspicions if they witnessed other staff abusing people.

Members of staff said the staffing levels had improved and less agency staff was used. This meant people’s care and treatment was delivered by a consistent staff team.

Training to increase staff skills was provided and they were well supported to deliver people’s care and treatment. Staff said they attended training such as Mental Capacity Act 2005 (MCA), safeguarding adults and other specific training such as dementia awareness.

There was a person centred approach to care planning. People we spoke said they were involved in the planning of their care and their relatives said they were invited to review meetings. Members of staff said the care plans and the quality of the handovers had improved. Care plans detailed the way people liked their care to be provided and the action plans gave staff guidance on meeting people’s current needs.

The quality assurance process was effective. Audits were in place to assess the care and treatment people received. For example, care plans and medicine audits. Accident and incidents were analysed to identify trends and patterns. Where aspects of the service standards were not being met action plans were developed on improving the standards.

We found the care provided was variable. Some people had fully up to date care plans and staff knew about significant changes in people's needs. This was not the case for all people. Some care plans did not include relevant information about how people's needs were to be met. This included best interest decisions for people living with dementia. Staff also gave us differing information about how they met these people's needs. Assessment of needs for some people were not accurate or needed to be completed with more information, to ensure appropriate care plans were in place.

People made a range of comments about staffing levels. One person told us there were 'enough staff to do the things I need' however another person told us there were 'not enough staff.' Staff and managers told us about a recent recruitment drive, which had been effective. They said they anticipated that once all the newly appointed staff were in post, the home would be up to its establishment for staff. The home had not had a registered manager in post for an extended period of time. At the time of our inspection, the provider had a peripatetic manager who was acting into the role.

Three people in the residential unit said the food was not always of a good standard. The relative told us a 'green book' had been introduced for people to record their comments about the food.

We were told the staff knew how to care for them and one person knew they had a care plan in the office but had not read their care plan.

One person told us there were staff shortages and gave us examples of when they had to wait for an unreasonable amount of time for staff support.

The following comments were made by the people in the dementia unit when we asked them about their experiences of living in the home. 'They came quickly', 'Everybody seems to be taken care of individually', 'I don't need to complain,' 'It's alright here' and 'It's lovely'. A member of staff helped one person tell us they did singing for the brain.

We used the Short Observational Framework for Inspectors (SOFI) to observe the interaction staff had with people living with dementia. We observed that although staff used a gentle approach with people and they carried out tasks for people, they did not engage with them. For example, we saw one person direct their conversation to a member of staff but they were not acknowledged and the staff walked away while the person was speaking.

The standard of cleanliness had improved. Additional staff had been recruited and were completing induction programmes. The level of agency staff had reduced. Care planning documentation showed clearer accounts of people's care needs. People's dietary intake was monitored. People were supported to minimise their risk of developing a pressure ulcer. There continued however, to be some shortfalls with inconsistent recording of people's fluid intake.

People told us they liked the staff and were well supported. People could make choices and their rights to privacy and dignity were maintained. People felt safe within the home and staff were aware of their responsibilities to recognise and report a suspicion or allegation of abuse. People told us staff were busy yet they did not feel this impacted upon the care they received. People were well supported with their mobility and nutrition yet there were two occasions when people would have benefitted from more timely staff support. A detailed analysis of the number of falls would have enabled better management of risk and people's safety.