Archived: Coombe Grange Residential Home

Updated 14 July 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 was meeting legal requirements and regulations associated with the Health and Social Care Act 2008, to check the provider had made the necessary improvements and to decide whether it was appropriate to revise their rating under the Care Act 2014.

We undertook a focussed inspection of Coombe Grange on 10 June 2015. This inspection was completed to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on 8 December 2015 had been made. We inspected the service against two of the five questions we ask about services. This is because the service was not meeting legal requirements in relation to its effectiveness and required improvement in respect of providing safe care.

Before the inspection, we reviewed all the information we held about the home, this included the provider’s action plan, which set out the action they would take to meet legal requirements. We spoke with the provider, the registered manager, the deputy manager, three care workers, the administrator and two people. We looked at policies and procedures relating to safeguarding and checked the provider had implemented an effective tool to assess and support people to make decisions.

One inspector conducted this inspection.

You can find full information about our findings in the detailed key questions of this report.

Updated 14 July 2015

We carried out an unannounced comprehensive inspection at Coombe Grange on 8 December 2015. We found some staff were not familiar about how to report abuse if they suspected this might take place. Some staff were not knowledgeable about how to assess people’s capacity to make decisions and could not tell us how they applied the Mental Capacity Act 2005 (MCA).

We found Coombe Grange to be in breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds with Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Need for consent.

After the comprehensive inspection, we published a report in which we asked them to tell us what they would do to meet legal requirements in relation to the one breach we identified and how they would improve their safeguarding procedures. The provider sent us an action plan which stated that they would have made the required improvements by the 10 June 2015.

We carried out an unannounced focussed inspection on 10 June 2015 to check whether action had been taken in relation to the breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds with Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Need for consent. We found the provider had made the required improvements.

This report only covers our findings at the inspection on 10 June 2015. You can read the reports from our last comprehensive and focussed inspection, by selecting the ‘all reports’ link for ‘Coombe Grange’ on our website at www.cqc.org.uk.

Coombe Grange provides care and support for up to 40 people. At the time of our inspection there were 25 people living there.

Coombe Grange did have a registered manager on the day of the inspection. 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.

Staff were knowledgeable about the different types of abuse that could take place and told us how they would inform the local authority and the Care Quality Commission (CQC) if they suspected someone was being abused. Safeguarding policies contained sufficient contact details should staff need to contact the local authority and CQC.

Records showed all care staff had received training in the use of the Mental Capacity Act 2005 (MCA). They were knowledgeable about the requirements of the MCA and were able to describe how they supported people to make decisions.

As a result of this inspection, we revised the ratings in respect of the ‘safe’ and ‘effective’ domains and this meant the overall rating changed from requires improvement to good.