Signature at Coombe Hill Manor

Updated 5 October 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 Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors, a specialist nursing 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

Coombe Hill Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The service is a care home with nursing care. 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

The first day of inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with 23 people who lived at the care home and three visitors. We also spoke with the managers and staff who worked there including, the registered manager, a regional operations clinical manager, a unit manager, three nurses, 13 care staff (11 permanent and two agency), two activities coordinators, two business administrators and two housekeepers/cleaners.

Records looked at as part of this inspection included 12 staff files in relation to their recruitment, training and supervision. In addition, we saw electronic staff training records, the supervision and appraisal matrix, and weekly activities schedules.

Throughout our inspection we observed how staff interacted with people living in the care home and undertook their roles and responsibilities. Following the inspection, we received further documentation from the registered manager and written feedback from two relatives and two healthcare professionals.

Updated 5 October 2022

Coombe Hill Manor is a care home providing nursing, personal care and support for up to 104 older people. The service has a specialist dementia care unit known as ‘Augusta’ which can accommodate and care for up to 24 people. At the time of our inspection 79 people were living at the home.

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

We continued to find areas of outstanding practice in the care provided by Coombe Hill Manor. As at our previous inspections, the registered manager and staff team demonstrated an exceptional commitment in enabling people to receive high-quality care that met and exceeded their needs.

People using the service and their relatives were very positive about the care and support provided at Coombe Hill Manor. Typical comments included, “The staff are sympathetic – caring. They are never brusque”, “I can’t think what they could do better”, “I think it is very good” and, “I wouldn’t want to move out of here.”

The registered manager and her staff team remained committed to providing high quality compassionate care. There was also a strong emphasis on ensuring compassion, dignity and respect at the end of a person’s life. The Augusta floor supporting people living with dementia continued to demonstrate best practice in this specialist area.

The service continued to be exceptionally responsive to people’s changing needs. People had access to a wide range of activities and events along with excellent facilities.

Care and nursing staff and the registered manager continued to ensure people’s changing needs were met and strove to ensure people received exceptional person-centred care. People and their relatives said their concerns and views were listened to and acted upon. Records confirmed this.

Individual care and support needs were fully assessed, documented and reviewed at regular intervals. The electronic system for care planning provided an effective tool for staff to do this.

People were kept safe. Despite difficulties in recruitment locally, we found there were enough staff deployed to help ensure people’s needs were being met. Staff received training around safeguarding vulnerable people and knew what action to take if they had or received a concern.

People received their medicines as prescribed. Any risks associated with people’s care were managed well and people were supported to maintain their independence wherever possible. Systems and records were up to date and continually monitored.

People and their relatives told us that they received an effective service. People received the support they required to meet their health and nutritional needs. Feedback about the food provided was mixed however we saw the service continued to actively engage with people using the service to try to increase satisfaction levels.

Staff were safely recruited and received a full induction to the home followed by a comprehensive programme of training. Staff we spoke with were positive about the service provided and said they felt able to recommend the home to others.

We found people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The registered manager and her staff team remained committed to providing high quality compassionate care. There was also a strong emphasis on ensuring compassion, dignity and respect at the end of a person’s life. The Augusta floor supporting people living with dementia continued to demonstrate best practice in this specialist area.

Good leadership, management and governance of the service continued to support the delivery of high-quality and person-centred care. Effective systems were in place to monitor and continually improve the quality of service people received at Coombe Hill Manor.

The registered manager kept up to date with good practice and continued to be committed to ensuring the highest standards at Coombe Hill Manor. There was praise from people and relatives as to how the service navigated the COVID-19 pandemic since 2020 and the associated staffing pressures. A relative complimented the home saying, “It is in no small measure thanks to your professionalism and kindness that my [relative] has survived and that I can visit them now that it is possible to travel again.”

Rating at last inspection and update

The last rating for the service under the previous provider, Signature of Coombe (Operations) Ltd was outstanding, published on 9 February 2019.