CQC report explained · a residential care home
What the CQC found at Combe Lea Community Resource Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Combe Lea Community Resource Centre was rated Requires Improvement because fire safety, medicines, consent and management checks were not always reliable, although care was kind and responsive.
Inspectors visited without notice on 26 and 27 September 2022. They reviewed records, toured the home and spoke with residents, relatives and staff. They checked all five areas of care, including infection prevention and control.
The home was not always safe. Fire safety problems identified in 2020 had not all been fixed, and medicines records did not always show that patches were rotated correctly or that as-required medicines had worked. People were also at risk because mental capacity and best-interest decisions were not always recorded properly.
Inspectors found kind, respectful care and person-centred support. People had choices, could maintain relationships and were supported with food, drink and healthcare. However, audits and checks did not consistently identify problems or show what had been done after accidents and incidents.
The overall rating Requires Improvement means the home was not consistently meeting the required standard. The report says this was the first inspection since the service was registered under the current provider. The previous provider had been rated Good in 2018.
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors also observed staff speaking with people respectfully and spending meaningful time with them.
“We observed kind and caring interactions between staff and people.” from the report
Choice and personalised support
Care plans included people's preferences, such as when they liked to get up and how they preferred to spend their time. People said they had choices and their preferences were respected.
“Care plans were person centred and included information about people's choices and preferences, such as people's preferred time for getting up and how they like to spend their time.” from the report
Support with relationships and activities
People were supported to keep in touch with important people and to take part in activities. An activities coordinator was developing the activities programme.
“People were supported to maintain relationships that were important to them.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs. Staff had relevant training, supervision, competency checks and appraisals.
“There were sufficient numbers of staff to meet the needs of people.” from the report
Fire safety had not been put right
seriousThe provider had not acted on fire safety problems identified in October 2020. An area was still being used for storage and broken self-closing doors had not been repaired, increasing the risk of avoidable harm.
“We found the provider failed to act and rectify fire safety shortfalls identified by a risk assessment commissioned in October 2020.” from the report
Medicines records were incomplete
needs fixingRecords did not always show that patches were rotated according to manufacturer guidance. Staff also did not always record why as-required medicines were given or what the outcome was.
“This meant the provider could not understand the efficacy of these medicines.” from the report
Consent decisions were not properly recorded
seriousMental capacity assessments and best-interest decisions were missing in some cases. This included sensor alarms and medicines given covertly, meaning the home could not show that decisions were lawful and least restrictive.
“Consent to care was not always sought in line with guidance and regulation; when people were unable to consent, mental capacity assessments had not always been completed and best interest decisions had not always been documented.” from the report
Management checks did not find problems
needs fixingAudits and provider-level checks were not effective enough to identify shortfalls. Records also did not always show what action had been taken after accidents and incidents.
“Provider level checks and audits were not being undertaken.” from the report
Some care guidance was missing
needs fixingOne person's diabetes plan did not explain the signs of high or low blood sugar or what staff should do. This could leave staff without clear instructions during an event.
“This meant there was a risk staff may not know how to respond to such an event.” from the report
- 01Have all the fire safety issues identified in the October 2020 risk assessment now been fixed, including the storage area and self-closing doors?
- 02How do you check that transdermal patches are rotated according to the manufacturer's instructions?
- 03How do you record the reason and outcome when as-required medicines are given?
- 04How do you make sure mental capacity assessments and best-interest decisions are completed before using sensor alarms or giving medicines covertly?
- 05What provider-level audits now check care quality, accidents, incidents and fire safety?
This was an unannounced first inspection that considered all five key questions and infection prevention and control; the report says the service had not previously been inspected under the current registration. This explanation was written from the published report of 29 October 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Combe Lea Community Resource Centre
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Combe Lea Community Resource Centre →
- May 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2020
Registered with the Care Quality Commission on 1 October 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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