CQC report explained · a residential care home
What the CQC found at Coumes Brook Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2019
Rated Requires Improvement; inspectors found kind, effective care, but medicines, staffing systems and management checks needed strengthening.
This was an unannounced planned inspection on 16 April 2019. Two inspectors spoke with people, staff and visiting professionals. They examined care and medicines records, staff files, management records and the building.
People were generally safe, cared for with kindness and treated with respect. Staff were recruited safely, care plans were detailed, meals and healthcare needs were met, and activities were available. The ratings for Effective, Caring and Responsive were Good.
The Safe and Well-led ratings were Requires Improvement. The home did not have a reliable system to show how staffing levels were calculated. Medicines policies and some staff medicines checks were not up to date, and consent records and management checks needed improvement.
The overall rating fell from Good at the previous inspection, published on 5 November 2016, to Requires Improvement. The manager sent evidence of some changes after the visit, but inspectors wanted to see these improvements continue in practice.
Kind and respectful care
People were consistently described as happy and well treated. Inspectors found a strong culture of dignity, respect and compassion.
“There was a strongly embedded culture within the service of treating people with dignity, respect, compassion and love.” from the report
Personalised support
Care plans recorded people's likes, dislikes and communication needs. Staff knew people's preferences and adjusted support accordingly.
“People's likes, dislikes and what was important to the person were recorded in person centred care plans.” from the report
Activities and outings
The home offered group and individual activities, entertainment and trips that reflected people's interests.
“The service provided a stimulating program of activities, entertainment and outings to keep people occupied.” from the report
Safe recruitment and risk planning
Recruitment checks were completed and individual risk assessments gave staff information about how to provide safer care.
“Risks to people were identified by individual risk assessments and appropriate risk management plans were incorporated in to care plans.” from the report
Food and healthcare
People had choices of homemade meals, with dietary needs recorded. The home worked with healthcare professionals and made appropriate referrals.
“People were offered a choice of meals and all the food was homemade.” from the report
Staffing calculations
needs fixingInspectors saw enough staff during the visit, but the home could not show a robust process for calculating safe staffing levels. This had also been raised at the previous inspection.
“We found there was no systems in place to evidence how safe staffing levels were calculated.” from the report
Medicines checks and policy
needs fixingMedicines were generally managed safely, but the medicines policy had not been reviewed since 2009. Not all staff had received an annual competency review at the time of inspection.
“The provider's medicine policy had not been reviewed at appropriate intervals since the date of issue in 2009” from the report
Consent records
needs fixingThe home did not consistently record mental capacity as part of admission or complete consent forms. The manager provided evidence of corrections after the inspection.
“mental capacity was not considered as part of the admission process and consent forms were not consistently completed.” from the report
Management oversight
needs fixingQuality checks had not identified several issues, and some feedback from the previous inspection had not been acted on. Policies also needed updating.
“We saw not all feedback from the previous inspection had been acted on by the registered manager.” from the report
Resident and relative meetings
minorMeetings to discuss what people wanted from the service had lapsed in recent months. The manager had planned meetings for 2019.
“However, these had lapsed in recent months.” from the report
- 01How is the current staffing level calculated for each person's assessed needs, and how is this checked?
- 02When was the medicines policy last reviewed, and how are staff medicines competencies reviewed now?
- 03How do you check that mental capacity, consent and any Deprivation of Liberty Safeguards considerations are recorded at admission?
- 04What changes were made after this inspection, and what evidence shows they have been sustained?
- 05How often are resident and relative meetings now held, and how are concerns from those meetings acted on?
This was an unannounced planned inspection that looked at the overall service, including care, premises, records, staffing and management, and assessed all five CQC questions. This explanation was written from the published report of 23 May 2019 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.
What inspectors found, November 2016
Coumes Brook Home Limited was rated Good; inspectors found kind, safe care, with some medicines, infection control and record-keeping improvements needed.
The inspection was unannounced and took place on 17 October 2016. Inspectors spoke with 11 people using the home, staff, the manager and a visiting health professional. They observed care and checked care plans, medicines, staff records and management systems.
All five areas were rated Good: safe, effective, caring, responsive and well-led. People said staff were kind and that they felt safe. Inspectors found enough staff, suitable training, personalised care plans, good access to healthcare, activities and systems for handling complaints and incidents.
The report also identified improvements. Medicines records were not always complete, the staffing tool did not show the hours needed, food and fluid charts lacked detail, and the combined laundry and sluice room created a risk of cross infection. The home agreed to address these points.
Kind and respectful care
Inspectors saw caring interactions, with staff respecting privacy, dignity and personal choices.
“People we spoke with told us the staff were always patient and kind.” from the report
Activities and involvement
People had access to activities such as exercise sessions, entertainers and trips out. People and relatives were asked for their views.
“There was a range of activities on offer at the home. These were enjoyed by people.” from the report
Open management
Staff said managers were approachable and listened to concerns and ideas. Audits, meetings and feedback were used to monitor the service.
“We found there was an open, fair and transparent culture within the home.” from the report
Medicines records
needs fixingSome carried-over medicine amounts were not recorded on the medication records. Some handwritten entries were not signed by the person who made or checked them.
“However, we saw carried over amounts were not always recorded and hand written entries were not signed by the staff member writing the medication, or by the staff member who checked them.” from the report
Staffing assessment
minorThere were enough staff on the inspection day, but the staffing tool only classified needs as low, medium or high. It did not show the staffing hours required.
“However, the tool they were using identified if people had low, medium or high needs, but did not actually show the staffing hours required to meet those needs.” from the report
Food and fluid records
needs fixingMonitoring charts did not record the amount served. This meant staff could not tell exactly how much a person had eaten when the chart said half or a quarter.
“The charts were completed, however, we saw these did not detail the amount served so when staff put they had eaten half or a quarter it was not possible to determine what amount was eaten.” from the report
Laundry and infection risk
needs fixingThe laundry and sluice room was small and used for several different tasks. Inspectors said its layout created a risk of cross infection.
“The multi-use and lack of space meant it posed a risk of cross infection.” from the report
- 01What changes have you made to record carried-over medicines and signatures on medication records?
- 02How do you now calculate the staffing hours needed for each resident?
- 03How are food and fluid charts completed so that the amount served and eaten is clear?
- 04What work has been done to reduce the cross infection risk in the combined laundry and sluice room?
- 05How are actions from audits recorded and checked until they are complete?
This was an unannounced inspection of the overall quality of the service, covering all five CQC questions and checking whether the legal requirements were being met. This explanation was written from the published report of 5 November 2016 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 Coumes Brook Home Limited
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- May 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 2010.
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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