CQC report explained · a residential care home
What the CQC found at OSJCT Coombe End Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2022
Targeted inspection, not rated; the previous Requires Improvement rating remained, with improvements but some internal doors still unlocked.
Inspectors visited without notice on 5 and 19 May 2022. They checked whether the home had fixed problems from its previous inspection, especially night security and risk records. They also checked infection prevention and control.
The home had improved its checks and records. Night security forms were checked more carefully, risk monitoring records had no gaps in those reviewed, and the home was clean. Staff had suitable protective equipment and people could receive visitors.
Some internal doors were still left unlocked, including doors the provider had said should be locked. The provider added this to its improvement plan, and inspectors recommended reviewing the door locks. This targeted visit did not give new ratings. The previous overall rating of Requires Improvement remained.
Improved records
The records inspectors reviewed for repositioning and falls monitoring were completed properly, with no gaps found.
“The records we reviewed had been completed as appropriate with no gaps in recording.” from the report
Better management checks
Management had introduced stronger checks of night security forms and made sure records reflected the people living in the home.
“At this inspection a different system was in place which meant the registered manager thoroughly checked forms before storing them.” from the report
Clean environment
The home was clean on both inspection days. Earlier problems with maintenance and pedal bins had been addressed.
“At this inspection, the home was clean, maintenance works had been carried out and pedal bins were working.” from the report
Infection control
Inspectors were assured about the home's infection control arrangements, including protective equipment, testing and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Internal doors left unlocked
needs fixingSome internal doors were left on the latch, including doors the provider had assessed as needing to be locked. The home was asked to review the locking systems.
“We found this had not worked and some internal doors were unlocked on both days of our inspection.” from the report
One area had an odour
minorOne area of the home had an odour on both inspection days. The manager said the provider was sourcing a new carpet.
“We did, however, note one area of the home had an odour which was present on both days.” from the report
- 01Have all internal doors that need to be locked now been repaired or adjusted, and how are staff checks recorded?
- 02What action has been taken about the odour noted in one area of the home?
- 03How are night security forms checked now, and what happens if a check is missed?
- 04How are falls monitoring and repositioning records checked for gaps?
- 05When is the next comprehensive inspection expected, given that the previous Requires Improvement rating was not changed by this visit?
This was an unannounced targeted inspection of the previous Regulation 17 concerns and infection control; it did not assess the full Safe or Well-led questions, and the other key questions were not reviewed. This explanation was written from the published report of 14 June 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.
What inspectors found, April 2022
Rated Requires Improvement; inspectors found risks in night checks, staffing and management oversight, although medicines and infection controls were generally safe.
This was an unannounced inspection on 9 and 16 February 2022. It followed a notification about a death, but inspectors did not examine that incident because it was still being investigated. They focused on wider safety arrangements at night and infection control.
Inspectors found that some night checks were missed, recorded late or recorded for someone who was not at the home. Some risk records were also not completed at the time actions were taken. Staffing was sometimes below planned levels, and this put pressure on permanent staff and delayed care.
There were also cleaning and maintenance problems on the first visit. These were addressed by the second visit. Medicines were given as prescribed, and staff followed safe medicines practice. People, relatives and staff described the care as kind, but quality checks had not found all the problems.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected in this visit, so their previous ratings were carried forward.
Medicines
People received their medicines as prescribed. Records seen by inspectors had no gaps, and staff had been trained and checked as competent.
“People had their medicines as prescribed. Systems were in place to make sure medicines were checked into the home safely and stock checks were carried out regularly.” from the report
Kind staff
People and relatives were generally positive about the care. They described staff as kind and said people enjoyed living at the home.
“People told us they enjoyed living at the home and the staff were kind.” from the report
Family contact
Indoor and outdoor visiting was supported. Essential care givers could visit at any time, including during COVID-19 outbreaks.
“Relatives spoke to us about being essential care givers which meant they could visit at any time even during outbreaks of COVID-19.” from the report
Recruitment checks
The home completed the required checks before employing staff, including checking employment history and the disclosure and barring service.
“Staff were recruited following the required pre-employment checks being carried out.” from the report
Night-time safety
seriousInspectors found that some hourly checks were missed, not recorded when due, or recorded for someone who was not in the home. An external door was also left locked but without its alarm active.
“The provider could not be assured checks were being carried out as required.” from the report
Incomplete risk records
seriousSome risk monitoring records were not completed at the time actions were taken. This meant the provider could not confirm that people had received the necessary support when needed.
“This meant the provider could not be assured the necessary actions had been completed at the time they were needed which placed people at risk of harm.” from the report
Staffing pressure
needs fixingStaffing was sometimes below planned levels, with agency cover not always available. Care was still delivered, but it took longer and there was less time for social interaction.
“There is not enough time for the human side of things. You get washed and dressed but there is no time for a talk” from the report
Weak management checks
seriousAudits were being completed but did not identify all the problems inspectors found. Some documents and evidence of action were not available when requested.
“Quality monitoring checks were being carried out but had not identified the shortfalls we found at this inspection.” from the report
Cleanliness and maintenance
minorOn the first visit, one area needed cleaning, some bins were broken and some fixtures showed flaking paint and rust. These issues were addressed by the second visit.
“During our first site visit we observed one area of the home that was dirty and in need of a clean.” from the report
- 01What has changed in the hourly night checks, and how do you now confirm that every check is completed and recorded correctly?
- 02How do you make sure external doors remain alarmed overnight after someone has used them?
- 03What staffing levels do you expect on each shift, and what happens when agency cover is unavailable?
- 04How are risk records, repositioning records and falls records checked to make sure actions are recorded at the time?
- 05What action has been taken in response to the Regulation 17 Warning Notice, and how will you show that the improvements are working?
This was an unannounced focused inspection prompted by a serious incident, covering Safe and Well-led and infection control; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 29 April 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 OSJCT Coombe End Court
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2022Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- February 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about two hours of Wiltshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,340 a week. 82 can care for a couple. 12 years' experience on average.
“Linet became her carer and all changed, my daughter started eating, taking her medications and more important her happiness came back.”
“I cannot recommend Prisca highly enough, she is one in a million.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.