CQC report explained · a nursing home
What the CQC found at Signature at Coombe Hill Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable risk assessments, safe medicines systems, enough staff and appropriate infection control arrangements.
- Effective?
- Good
- People's needs were assessed and care plans were regularly updated. Staff received induction, training, supervision and support, although feedback about the quality of meals was mixed.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff offered choices and supported independence, but this rating was lower than the Outstanding rating at the previous inspection.
- Responsive?
- Outstanding
- Care was highly personalised and adapted to people's changing needs. Inspectors found an exceptional range of activities, strong dementia support and respectful end of life care.
- Well-led?
- Good
- The home had positive leadership, regular feedback forums and thorough quality checks. Managers monitored staffing, incidents and the quality of care.
What inspectors found, October 2022
Signature at Coombe Hill Manor was rated Good overall, with Outstanding responsiveness, although inspectors found mixed views about the food.
Inspectors visited on 26 May and 21 July 2022. The first visit was unannounced. They spoke with 23 people living at the home, visitors, staff and managers. They also reviewed care records, staff files, training records and activity plans.
People were found to be safe and received their medicines as prescribed. Staff were trained, recruitment checks were completed, and care plans and risk assessments were regularly reviewed. People were treated with kindness, dignity and respect, and were involved in choices about their care.
The home was rated Outstanding for being responsive to people's needs. Inspectors praised the wide range of activities, dementia support and end of life care. The overall rating was Good. Safe, effective, caring and well-led were also rated Good. Caring had fallen from Outstanding at the previous inspection, while responsive remained Outstanding.
Personalised care
Care plans were detailed and staff adapted care to people's needs, preferences, beliefs and wishes.
“People received a high standard of personalised care that was responsive to their needs.” from the report
Activities and dementia support
People could choose from many activities and facilities. Inspectors found innovative support for people living with dementia, including sensory and meaningful engagement activities.
“There continued to be a strong awareness of best practice, innovation and going the extra mile to meet the social needs of people living with dementia.” from the report
Kind and respectful staff
People were observed to be comfortable with staff, who communicated warmly and supported dignity, choice and independence.
“Staff interaction with people was characterised by warmth and kindness.” from the report
End of life care
People's end of life wishes, including spiritual and cultural wishes, were recorded. Staff had relevant training and links with a hospice.
“This ensured staff were aware of people's wishes and that people would have dignity, comfort and respect at the end of their life.” from the report
Mixed views about food
minorPeople gave different views about the meals. Some described the food as very good, while others said the quality was inconsistent or had declined.
“It is very hit and miss. One day brilliant, the next not so good” from the report
- 01How are you responding to residents who feel the food is inconsistent or has declined?
- 02How many permanent and agency staff are usually on duty on each floor, including at night?
- 03How would you tailor activities and daily routines to my relative's interests, culture, religion or dementia needs?
- 04How will my relative and our family be involved in reviewing their care plan and raising concerns?
- 05What support is available for end of life wishes, including spiritual and cultural preferences?
This was a comprehensive inspection covering all five key questions, the care provided and the premises, including infection prevention and control measures; the first day was unannounced. This explanation was written from the published report of 5 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 Signature at Coombe Hill Manor
Each visit the CQC has published, newest first, back to the day the home was registered.
- October 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
Read what inspectors found at Signature at Coombe Hill Manor →
- January 2021
Registered with the Care Quality Commission on 27 January 2021.
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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