Background to this inspection
Updated
20 April 2024
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.
Inspection team
Inspection team consisted of 2 inspector, 1 specialist adviser who was a nurse and 1 Expert by Experience who completed an onsite visit and relative calls remotely. 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
Comberton Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Comberton Nursing home 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with 7 people who used the service and 13 relatives to ask about their experience of the care provided. Some people were unable to tell us their experience of their life in the home, so we observed how the staff interacted with people in communal areas. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 5 members of staff, including care staff, nursing staff, the registered manager. We reviewed a range of records. This included 7 people's care records and all medicine records in the home. We also reviewed the process used for staff recruitment, records in relation to training and supervision, records relating to the management of the home and a range of policies and procedures.
Updated
20 April 2024
About the service
Comberton nursing home provides personal and nursing care for to up to 38 people. The service provides support to older people and people who live with dementia. At the time of our inspection there were 30 people using the service.
Comberton Nursing home is split across 2 floors, on both floors nursing care is provided to meet a variety of people needs. The home has accessible parking and a maintained garden outside.
People’s experience of using this service and what we found
Medication management was not effective in identifying concerns. Medication was not always stored correctly.
People’s weights were not effectively monitored. Systems were not in place to closely oversee peoples weight related to their health needs.
Guidance for staff to support people with specific health needs was not always sufficient. There was not always enough staff to care for and monitor people. This left people at risk of unsafe care.
We observed interaction with people. There was a lack of activities and no planned activities were scheduled. This meant we found people were sat in the same position for periods of time.
Mealtimes in the home were not always served in a way that met all peoples needs and preferences. People were not offered choices to where they would like to have meals and who they had their meals with.
The environment lacked person centred detail. People’s characteristics were not captured.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported best practice.
The provider was asked during our inspection to provide an immediate action plan due to the high risk concerns we found during our inspection visit. The provider sent an action plan that identified timescales to improve high risk areas.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection-
The last rating for this service with the previous provider was good. (published 9 November 2019)
Why we inspected
This inspection was prompted by a review of the information we held about this service. The inspection was prompted in part due to concerns received about staffing, response times to providing care to people and medicines management.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Comberton Nursing Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to regulation 9 (Person centred care), regulation 12 (Safe care and treatment) and regulation 17 (good governance)
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.