Archived: The Priory Grange Coombe House

The purpose of this inspection on 20 June 2012 was to check compliance in these areas. We looked at key outcomes covering respect and involvement, consent, care and welfare, safeguarding people from abuse, management of medicines, recruitment practices, staffing, supporting staff and assessment and monitoring the quality of the service.

We looked at the records of four people in detail; and spoke with people about their experiences at the service. We observed interactions that took place with people using the service. We spoke with eight staff, including the medical, nursing and occupational therapy staff.

The provider had achieved compliance in all the outcomes that we previously had concerns about. This was supported by the comments people made about their experiences at the hospital:

People told us that there had been a lot of improvements and that they were fully involved in the assessment and planning of their care. For example, we were told 'Everything's changed. We make a diary about what we want to do and we get much more of a say'.

A person told us they had a 'Good chat with the doctor about my stay here' and been asked whether they were 'Happy with everything and want to continue on the programme and treatment, which I do.'

People had clear goals and were working towards discharge; one person said and they had 'Healed' because there was 'Loads to do now'.

The staff were described as being 'Great, they always seem to know when I'm not feeling too good and will always come and talk to me about it to find out if I'm ok'. And people said they felt 'Much more safe' and that 'Things are calmer here now',

At this inspection, we found that there were risks associated with medicines because the provider did not have appropriate arrangements in place to ensure that medicines were stored suitably to maintain the correct temperature. We have made a compliance action about this.

On the day of our visit there were 10 people residing at Coombe House, one of which was currently in hospital due to her physical health, one person was on leave and during our visit, another person was discharged. At the conclusion of our visit there were seven people remaining at Coombe House. We spoke with three people who lived at Coombe House. Overall they told us that they were happy with the care and support they received but all voiced their concerns about the staffing levels with this impacting on them being able to meet their individual needs and involve them in their care planning.

Staff had knowledge of privacy, dignity and independence. For example, how to maintain privacy and dignity when engaging in one-to-one sessions and the importance of people accessing activities within the home and the community. They showed an understanding of the need to encourage people to be involved in their care, but this was not reflected in care records that we saw and what people told us.

People we spoke with who lived at Coombe House said that their care and welfare needs were generally met. However, all voiced their concerns over the staffing levels at the time when there were two people requiring one-to-one support due to the complexity of their needs. They all commented that staff do their best to meet people's needs, but that at times staff were stretched and therefore on occasions they had not felt safe and community activities had to be cancelled.

Certain care plans made reference to the use of a contract and these were generally associated with behaviour management and safeguarding people from harm to themselves or that of others. The contracts meant that whilst people were on a contract they would not have access to their bedroom in the daytime, or they were moved to another bedroom which had minimal furniture, their fob was removed and no leave was to be taken. We were unable to see care plans specifically about the use of contracts. We asked the interim manager for a copy of the relevant policy for the use of contracts. We were told by them that there was no local policy/procedure in place for the use of contracts, with them adding that they acknowledged that this needed to be addressed.

We spoke with staff about their understanding of what constituted abuse and how to raise concerns. They demonstrated an understanding of what kinds of things might constitute abuse. Staff varied on where they should go to report any suspicions they may have, from raising concerns to a registered nurse or senior staff member, contacting the local authority and contacting the Care Quality Commission through the whistle blowing procedure. This demonstrated inconsistencies in managing and responding to safeguarding concerns and highlighted that the necessary procedures would not necessarily be followed to safeguard people from abuse.

We had received information expressing concerns that staff could not meet the needs of people due to insufficient staffing levels, with the need to rely on a high level of agency staff that were inexperienced in mental health care, risk management and observations. High turnover of permanent staff coupled with an over reliance on agency staff impacting on continuity of care.

We spoke to people living at Coombe House, staff members and other health and social care professionals and they all expressed concern about the staffing levels at the time when there were two people requiring one-to-one support due to the complexity of their needs and 23 staff members leaving over the past year.

The training matrix that we saw dated 13 February 2012 highlighted the mandatory staff training. We asked the manager to identify which were face to face and which were e-learning. The training courses in total were 25, 21 of which were e-learning (these included, the Mental Health Act as amended in 2007, clinical risk assessment and confidentiality and data protection). The remaining four which were face to face, included basic life support, breakaway, moving and handling and control and restraint. Staff completion of these four modules were:

' Basic Life Support ' 3%

' Breakaway ' 0%

' Moving and Handling ' 47%

' Control and Restraint ' 0%

We were told by the consultant psychiatrist that Coombe House currently did not have a medical secretary so that documents were not managed properly. They stated, 'people have arrived with no information from previous placements and I have had to chase up this information myself.' They informed us that recently there had been different temporary office staff at Coombe House every day and they were not able to be effective. They added that unless Coombe House has a medical secretary the work could not be done properly as it was a specific role. We asked the consultant psychiatrist about Coombe House' admission criteria. They said that there was no current admission criteria to decide who could be safely admitted.

Information for people is clear and explained when they are admitted to the hospital and commented that they "came for a visit, they were very kind and helpful and made me feel at ease". People told us that their needs were discussed and written up in a plan of care, but didn't yet have a copy of it.

People told us that they were very happy with their care and that when they feel unwell care workers are 'very sensitive" to their needs. There was a strong sense that people are on the road to recovery and they told us they feel "very safe" and had "never seen anyone restrained, there is always someone you can talk to so it doesn't get that it's very calm here is and people are very relaxed"

Meals were said to be 'very healthy' and there is a choice, which people make every day after the daily community meeting. Similarly, there are opportunities for people to learn about healthy eating in a weight management and cookery group held every week.

Everyone has their own plan that is agreed with them so that they are occupied in meaningful activities and we were told "there's so much to do here, we have a good choice of things to do at every session for example this morning I could have done aqua aerobics, Weight Watchers or a computer class -I went to aqua aerobics and really enjoyed it".

We talked to people about the environment and they told us that they had their own room and care workers always knock and it's seen as 'your own space and encouraged to be your own space'. People told us that The Priory, Coombe House is kept spotlessly clean.

Some people told us about restrictions, such as how much contact they would have with their family, but they had signed up to this as part of their recovery plan. Similarly, people understand and appreciate the checks being done and told us that this is to keep them safe.