Regulator finds Coombe End Court care home still in need of improvement

Written by Tony Millett on .


A new report from the Care Quality Commission (CQC) on the Coombe End care home in London Road, Marlborough still gives it an overall rating of "requires improvement" - but emphasises that the service it provides is "caring".

This report (May 25) follows one in April 2015 which rated the home's service as 'inadequate' and imposed 'enforcement action' on various issues.  The follow-up inspection in January 2016 found that the home still required improvements.

CQC inspectors made a further and unannounced (on the first day) inspection earlier this year (January 31-February 6.)  It was made by a single inspector who found that while "...some improvements were embedded into consistent practice there were insufficient improvements in all areas."  


The report says the home 'requires improvements' to make the service safe, effective, responsive and well-led.  They rate the caring provided at Coombe End Court as 'good'.


The home, which is run by The Orders of St John Care Trust, provides accommodation for up to 60 older people and has a unit on the ground floor for people living with dementia.  This latter has recently been extensively refurbished.


The inspectors found that "People were at risk from unsafe medicine systems.  People were not always having their medicines at the prescribed times."   A review by a pharmacist of the medicines regime discovered a breach of regulations under the Health and Social Care Act 2008.


But the main problem emerging from the inspection is staff shortages.


People living at the care home, relatives and staff told the CQC "...there was heavy reliance on agency staff. The registered manager said recruitment of staff was a priority and that consistent agency staff was used...People were sympathetic about staff shortages but wanted the organisation to employ consistent staff to deliver their personal care."


Some of the first hand opinions of people living at Coombe End Court that are included in the report centre on the lack of staff and problems with the quality of agency staff - and the impact on how long people have to wait for care. The report states: "A significant number of staff had left the service and we were told there were 21 full time equivalent care staff vacancies."


Other issues raised by the inspectors included staff not reporting falls, care plans lacking detail and not being updated, and people not being aware they had a care plan.


The report cites one case of a person sustaining 'significant bruising' to their face.  This happened on the third day of the inspection and the inspector says that he had to alert the manager to the seriousness of the case and implement observations on the person in case of a head injury.


However, the detailed report says: "People told us they felt safe with the staff...People told us the staff were caring."  It also makes clear that people at the home had access to GP and healthcare specialists - and had regular check-ups with opticians, dentists and chiropodists.   The report outlines the recent improvements made to the dementia unit and the main foyer area. has shown this report to someone with experience of care homes and they think that it contains so many positive aspects and examples that it is quite difficult to know why the 'requires improvement' rating has been used for the overall rating.