Inspection on 18/12/07 for Coach House

This inspection was carried out on 18th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coach House 03/06/10

Coach House 16/12/09

Coach House 28/01/09

Coach House 09/01/07

Coach House 28/02/06

Coach House 03/01/06

Coach House 24/02/05

Coach House 20/08/04

Coach House 09/02/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Coach House 10 Woodwards Heights Off Ward Avenue Grays Essex RM17 5RR Lead Inspector Miss Helen Laker Unannounced Inspection 18th December 2007 10:00 Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coach House Address 10 Woodwards Heights Off Ward Avenue Grays Essex RM17 5RR 01375 396041 01375 393197 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.familymosaic.co.uk Family Mosaic Mrs Jane Elizabeth Richards Care Home 13 Category(ies) of Physical disability (13) registration, with number of places Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal and nursing care to be provided to up to 13 younger adults with physical disabilities. Personal and nursing care for people over 65 years of age is limited to 2 service users whose names are known to the CSCI. Maximum number to be cared for shall not exceed 13. Date of last inspection 9th January 2007 Brief Description of the Service: The Coach House is a registered home, providing nursing care for younger people with severe physical disabilities. The accommodation is a large, detached property of traditional construction on three floors. It is situated in a residential area of Grays and is fairly convenient for both rail and bus transport. The care provision is currently for thirteen service users requiring long-term care. The home employs trained nurses and carers to support personal and nursing care. Activities for service users in the community are encouraged and staff support service users in pursuing activities according to assessed needs. The Service User Guide and Statement of Purpose are available and the residents and their representatives can be provided with this information and the inspector was informed that the home would provide them with Commission for Social Care Inspection reports as well. Information regarding the level of fees within this home has not yet been provided to the Commission. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection site visit took place over one day. The site visit consisted of a tour of the home, talking with staff and residents, observing the care given and reading of documents. Most of the residents were seen and some were spoken to. The assistant manager on duty assisted with the inspection as the manager was off duty. A number of surveys were sent to service users, relatives/representatives and to health care professionals and these were completed and returned to the Commission. Seven service user surveys, three relative’s surveys, one staff survey were returned. Information contained within these surveys will be reflected within the report. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment, detailing what they do well, what could be done better and what needs improving. The inspector would like to thank the staff and residents for their help and hospitality during the visit. What the service does well: What has improved since the last inspection? Areas requiring refurbishment within the home have been attended to with carpet being replaced and decoration being undertaken. A training officer has now been appointed for the company. Person centred care planning continues within the home and pre admission assessment is now comprehensive and individualised. Assessments sampled during the inspection were of a good standard. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure includes an assessment, which helps to ensure that service users needs can be met at the home. EVIDENCE: The care plan regarding the two newest admitted residents to the home were examined for evidence of pre admission assessment. It was positive to note that the assessment information contained in the care plan was thorough and detailed. Information from the admission policy indicates that the assessment process is undertaken by an experienced member of staff. There is a comprehensive written admission procedure that gives prospective residents time to visit the home out before accepting a place. It indicated what the identified needs of the prospective resident were and how the home would meet these. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, as far as possible, are assisted to lead independent lifestyles giving them positive outcomes overall. EVIDENCE: Two care plans were sampled during the course of this inspection. At the last inspection, care plans were deemed to be of a good standard. A person centred care planning format has been introduced at the Coach House. Both of the care plans examined were comprehensive documents which contained detailed support plans regarding all of the identified needs of the individual i.e. communication/personal hygiene/mouth care/ foot care and fingernails/ elimination/mobility/tissue viability/nutrition/pain/mental health/family involvement and spiritual care. Risk assessments were also completed but were brief in some areas requiring clarification of the nature of the risk. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 10 Both care plans sampled provided clear guidance as to the complex support needs of individuals and how staff should address these. Consideration was given to issues of privacy and dignity. However, there were aspects of both care plans that had not yet been completed. These included manual handling risk assessments and monthly reviews. One care plan stated for the morning entry “ mouth and hair care given and taken downstairs into lounge” no more clear entries were evident except one evening entry which stated “just hoisted back to bed” this did not give a clear reflection of the service users day and did not evidence staffs reference to the activities of daily living assessment. In light of this, the team’s person centred approach needs more emphasis and attention in care plan documentation. An oral care assessment did state ‘Likes toothbrush changed every three months’ which did show some attention to personal choice. The AQAA does state ‘They need to use better connection of the assessment tools to the individual care plans they relate to. Daily entries need to be more detailed’. The manager’s plans are ‘To make better use of the assessment tools, better evaluations of the care plans, incorporate the effects of the neurological condition in the care plans, for every service user where possible to have an end of life care plan as suggested by the Liverpool pathway and adhering to the mental capacity act and ensure all careplans and files are completed within a week of admission for new service users.’ Observations during the course of the day demonstrated that the staff team interacted in a familiar and supportive manner with residents and that resident’s needs were being met. Staff members spoken with had a clear knowledge of the individual needs of residents. For some residents choices are limited because of their ability. However staff try to ensure that residents are listened to and that their future goals are recorded. Surveys reported that “Staff are good at interpreting needs” “the always inform me of issues regarding my relative” and the care is of a good standard. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to his service. Social activities take place and service users are generally happy with the choices in routine available to them. Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: The residents within the Coach House have complex needs and consequently no one is currently able to gain employment or to access education facilities. There are now two therapy assistants within the home who undertake therapybased work with the residents. This includes passive physiotherapy and chest physiotherapy, manicures, quizzes, bingo and other in house activities. Social and leisure activities are also arranged outside of the home and these include pantomimes, shopping, cinema, football, a visit to West Ham at Upton Park for one service users birthday whose bedroom is decorated in their colours, and Thameside theatre. The home has a mini bus and lease vehicle. Social activity Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 12 recording sheets also record one to ones completed by support workers in their team. The last one for one service users plan looked at was 4/12/07. The homes AQAA states ‘There is a weekly timetable, a Monthly calendar of day trips out, All service users have a careplan giving an indication of their interests and preferences. We have supported service users to spend time with their families and have weekend leave’. Evidence via surveys did not comment on this area in detail but conversations with residents indicated that they are generally happy with the social activities. The manager’s AQAA identifies that they need to ensure that all service users have equal access and that there are more activities provided. And that the service users are able to choose the activities they wish to participate in and staff are continuously looking for new resources to give them ideas. The home encourages visitors and has an open visiting policy. Some residents go home for the weekends and day visits. The kitchen area within the home was clean and well organised. Menus were examined and these demonstrated that residents received a nourishing well balanced diet. Vegetarian diets were also catered for. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the healthcare needs of residents are met which gives them positive outcomes. EVIDENCE: Care plans sampled during the inspection provided clear evidence that the health care needs of residents were being addressed. For example there were detailed GP and physiotherapist records in care plans. There was evidence to demonstrate that medical intervention was sought on the residents behalf whenever necessary. The homes AQAA states ‘The service users receive personal care and assistance as needed detailed in their careplans. They use the toiletries of their preference and wherever possible if they request additional shower or hair washs then if it can be accomodated, it is. The service users are supported to attend hair dressers and if unable arrangements are made for one to visit. Despite caring for service users who are largely immobile and at high risk of developing pressure ulcers the home rarely has any residents with pressure Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 14 ulcers and they are healed quickly wherever possible. They are supported to attend regular dental check ups and visited by a chiropodist’. Both of the care plans were compiled with an emphasis on maintaining the dignity of the resident. Medication processes were examined within the home. The assistant manager stated that a new medication trolley had been obtained following a requirement from the last inspection. The home use a monitored dosage system for administering medication. The medication was stored in a small room. The temperature was recorded daily and was seen to be within the required limit. The fridge temperatures are also recorded. The MAR files were examined and the service users were identified by the number of their room. It was positive to note that information regarding changes in medication from hospital clinics etc. was contained within the MAR file. There were some omissions noted on the MAR file. Some minor recording errors regarding transcribed medication for one service user was noted. The deputy manager was advised that any transcribed medication must have two signatures but any transcription of medication is not considered best practice. The homes AQAA states ‘The home needs to evidence staff competency for caring for residents who have complex needs. All medication transcribed will have 2 signatures.’ The assistant manager stated that there were currently no controlled drugs at the home. The CD cupboard was examined. This has now been replaced with a metal cupboard and is now compliant with the Misuse of Drugs (Safe Custody) Regulation 1973 as amended, which has clear specifications for the safe storage of controlled drugs. The clinic room has had additional storage cupboards installed for better storage of the medication. Records of drugs disposed of are now kept. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are generally in place to act on residents concerns and to protect them from harm or abuse. EVIDENCE: There have been four complaints since the last inspection. A new complaint log has been developed, however the recording of such complaints must be more specific and the outcomes and actions taken be more clearly outlined. For example one incidence tentatively highlighted an action of moving a resident from their room who was unrelated to the complaint to resolve a noise issue with another. This is considered inappropriate and better solutions should be investigated. This was discussed with the acting manager on the day of inspection. The previous complaints log was also being misused as a log of complaints by residents against other resident’s i.e. regarding issues such as noise. The homes AQAA states that ‘All concerns or complaints are responded to in a timely manner and outcomes of investigations are reported back to the people concerned. All staff have had or are booked for POVA training this year and there is the plan to obtain a training pack so that in future staff can maintain their knowledge in house.’ It was not possible to see information regarding POVA training as the registered manager was on leave on the day of the inspection and other staff members were unsure as to where it was located but stated it was on Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 16 computer. This information was provided at a later date to the CSCI but not on the day of inspection. It showed 18 out of 28 staff had attended POVA training in 2007, so some staff updates are required. A copy of ‘No Secrets’ was seen within the office, as was Essex Vulnerable Adults Protection Committee information. Staff members spoken with confirmed the procedure if abuse was suspected and the last POVA course was held on 15/06/07. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of accommodation, which meets the needs of the residents. EVIDENCE: This standard remains unchanged overall since the last inspection. A tour of the premises was undertaken. Overall the home provides a good standard of accommodation. All residents have their own rooms and these are personalised according to individual taste. There are communal areas on the ground floor, which consist of a lounge/diner, and a lounge area. The carpet in the lounge area, which was previously noted to be in need of replacement as it was stained in some areas, has been replaced. A border noted to be hanging off the wall in the large lounge has been redecorated. The staff room’s carpet that was in need of refurbishment has also been replaced. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 18 The top floor accommodation is currently serving as an office for the registered manager. At the last inspection there were plans to make this into a second lounge for residents. This has now been done and needs some finishing touches to make it homely and welcoming but is being used by the residents now. The home was generally clean and tidy and external contractors were dealing with an odour that had occurred within the home’s lift area and upper floor, on the day of inspection. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The procedures for the recruitment and training of staff did not evidence sufficiently safeguards in place to offer protection to people living in the home. The home has an effective and competent staff team. EVIDENCE: The home currently has a shortage of trained staff and is in the process of recruiting. The staffing levels within the home are: Morning, one trained staff and six carers; afternoon, one trained staff and three carers; night, one trained staff and two carers. The assistant manager stated that the home is still using agency staff and that the registered manager and herself are extra staff on duty. One of the staff comment cards received by the Commission expressed concerned that there was not enough recruitment taking place. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 20 During the course of the inspection staff records were to be examined. However, the files containing staff records did not contain any recruitment or induction information. Family Mosaic did have an agreement with the Commission stating that a pro forma could be completed and kept on the staff file as proof of the corporate recruitment process. There were no pro-forma’s available and no other evidence to demonstrate the robustness of their recruitment process. This was the case at the last inspection and the home and proprietors are reminded that recruitment records must be available at all times within the home, as all key inspections are now unannounced and could be required at any time. The homes AQAA concurs that ‘We need more staff trained to NVQ standard, there needs to be more access to mandatory training, staff personnel records need to be accessible during inspection to provide evidence of strict recruitment procedures.’ The registered manager was on leave at the time of the inspection and it was not possible to access training files for the staff team therefore it was not possible to ascertain fully the homes approach to training, NVQ levels or if updates were required. During feedback it was requested that the homes training matrix be forwarded to the Commission, at the time of writing this report, the training information has now been received. It showed additional external training courses are undertaken such as gastrostomy care, ear care and postural positioning in multiple sclerosis. Certification for these courses was not available on the day of inspection and the homes AQAA states ‘Staff need to be more proactive in keeping their training up to date and recording it in their file.’ Although mandatory training and review sheets are now in place not all were completed fully. The inspector was informed that a training officer has now been appointed for the company. Staff members were observed interacting with the residents in a sensitive and respectful manner. Staff members spoken with stated that they had received training specific to their role i.e., manual handling training, administration of medication training and POVA training. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence of leadership, guidance and direction to staff and the management team has in place overall, practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager at the Coach House is a registered nurse, an NVQ assessor and a manual-handling trainer. The assistant manager stated that the registered manager has completed the registered managers award now. The CSCI is aware that the home is to be overseen by the deputy manager who is an enrolled nurse and the proprietor is reminded that supportive 24 Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 22 hour registered nurse cover must be in place until the current registered manager returns from leave. All of the staff members spoken with at this and the last inspection held the registered manager in high regard, stating that she is approachable and has a ‘hands on’ approach to the home. Staff and residents meetings are held on a regular basis and are minuted. Residents meetings address such areas as what activities they would like to undertake, menus, shopping, complaints and compliments and any other business. There was no evidence available during the inspection to demonstrate that a formal system for monitoring and reviewing the quality of care within the home had been put in place. This was a requirement at the last two inspections. In house audits do include finance and pressure ulcer incidence, gastrostomy and medication. Various safety certificates were examined during the inspection and these were seen to be in date. A new fire system was installed within the home in November 2006. Records of fire alarm tests were examined and the last fire drill was held on 24/10/07. Fire drills have previously been erratic and best practice denotes that they take place at least quarterly for all staff. Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement To ensure that there is a policy and staff adhere to the procedures for the receipt of recording, storage, handling administration and disposal of medicines, within a risk management framework. This refers to the issues raised in the body of the report, and discussed at the site visit relating to medication recording errors. 2. YA22 22 sch 4 To ensure that they establish a complaints procedure and make this available to residents and their representatives and that any complaint made is fully investigated and inform the person who made the complaint of any action taken and outcome within 28 days. This refers to the issues raised in the body of the report, and discussed at the site visit relating to a lack of formal records regarding complaints. 31/03/08 Timescale for action 31/03/08 Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 25 3. YA34 17(3)(b) & Sch4 19(5)(d)& Sch2 To ensure that all records referred to in Sch 4 are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The registered person(s) must ensure that full and satisfactory information as specified in Sch 2 is available in respect of each person working at the care home. This refers to the issues raised in the body of the report, and discussed at the site visit relating to staff recruitment records not being available for inspection. 31/03/08 4. YA35 18(1)(a) and (c)(i) To ensure that at all times there are suitably qualified persons working at the care home and that all persons employed by the care home receive training appropriate to the work they are to perform. This refers to the issues raised in the body of the report, and discussed at the site visit relating to staff training records not being available for inspection and consequently a lack of evidence regarding the training that staff members have undertaken. 31/03/08 5. YA39 24 To establish and maintain a system for monitoring and reviewing the quality of care and nursing provided by the home. This refers to the issues raised in the body of the report, and 31/03/08 Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 26 discussed at the site visit relating to there being no evidence of quality assurance systems during the inspection. 6. YA42 23(4)(a)(b) To ensure that adequate & (e) precautions are taken against the risk of fire. This refers to the issues raised in the body of the report, and discussed at the site visit relating to regular fire drills being undertaken. 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coach House DS0000015529.V349781.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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