Inspection on 28/02/06 for Coach House

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 1 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 18/12/07

Coach House 09/01/07

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 Mr Ron Reeves Unannounced Inspection 28th February 2006 10:00 Coach House DS0000015529.V285626.R01.S.doc Version 5.1 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.V285626.R01.S.doc Version 5.1 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.V285626.R01.S.doc Version 5.1 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) Mosaic Essex Mrs Jane Elizabeth Richards Care Home 13 Category(ies) of Physical disability (13) registration, with number of places Coach House DS0000015529.V285626.R01.S.doc Version 5.1 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 3rd January 2006 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 home was originally registered to provide care for fourteen service users. This number is to be reduced to thirteen, by the home since registration. 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. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place during the day of the 28th February 2006 and lasted 5 ½ hours. The inspection process included a tour of the building, discussions with the manager, inspection of a sample of Polices, procedures and records. Time was taken to speak to two residents, visiting relative and four members of staff. What the service does well: What has improved since the last inspection? 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. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 6 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.V285626.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The admission process is well managed. Appropriate written and verbal information is provided to prospective residents and their families enabling informed choices. Individual needs are being met by the home. EVIDENCE: The home has an appropriate Statement of Purpose and Service Users Guide. Care plans seen contained comprehensive assessments, by the home and from various hospital consultants. Due to the complex needs of the residents unplanned admissions are not accepted. Prospective residents are offered the opportunity to visit the home before admission, however due to their disabilities pre-admission visits are normally carried out by relatives. The manager informed that arising from the last inspection the proprietors are reviewing the home’s contract with the residents. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-9 Resident’s needs are being met by the home. EVIDENCE: Care plans seen were to a high standard and covered all residents’ needs together with appropriate risk assessments. They contained clear and comprehensive details of action to be taken by staff to meet the resident’s needs. Residents limited abilities restrict their involvement in the care planning process and in the day to day running of the home, however care plans evidenced involved of relatives. From observations throughout the day and discussions with staff, a visiting relative and residents it was clear residents needs were being met. The manager informed that she is in the process of introducing Person Centred Planning which with further enhance greater involvement of resident and their families. Staff spoken with demonstrated a sound knowledge of the residents needs. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11- 17 Social activities are generally well managed. The home continues to provide appropriate activities both inside and outside the home. Residents nutritional needs were being met by the home. EVIDENCE: Due to the complex needs of the residents, no one is able to gain employment or attend education facilities. The home has a full-time enthusiastic therapy assistant who undertakes daily exercises with the residents and organises inhouse activities and arrange social and leisure activities outside the home. The Manager said there are plans to recruit a second therapy assistant in the home’s next financial year. The home has it’s own transport which enables residents to access the full range of local community activities including visits to local pubs, restaurants, cinemas and the Lakeside and Bluewater shopping centres. The home operates an open visiting policy and actively encourages and welcomes visitors. All residents do receive regular visitors. Three residents go home every weekend. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 10 Detailed nutritional assessments are carried out on admission. Menus seen were wide and varied and appeared nourishing. Only half of the residents are able to eat normally with assistance from staff. Nutritional records are now being monitored appropriately. The kitchen is well equipped and was clean and tidy and well maintained. Dry foods are now being stored appropriately and prepared food stored in the refrigerators were labelled and dated. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18-20 Resident’s personal and health care needs are being well managed by the home. EVIDENCE: Care plans evidenced that resident’s personal care needs were being met by the home. Personal care is provided in the privacy of residents’ bedrooms or in the home’s shower/bathroom. Where possible residents are encouraged to choose and shop for their own clothes. The home enables residents’ to access all the local health facilities and specialist services. Staff monitor residents medical conditions and arrange for medical intervention when necessary. Medication administration was seen to be appropriate. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 The home has appropriate policies, procedures and staff training in place for responding to residents’ concerns and protecting them from abuse. EVIDENCE: Examination of the home’s complaints recorded evidenced that ten complaints had been received by the home since last inspection. These were from residents complaining of noise generated by other residents. Records evidenced that the home has taken action to remedy the situation. A further complaint regarding care of a resident is being investigated by the proprietors. The home has appropriate complaints, Adult Protection and Whistle Blowing policies and a copy of the local Authority’s Protection of Vulnerable Adults procedure. All staff apart from those recently appointed have attended Protection of Vulnerable Adults training. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 The home provides a good standard of accommodation that meets residents’ needs. EVIDENCE: The home continues to provide a good standard of accommodation for the residents. The premises are large and airy which enable residents and their wheelchairs to move easily throughout. Communal facilities are on ground floor level and consist of a large lounge/diner and a second lounge. The home has a large shower room on the ground floor and an adapted bathroom on the first floor. The Manager explained that she hopes to change the first floor bathroom into a shower room that can access the home’s shower trolleys. The Manager informed that the top floor accommodation is no longer used by residents and the redesign of the accommodation has been put on hold. The home was found to be clean, tidy, odour free and generally well maintained. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 14 The Manager is in the process of protecting the damaged doors and door frames identified at the previous inspections. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32-36 The home benefits from an enthusiastic well trained staff team who are well supported and supervised. EVIDENCE: The Manager informed that the home is now fully staffed and agency staff are only used in emergency situations. Staffing levels continue to be adequate to meet residents’ needs. Staff spoken with said they now have a good staff team who support each other and felt that their workload was not too heavy and allowed them time to sit and talk with the residents. Staff were satisfied with the range of training available to them including access to NVQ 2 & 3 training. Staff receive regular supervision. Supervision is cascaded down from the Manager to the qualified nursing staff who supervise support workers. Staff were observed throughout the day to care for the residents in a sensitive and respectful manner. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 16 The home’s recruitment process is managed by the proprietor’s human resources section. Copies have been obtained by the Manager which confirmed the recruitment to the proprietor’s homes is well managed. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 The home benefits from an experienced competent manager who provides good guidance and direction for staff. EVIDENCE: The Manager is a Registered Nurse, NVQ Assessor and Manual Handling Trainer. She has managed the home since September 2003 and in the process of achieving the Registered Managers Award at NVQ Level 4. She holds regular qualified staff, general staff and residents’ meetings. Staff spoke highly of the manager and felt she was open, easily accessible and very supportive. The home has the Proprietor’s comprehensive policies and procedures. The records examined during this inspection were generally well maintained and securely stored. The Manager informed she will be sending quality questionnaires to residents and their families in the near future. Discussion took place regarding the Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 18 implementation of a full quality assurance system for the home and that the Manager should liaise with the Proprietors regarding a corporate system. A sample of safety certificates for services and equipment were examined and seen to comply with the requirements. Regular checks are maintained on the home’s fire precaution systems. Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 19 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 3 3 3 3 Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO 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 YA39 Regulation 24 Requirement The registered person shall establish and maintain a system for monitoring and reviewing the quality of care and nursing provided by the home. Timescale for action 31/03/06 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.V285626.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Coach House DS0000015529.V285626.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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