Inspection on 09/01/07 for Coach House

This inspection was carried out on 9th January 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 18/12/07

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Coach House 10 Woodwards Heights Off Ward Avenue Grays Essex RM17 5RR Lead Inspector Sarah Buckle Key Inspection 11:45 9 January 2007 th Coach House DS0000015529.V310794.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.V310794.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 Older People and 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.V310794.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) Mosaic Essex Mrs Jane Elizabeth Richards Care Home 13 Category(ies) of Physical disability (13) registration, with number of places Coach House DS0000015529.V310794.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 28th February 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. Information regarding the level of fees within this home has not yet been provided to the Commission. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection. The inspection included a site visit to the premises on the 9th January 2007, which lasted 6 hours. During the site visit a tour of the building was undertaken, residents and staff were observed within the home environment and pertinent records, documents and policies were examined. The assistant manager and one staff member were spoken with. A number of surveys were sent to relatives/representatives and to health care professionals and these were completed and returned to the Commission. Information contained within these surveys will be reflected within the report. What the service does well: What has improved since the last inspection? What they could do better: There are some areas within the home that would benefit from refurbishment. The controlled drugs cupboard does not meet with the requirements specified in the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. Information regarding staff recruitment, which is required to be available for the purposes of inspection, was not in evidence. It was not possible to ascertain the level of training undertaken by the staff team within the Coach House as a training matrix was not available. A number of relatives commented that the staffing level within the home is not adequate. There was one requirement made at the last inspection in February 2006 and this was regarding quality assurance. During the inspection site visit no Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 6 evidence was available to demonstrate that a comprehensive system has been put in place. The recording of tests relating to health and safety were not consistently regular. 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.V310794.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. 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 process at the Coach House is well managed. EVIDENCE: The Statement of Purpose and Service User Guide for the Coach House has been revised and these documents have been forwarded to the Commission. The care plan regarding the newest admitted resident to the home was 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. It clearly indicated what the identified needs of the prospective resident were and how the home would meet these. Prior to admittance the Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 9 resident was able to visit the home for a day and for an overnight stay. Alongside the detailed assessment there was also two sides of A4 information relating to the residents care needs that had been completed by a relative. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of individual residents are adequately met by the home. EVIDENCE: Two care plans were sampled during the course of this inspection. At the last two inspections, care plans were deemed to be of a good standard. Person centred care planning has now 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 Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 11 health/family involvement and spiritual care. Appropriate risk assessments were also completed. For example, one risk assessment in relation to the possibility of a resident having an epileptic seizure during showering stated: “Ensure that at least two members of nursing staff are present at all times during showering, plus prior to and after showering whilst resident is on shower trolley. Monitor for symptoms of seizure onset e.g. restlessness, pyrexia, agitation, twitching or involuntary spasm. Return to bed, omit shower if presented with any of the above”. 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 nutrition screening. One care plan did not have a completed weight chart and the second had a pain-monitoring tool that had not been completed. 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. Both of the staff members spoken with had a clear knowledge of the individual needs of residents. Relative comments cards received by the Commission reiterated this good level of care and support with comments such as: “(The resident) is very content (at Coach House). I check with him periodically whether he would like to change homes if possible, but he definitely says ‘No’. As a visitor, from what I see, I would give (the Coach House) 10 out of 10!” and “Warm and welcoming home, cleanliness very good, (the resident) loved the food, overall very good value for money”. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. 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. Appropriate activities are, in the main part, provided for residents. Residents receive a healthy balanced diet. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 13 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. However, there is a full-time therapy assistant within the home who undertakes therapy-based 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 the London Eye and to Upton Park. The home has a mini bus and a new lease vehicle has been arranged from April 2007. A second therapy assistant was due to be recruited at the home, however, this has not happened. One relative comment card did state that they did not believe there were enough activities to keep the residents stimulated and that there was not enough one to one time with residents which could lead to them feeling isolated. The home encourages visitors and has an open visiting policy. Some residents go home for the weekends. The kitchen area within the home was seen to be 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.V310794.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs are well managed by the home. Medication is in the main part adequate; however, storage and systems regarding controlled drugs are not satisfactory. 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 one care plan. The second care plan seen did not have any information in this area, but the resident was newly admitted. There was evidence to demonstrate that medical intervention was sought on the residents behalf whenever necessary i.e. a resident was noticed to have ‘thick offensive secretions from the trachea’ on 08/01/07 and Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 15 the records show that the GP was called and prescribed antibiotics on the same day. One health care professional commented that oral hygiene within the home could be improved; another stated that they were satisfied with the overall care provided to residents within the home. 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 the medication trolley was currently out of use as the wheel had fallen off. She stated that a new one had been ordered and was due to be delivered within the week. However, she did state that the trolley had been out of use for a number of months. The home use the Boots 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 temperature was also recorded and was at 2 degrees Celsius within the required range. The MAR file was well organised and the residents 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 no omissions noted on the MAR file. The assistant manager stated that there were currently no controlled drugs at the home. The CD cupboard was examined. This was made of wood rather than metal and therefore not compliant with the Misuse of Drugs (Safe Custody) Regulation 1973 as amended, which has clear specifications for the safe storage of controlled drugs. There were items other than controlled drugs contained within the controlled drug cupboard. One resident was prescribed Phenobarbital, which is a Schedule 3 controlled drug. This does not have to be stored in a CD cupboard or recorded in a CD register, however, it is good practice to do so. At Coach House, these drugs are stored in the CD cupboard but not recorded in the CD register. Seven controlled drug patches were awaiting disposal. These were dated 02/07/06. There was no record of disposed/ refused medication at the home. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place to act on residents concerns and to protect them from harm or abuse. EVIDENCE: There has been one complaint since the last inspection. A new complaints log has been developed as the previous one was being misused as a log of complaints by residents against other resident’s i.e. regarding issues such as noise. It was not possible to see the information regarding the one complaint since the last inspection 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. A copy of ‘No Secrets’ was seen within the office, as was Essex Vulnerable Adults Protection Committee information. One staff member spoken with was clearly aware of the procedure if abuse was suspected and stated that he had received adult protection training as part of Topps 1 and 2. He stated that he was aware that this needed to be updated. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 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, in the main part, provides a good standard of accommodation. EVIDENCE: 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 Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 18 ground floor, which consist of a lounge/diner, and a lounge area. The carpet in the lounge area was noted to be in need of replacement as it was stained in some areas. A border was also noted to be hanging off of the wall in the large lounge. The staff room is located in a balcony that overlooks the main lounge area. This also had stained and threadbare carpet that was in need of refurbishment. The assistant manager stated that quotes have been undertaken in relation to this and the work is due to start in the near future. The top floor accommodation is currently serving as an office for the registered manager. There are plans to make this into a second lounge for residents. The home was clean, tidy and odour free. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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, 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 staff team are competent, however, it has not been possible to examine training or recruitment records, as these were not available on the day of the site visit to this home. EVIDENCE: The home currently has a shortage of trained staff and is in the process of recruiting new staff. 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. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 20 The assistant manager stated that the home is using agency staff and that the registered manager and herself are extra staff on duty. One staff member spoken with stated that he feels supported in his role and that the staff members all work together as an integrated team. He also stated that he believes that the needs of residents are fully met within the home. Three of the relative comment cards received by the Commission were concerned that there were not enough staff on duty to meet the needs of the residents. One relative stated that there are “staff shortages due to staff sickness” and that his relative had not received personal care until 11:45am. Another stated that the home “could do with more staff” and a third comment stated: “I feel sorry for the night staff and think with the number of patients they care for, that an extra nurse is needed”. One health care professional stated that there was not always a senior member of staff to confer with. During the course of the inspection staff records were examined. However, the files containing staff records did not contain any recruitment 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. 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. During feedback it was requested that the homes training matrix be forwarded to the Commission, however at the time of writing this report, the training information has not been received. Staff members were observed interacting with the residents in a sensitive and respectful manner. One staff member spoken with stated that he had received manual handling training, administration of medication training and personal safety training. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident’s living within the Coach House benefit from the support and leadership of an experienced and able manager. Quality assurance within the home is not adequate. Health and safety is in the main part well managed, however, there are some areas that need to be addressed. Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 22 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 encountered some problems with completing the RMA and is due to re-register. All of the staff members spoken with held the registered manager in high regard, stated that they felt supported by her, 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 system for monitoring and reviewing the quality of care within the home had been put in place. This was a requirement at the last inspection. Various safety certificates were examined during the inspection and these were seen to be in date. A new fire system had been installed within the home in approximately November 2006. Records of fire alarm tests were examined and these were erratic between September and January with no tests being recorded for November. The means of escape records were equally erratic. The last recorded fire drill within the home was 29/05/06. Coach House DS0000015529.V310794.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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 X 42 2 43 X 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 Coach House Score 3 3 2 X DS0000015529.V310794.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? 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 The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Timescale for action 01/05/07 2. YA24 23(2)(b) This is in relation to the controlled drugs cupboard within the home not meeting the requirements as specified in the Misuse of Drugs (Safe Custody) Regulation 1973 as amended, which specifies the quality, construction, method of fixing and lock and key and to items other than controlled drugs being stored in the cupboard. It is also in relation to the home not recording medication that is returned/ disposed of. The registered person must 01/05/07 ensure that the premises are kept in a good state of repair both internally and externally. This is in relation to areas of the home that require Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 25 3. YA34 17(3)(b) & Sch4 19(5)(d)& Sch2 refurbishment, including the carpet in the downstairs communal areas which is stained and the carpet in the staff area. The registered person must 01/04/07 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 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 is in relation to staff recruitment records not being available for inspection. The registered person must 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 is in relation to staff training records not being available for inspection and consequently a lack of evidence regarding the training that staff members have undertaken. The registered person shall establish and maintain a system for monitoring and reviewing the quality of care and nursing provided by the home. This is in relation to there being no evidence of quality assurance systems during the inspection. 4. YA35 18(1)(a) and (c)(i) 01/05/07 5. YA39 24 30/04/07 Coach House DS0000015529.V310794.R01.S.doc Version 5.2 Page 26 6. YA42 23(4)(a) (b) & (e) This is a repeat requirement with the previous timescale 31/03/06 not met. The registered person must ensure that adequate precautions are taken against the risk of fire. This is in relation to irregular fire and means of escape checks. 30/04/07 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.V310794.R01.S.doc Version 5.2 Page 27 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.V310794.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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