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Inspection on 12/01/06 for Coach House Nursing Home

Also see our care home review for Coach House Nursing Home for more information

This inspection was carried out on 12th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents were most complimentary about the staff, and the facilities available to them at the home. Food provided, according to the residents, is excellent with a good level of choice available. The home follows an appropriate recruitment procedure for staff. The home is maintained to a high standard providing a pleasant environment for the resident`s living at the home.

What has improved since the last inspection?

The residents care records have been maintained since the last inspection. Staff training and supervision records have improved.

What the care home could do better:

The home could further review suitable activities for the residents`

CARE HOMES FOR OLDER PEOPLE Coach House Nursing Home Broome Clent Worcestershire DY9 OHB Lead Inspector Chris Potter Unannounced Inspection 12th January 2006 10:00 X10015.doc Version 1.40 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 Nursing Home DS0000004104.V273664.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 Older People. 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 Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Coach House Nursing Home Address Broome Clent Worcestershire DY9 OHB 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) 01562 700417 01562 700417 Ms Tania Mary Hilda Bradley Mrs Jermaine Kathleen Emily Lane, Mr Ernest Michael Lane Mrs Jermaine Kathleen Emily Lane Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17), Terminally ill (4) Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/08/05 Brief Description of the Service: The Coach House is registered to provide nursing care for 17 elderly residents. The home is a grade two-listed building and is located in the grounds of Broome House residential home. The home is privately owned by Mr and Mrs Lane. Mrs Lane is also a registered nurse with many years experience working in the health care sector and care of the elderly. The manager is Miss T Bradley, who is also a registered nurse with many years experience working in the health care sector and care of the elderly. The home has been tastefully modernised in the Georgian style providing a pleasant environment for the residents. Accommodation for the residents is available in both single and double rooms. Other areas of the home used by the residents include lounges and dining area. The home stands in well maintained grounds providing a picturesque view. When the weather permits, furniture is provided for the residents to sit outside. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of half a day and was undertaken by two regulation inspectors from the Worcester office of the Commission for Social Care Inspection (CSCI). The inspection lasted a total of 4 hours inspectors’ time. A part tour of the premises took place, residents’ care documentation, and medication, health and safety records were reviewed. What the service does well: What has improved since the last inspection? The residents care records have been maintained since the last inspection. Staff training and supervision records have improved. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 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. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 The home provides prospective residents and relatives with appropriate information and advice to assist them in making their choice about the home. The manager assesses all residents prior to admission to ensure the home can meet the assessed needs of the resident. EVIDENCE: The statement of terms and conditions given to people living at the home contains appropriate information to meet the standard. Care files inspected for people living at the home contained a signed copy of the terms and conditions. All prospective residents are assessed prior to being admitted to the home. The manager usually completes a care needs assessment to ensure the home is able to meet the residents assessed needs. The pre-admission assessment then forms the basis of the residents care documentation. Care records reviewed had the resident’s pre- admission assessment included. The manager Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 9 demonstrated a good knowledge and understanding of the resident’s care needs. Residents and relatives spoken with during the inspection stated they were pleased with the home, and how well their relatives care needs were being met. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 The residents care documentation reflected the residents care needs. EVIDENCE: Three residents care records were reviewed at the time of the inspection. The care documentation showed that progress has been made to ensure that aspects of health, personal and social care needs are identified and planned for. Plans were detailed, up to date and had been regularly reviewed. The home has implemented a system to review the resident’s care documentation with the resident and their next of kin. The comments were meaningful and assisted the staff to ensure they are meeting the resident’s needs. The management of medication was well organised, and audits confirmed that the amounts were accurate. It is recommended that the home develop a protocol for as required sedatives and analgesics. All creams must be named Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 11 and dated on opening and discarded after 28 days. A couple of creams were observed in use with no date of opening. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 The meals provided offer choice and specialist diets are catered for. Social activities are limited only meeting some resident’s needs. EVIDENCE: The homes routines are individualised to the residents needs and a record is available within the residents’ care documentation. Activities are limited in the Coach house. The manager confirmed that a couple of residents had expressed an interest for more activities and the manager is pursuing this. Residents were spoken to and everyone who commented on the food said how good it was and that they welcomed the daily choices offered. The homes feedback forms also acknowledged the choice and quality of the food provided. Catering staff have a detailed knowledge and understanding of individual residents’ dietary preferences and requirements. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The homes complaints policy is provided to residents on admission to the home. A vulnerable adults procedure is available to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The complaints records were examined during the visit. Since the last inspection neither the home nor CSCI have received any complaint about the service the home provides. The records demonstrated that the home had followed their complaints policy, and the outcome was recorded. A copy of the complaints procedure had been given to all residents, and was available for the relatives and visitors. A procedure for responding to allegations of abuse is available, and the homes manager was aware of the Protection of Vulnerable Adults register, and the procedures necessary to adopt in the instance when reporting is necessary. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24 and 26 The home continues to ensure that a high environmental standard is maintained, creating a comfortable and safe environment for those living there and visiting. EVIDENCE: The home is on one level, and provides lounges, and dining area for the residents to use. The home stands in spacious well maintained grounds providing a pleasant outlook and area for the residents to use when the weather permits. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 15 Each bedroom seen had been furnished with residents’ personal possessions, thereby generating ownership and a sense of autonomy for individuals. The standard of the environment within the home is good, providing residents with an attractive and homely place to live. Residents confirmed that they appreciated the physical environment. All areas of the home were clean and tidy; no odours were evident in any part of the home. Hot water temperatures have been risk assessed and had been regulated to prevent people being accidentally scalded when they have a bath. Water temperatures checked at the time of the inspection indicated that the thermostatic control valves were in need of being serviced, the water temperature was in excess of 44°C. This issue remains outstanding from the last visit; the home was issued with an immed9iate requirement notice to address this matter urgently. The home employs a “handyman” who undertakes maintenance, gardening and decorative work. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the people who were resident in the home at the time of inspection. The manager confirmed that maintaining staffing levels due to recruitment difficulties. The home maintains cover for the home without using Agency staff. Staff files evidenced that the home was following their recruitment policy. Records for staff training was available and showed that staff had completed their mandatory training updates. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36 and 38 There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager is appropriately qualified and experienced to manage the home. The residents and staff related easily to the manager, and she demonstrated a good knowledge and understanding about the residents and their care needs. The manager and senior staff continues to maintain staff supervision and a record is maintained of the meeting. Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 18 All appropriate maintenance records and certificates were available and up to date at the time of the inspection. Coach House Nursing Home DS0000004104.V273664.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X 3 3 2 4 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 X X X 3 X 3 Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 20 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 OP25 Regulation 13 Requirement Ensure the thermostatic valves on the hot water outlets are serviced to ensure water is delivered at a safe temperature i.e. 37 - 44 degrees Celsius. Remains outstanding from the last inspection Timescale for action 12/01/06 2 OP9 15 All creams should be named and dated on opening and discarded after 28 days to reduce the risk of cross infection. 12/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The home should develop a protocol for as required sedatives and analgesics Coach House Nursing Home DS0000004104.V273664.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Nursing Home DS0000004104.V273664.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. 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