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Inspection on 14/05/09 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 14th May 2009.

CQC 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 CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The atmosphere of the home is friendly, warm and welcoming. People using the service appear relaxed and were seen interacting well with the staff. Choices of meals are offered and food is well presented. The home can cater for special diets, including individual preferences, dietary and cultural needs which means people should receive food that they like. The accommodation for people is on the ground level which assists people with mobility problems to access all areas of the home. People are encouraged to personalise their rooms with items that are familiar to them so that they live in an environment which they prefer. There is a committed staff team, some of whom have worked at the home for many years, so people have staff they know looking after them. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 People told us: "it is lovely here really home from home --- loves it here" "it is more like a hotel than a care home" "lovely home cooked meals" "staff always have the time of day for you" "we are always greeted with a tray of tea when we visit, no matter what time of day, staff are really attentive"

What has improved since the last inspection?

There is an ongoing maintenance programme in respect of decorating and purchasing new furniture and equipment. This ensures that there is a homely and comfortable environment for people to live in. The kitchen has been upgraded and catering is now prepared and cooked in the home, so that people have their choice of food throughout the day.

What the care home could do better:

Information about the home should be made available to people so that they can make an informed decision about whether they may like to live at the home. Care plans must be written for all needs and reflect current care needs of individual people living at the home. The medicine management must improve to ensure that all medication is administered as prescribed at all times as the doctor requires. The recruitment procedure must be robust to ensure that people are safeguarded from harm. A system for following up injuries sustained to people where the cause is not known should be implemented to ensure that people are safeguarded from harm.

Key inspection report CARE HOMES FOR OLDER PEOPLE Coach House Nursing Home Broome Clent Worcestershire DY9 0HB Lead Inspector Chris Potter Key Unannounced Inspection 14th May 2009 09:30 DS0000004104.V375345.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coach House Nursing Home Address Broome Clent Worcestershire DY9 0HB 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 Tania Mary Hilda Bradley Mrs Jermaine Kathleen Emily Lane, Mr Ernest Michael Lane Mrs Jermaine Kathleen Emily Lane Miss Tania Mary Bradley 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.V375345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2007 Brief Description of the Service: The Coach House is a small homely property situated in a rural area in the village of Broome. The premises have been converted from a grade two listed building and registered to provide nursing care for a maximum of 17 older people. The home has been tastefully modernised in the Georgian style providing a pleasant environment for people. People are accommodated in single or shared bedrooms. All accommodation and communal areas are on ground level which assists people with mobility problems to access all areas of the home. There are two lounges, a dining area, and communal bathroom and toilet facilities. The home stands in picturesque grounds which are accessible for people to use when the weather permits. Adequate car parking is available to the side of the home via an electronic gate. The home is owned by Mr and Mrs Lane. The manager is Miss T Bradley, who is a registered nurse with many years experience working in the health care sector and care of the older people. Information regarding the home can be obtained from the Statement of Purpose and Service Users Guide, which are available in the home. Information about the fees are not included in the Service User Guide, for up to date information about the fees please contact the home direct as the fees are based on individual needs and assessments. Additional charges are made for hairdressing, daily newspapers and chiropody. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. That means the people who use the service experience adequate outcomes. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for the people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. We visited the service during the day on the 14th May 2009, the last Key Inspection was the 15th May 2007. We spent time observing daily life, and we met with people and relatives who use the service. We spoke to staff and the manager who was present throughout the inspection. We looked at care files and records completed by the service which must be kept by the home to show that it is being run properly. Before we visited the service we looked at the information we had about the service since the last inspection. This included an annual service review, notifications of incidents sent to us by the service, surveys sent to us by people using the service and the Annual Quality Assessment. The Annual Quality Assessment is completed by the manager and should tell us how well the home think they are performing and should give us some information about the home, staff and people who live there, improvements and plans for improvement which we would take into consideration. What the service does well: The atmosphere of the home is friendly, warm and welcoming. People using the service appear relaxed and were seen interacting well with the staff. Choices of meals are offered and food is well presented. The home can cater for special diets, including individual preferences, dietary and cultural needs which means people should receive food that they like. The accommodation for people is on the ground level which assists people with mobility problems to access all areas of the home. People are encouraged to personalise their rooms with items that are familiar to them so that they live in an environment which they prefer. There is a committed staff team, some of whom have worked at the home for many years, so people have staff they know looking after them. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 6 People told us: it is lovely here really home from home --- loves it here it is more like a hotel than a care home lovely home cooked meals staff always have the time of day for you we are always greeted with a tray of tea when we visit, no matter what time of day, staff are really attentive What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 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.V375345.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is sufficient information available for people to decide whether The Coach House is right for them. There are opportunities for people to visit the home before making up their minds. The home carries out assessments of peoples needs before they move in, so that staff can provide the care that is needed. EVIDENCE: The certificate of registration was clearly displayed in the reception area of the home however we have not updated the homes certificate to reflect changes in registration. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 9 There was no statement of purpose or service user guide displayed in the home. It was recommended that the documents and a copy of our most recent inspection report are made available in the home for people to refer to. Relatives of a person recently admitted to the home informed us that they had received sufficient information about the home prior to accepting a place there. We looked at the pre admission assessments for three people who had recently moved into the home. The assessments provided sufficient information for the service to decide whether they would be able to meet the persons needs on admission to the home. Relatives confirmed that the manager had assessed their relative prior to them being admitted to the home. For the three assessments that we reviewed the manager had not signed to confirm that they had completed the assessment. To ensure all people are accountable when auditing a persons care the assessment should be signed. We were told by relatives that they had signed a contract and been given a copy of the homes terms and conditions when accepting a place. People told us: We chose the home because being small it is home from home it is just perfect for -------. We have moved some of --- furniture in so it looks more like --- own room. It is more like a hotel than a care home. The Annual Quality Assurance Assessment accurately reflected how the service was meeting these standards. The response in the 2008 Annual Quality Assurance Assessment for the homes planned improvements for the next 12 months was the same as the response in 2009 Annual Quality Assurance Assessment. To continue to improve our services we will continue to encourage all comments, suggestions, complaints and compliments from both service users and their next of kin. Include comments from the multi disciplinary team who are involved with our home. The home is not registered for intermediate care; therefore the home was not assessed against standard six. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning arrangements do not ensure that staff have the information they need to meet people’s health and personal care needs consistently. The management of medication does not ensure that people receive their medication as prescribed. EVIDENCE: We looked in detail at the experiences of three people using the service. This included looking at their care files, meeting them, speaking to relatives if possible. There were inconsistencies with the quality of information in the care files. The manager contributed this to being more involved with the sister Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 11 service and not auditing the care plans as frequently as they had been audited previously. Two of the care files reviewed provided detailed information about some of the individuals health care needs. The third care file was incomplete and risk assessments had not been undertaken. This individual was admitted to the home on the 12/05/09 and only the moving and handling assessment dated May 13th 2009 had been started but not completed. The Waterlow assessment for skin damage, the fall risk assessment, and nutritional risk assessment had not been completed. No social history had been developed which helps staff to understand the person better and about their likes and dislikes with food etc. On visiting the person equipment was in place for the prevention of skin damage, but the documentation had not been completed. No care plan had been developed for the individuals health or social care needs. Relatives stated that they were pleased with the progress the person had made following transferring into the home. The second file showed that the person was admitted to the home on the 19/02/09 and the manual handling assessment, fall risk assessment and skin damage assessment had not been completed until the 25/02/09. This could potentially lead to the individuals care needs not being fully met. This person told us that they had settled well and were pleased with the care being provided by the staff. The third file recorded that the individual had developed skin damage however a wound care plan providing details for staff about dressings and the frequency of changing the dressing had not been developed. No record was seen in the notes to show if specialist advice had been requested. This person was observed moving around the home contentedly. The care records do not necessarily affect the outcome of care provided for the individual, and the comments from residents and relatives were positive about the care provision. However, the care records should accurately reflect the care provision. Not doing so may result in a lack of consistent care provision for the person. People seen were appropriately dressed for the temperature of the home, and in keeping with their gender and personal preferences. We observed staff respecting peoples privacy and dignity - for example, knocking on doors before entering private rooms, and speaking to them courteously. We were told by people using the service and relatives that all staff were respectful and courteous when addressing them. We looked at how the home managed peoples medication and we checked the medication for three people. The majority of medication records seen were well documented either with a signature for administration or a code to explain Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 12 why the medication was not administered. It was therefore disappointing to see three of the medication charts were not completed correctly. In one persons chart eye drops prescribed to be administered twice a day had gaps on the 14/04/09 and no code entered as to why the medication had not been given. In another chart several medications had gaps and no code entered during the period 25/04/09 to 25/05/09. On another medication chart the dosage of prescribed medication had been hand changed on the printed medication record which had not been countersigned by two nurses for accuracy purposes. This was pointed out to the manager at the inspection given that peoples health may be compromised if they are not receiving their prescribed medication correctly. The Annual Quality Assurance Assessment received form the home for this inspection stated: We have continued to provide more staff training in relation to elderly care and related subjects We continue to have closer liaison with outside services i.e. district nurses, incontinence advisors for help and advice. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provision of social and recreational activities for people living at the home meets all the peoples needs and expectations. People have nutritious meals and snacks, at a time and place to suit them. EVIDENCE: We were told by people living at the home, relatives and staff that the quality and choice of food was good. Since the last key inspection in 2007 the kitchen in the Coach house has been upgraded and checked by Environmental Health Officers to ensure that it is suitable to use for preparing and cooking food for the people who live there. The chef covering on the day of the inspection confirmed that the menus on display are reviewed, taking into account the peoples likes and dislikes. We looked at the menus which are displayed and rotated on a weekly basis. Alternatives to the daily choices are available for people to choose from. The Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 14 home caters for specialist diets including vegetarian option. The chef showed us the records which they keep to show the meals served and if there have been any variations to the planned menu of the day. Mealtimes and meal options are flexible and varied. For example, breakfast is served between 08:00am and 09:30am, and provides choices ranging from a full cooked breakfast, a bacon sandwich, cereals and toast. We observed the lunch being served on the day of the inspection which was Irish stew and creamed rice pudding, and this appeared appetising. Staff were assisting individuals appropriately where needed. Staff were sitting next to the person and not rushing them with their food. Comments received about the food were positive and included: excellent, good home cooked food better than a hotel food is very nice The home does not employ dedicated staff responsible for social activities. However a carer informed us that they were being given the responsibility of planning and arranging more suitable activities for the people living in the home. The manager told us that at the moment the people living in the home are high dependency and were not enthusiastic about participating in activities. Relatives told us that they felt that the activities were appropriate for their relative, who would not be able to participate actively due to their health needs. During the day we saw people in the lounges with the television and radio on, some people were in their bedrooms watching television, or enjoying visits from relatives. We were told that activities currently available for people living in the home included activities to music once a week, and a guitarist plays music regularly. The majority of people enjoy going out in the picturesque gardens when the weather permits which the manager told us that, from a day out at the Botanical gardens, people stated that the gardens were better at the home. We saw visitors coming and going throughout the day and we were told that the home make them welcome at whatever time they visit. The Annual Quality Assurance Assessment received from the home for 2009 stated in the section entitled “how we have improved in the last 12 months”: Further development of more specialist diets and choices and introduction of different recipes. The Annual Quality Assurance Assessment completed by the service recorded under improvements for the next 12 months that they would further develop dementia related activities, and develop a bigger activities program. The service appears not to have progressed with this planned improvement from their Annual Service Review in 2008. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to the home’s complaints procedure, and are confident that their views will be listened to and acted upon. EVIDENCE: Since the last Key inspection in 2007 and the Annual Service Review in 2008 the home had received no complaints. We were informed by a registered nurse whilst reviewing a person that the care records were inadequate. We were told that they were satisfied with how the home addressed the complaint. We were told by people using the service and relatives that they were aware of the complaints procedure and who to talk to. One person who had recently moved into the home told us that the complaints procedure was explained to them on admission to the home. Comments included: I am aware of how to make a complaint, but have never needed to” Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 16 We were told by staff that they had received “safeguarding” training and were aware of the home’s whistle blowing policy. Staff also confirmed that they would have no hesitation in reporting any concerns to the manager. The Annual Quality Assurance Assessment completed from the service informed us that they had received no complaints in the last 12 month period. Their plans for the next 12 months included to continue to promote staff awareness and updating of existing policies and procedures if new legislation is produced Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with a comfortable small homely environment in which to live. EVIDENCE: The home has been adapted to meet the needs of the people who use the service without using its character. There are homely touches, such as ornaments, pictures and plants. There are two sitting rooms with comfortable armchairs and a small dining area. Accommodation for people using the service is available in single and shared bedrooms. The manager told us that currently rooms were being used for one person to respect peoples preferences. Since Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 18 the last Key inspection the residential home which was on the same site next to the home closed and has been converted into luxury apartments. To compensate for this the nursing home had upgraded the Kitchen so that they can cook and prepare meals at the home. The Kitchen is clean and the cook completes all the relevant checks. The Kitchen does not have a dishwasher in place all washing up is completed by the staff. We discussed the advantages of having a dishwasher in the home, which includes timesaving for the staff and assist with infection control. Throughout the day of the inspection, it was apparent that people who live at the home regard it as their home, and the informal and friendly atmosphere adds to the sense of homeliness. Comments from professionals and people using the service included: The home is excellent, no odours it is just like home from home The home is surrounded by picturesque well maintained gardens which provide a pleasant outlook and for the people living in the home. All areas of the home were clean and tidy with no unpleasant odours. This is a compliment for the carers who include cleaning and laundry as part of their daily duties. Some staff have food hygiene and infection control training. The AQAA completed by the service told us that that their plans for the next 12 months are to continue with auditing and ongoing decorating and refurbishment as required. Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are trained and in sufficient numbers to provide the care that people need. EVIDENCE: We looked at the home’s duty rotas, which confirmed that, the home is providing sufficient staff proportionate to the number and needs of people living at the home. Daytime staffing levels are typically one nurse and two carers for the 11 people using the service. Relatives told us: there are always plenty of staff they never keep us waiting and are always checking -------, All the staff are wonderful, nothing is too much trouble for them. We were told by staff that there are enough staff working throughout the 24 hour period to meet the needs of the people who live at the home. The manager showed us the training matrix has been completed to assist in ensuring that staff receive appropriate training and refresher courses. The staff Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 20 told us that they receive regular training updates including moving and handling, adult abuse, fire, and infection control. People using the service told us that the staff were appropriately trained to meet their care needs. The records we reviewed confirmed that the home employs more than 50 of care staff with an NVQ qualification level two or above in care. The provision of staff trained to a national level of competency helps to ensure that the home employs competent staff that are able to effectively meet the needs of vulnerable people. We checked three staff files for people who had been employed in the last 12 months. The files showed that proper background checks had been carried out before their employment. The files contained proof of identity for the applicant. One of the files showed a two month gap in their employment history however the reason for this had not been explained. Two references in one file did not have a date to verify when the reference was written. The Annual Quality Assurance Assessment stated that the homes plans for the next 12 months include: To continue with the training program in all aspects of care and life in a nursing home. The introduction of a more structured staff supervision/appraisal program Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have confidence in the management and organisation of the care home. EVIDENCE: There has been no change with the management arrangements since the last key inspection in May 2007. The manager has been at the home for many Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 22 years and has currently been registered with the Commission for this home and Field House, which is The Coach Houses sister home. We were told by people using the service, relatives and staff that the manager is supportive and approachable - making herself available for them at any time. Comments received included; the manager is wonderful and so very kind and she listens to what we say. We looked at the fire records and these showed that the regular checks were being completed, so that in the event of a fire, people are protected by living in a home where smoke detection systems and evacuation procedures are regularly reviewed and tested. Staff keep a written record for all accidental occurrences that occur within the home, so it is easy to audit accidents that have occurred in the home to see whether there are any patterns developing. Some records show that people have developed skin tears and bruising of an unknown origin. This had not been explored by the manager. The homes Annual Quality Assurance Assessment (AQAA) was sent to us when requested. However the homes plans for improvement remain the same as last years. The manager said that priority had been given to improving the sister home, which had hindered developments at The Coach House. Quality assurance questionnaires are completed when new people are admitted to the home, and the questionnaires seen gave positive responses, and included comments such as, facilities and services are very good. However an annual survey to establish the views of people using the service is not completed. Nursing and care staff are supervised informally and, being a small home, all staff practises are observed. We discussed with the manager the need to develop a formal, documented supervision system to prove that supervision takes place and to formally assess staff training needs. The home has no involvement with peoples personal finances. The responsibility for this remains with the relatives or advocates of people using the service. Coach House Nursing Home DS0000004104.V375345.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 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement To safeguard people from harm, risk assessments and service user plans must be drawn up when new people are admitted to the service. Timescale for action 01/07/09 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 OP12 Good Practice Recommendations It is recommended that the home review the activities for their more dependant residents based on the individuals needs. To further protect the residents’ health and welfare it is recommended that the home review their risk assessments for a more updated version. To protect peoples health and welfare, medication records should be accurately completed when medication is given to people. When prescribed medication is not administered, a reason for non-administration should be recorded on the medication chart. DS0000004104.V375345.R01.S.doc Version 5.2 Page 25 2. OP8 3. OP9 Coach House Nursing Home Coach House Nursing Home DS0000004104.V375345.R01.S.doc Version 5.2 Page 26 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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