Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/05/07 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 15th May 2007.

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 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

Being a small home, it provides a very homely environment. The bedrooms are personalised by the resident to their preferred choice. The environment is maintained to a high standard and in good decorative order throughout. There is a pleasant atmosphere in the home and this is contributed from a committed staff team some have worked at the home for many years. The home is committed to training to further enable staff to meet the needs of residents. Comments about the choice and quality of the food were excellent. The home has a robust recruitment procedure in place, which assists in protecting the safety of the residents.

What has improved since the last inspection?

Since the last inspection the home has purchased more suitable chairs for the residents and to assist staff in moving them safely. The home had updated their bed rail risk assessments for all residents who are assessed as needing them.

What the care home could do better:

It was recommended that the home review their risk assessment formats, for a more updated model.

CARE HOMES FOR OLDER PEOPLE Coach House Nursing Home Broome Clent Worcestershire DY9 0HB Lead Inspector Chris Potter Key Unannounced Inspection 10:00 15th May 2007 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.V333355.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. 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.V333355.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 Ms 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.V333355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 all on ground floor level. 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. The fees charged at this home range between £495.00 to £595.00 per week. The fees do not include hairdressing, daily newspapers and chiropody. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes key unannounced inspection for 2007 and took place on the 15th of May 2007. The inspection lasted a total of five hours. On the day of the inspection the home was accommodating 16 residents. During the inspection the manager, deputy manager, care staff; residents and a relative were spoken to. The manager was available to help throughout the inspection and the inspector would like to thank her for her help and assistance throughout the inspection. The purpose of this inspection was to review the outstanding requirements and recommendations from the last inspection and to inspect the key standards. The inspection included a review of records and registers, observation of the care process and a tour of the premises. Five comments were returned from the residents. The residents had completed these with the help of relatives, no issues were raised in the questionnaires and all confirmed that they were satisfied with all aspects of their care and the homes environment. What the service does well: What has improved since the last inspection? Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has purchased more suitable chairs for the residents and to assist staff in moving them safely. The home had updated their bed rail risk assessments for all residents who are assessed as needing them. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coach House Nursing Home DS0000004104.V333355.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.V333355.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 (standard 6 is not applicable) Quality in this outcome area is good. The Statement of Purpose and Service User’s Guide gives sufficient information about the homes facilities and their philosophy of care. The pre-admission assessment provides appropriate information to ensure that the home can meet the needs of the prospective residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has reviewed their Statement of Purpose and Service User’s Guide, no amendments were required. The manager confirmed that a copy of the Service User’s Guide was given to potential Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 9 residents. Residents and relatives who commented confirmed that they had received a copy of the document to assist them with their choice. The care records for three residents recently admitted were reviewed at the time of the inspection. These showed that the pre-admission assessment had been completed prior to their admission. The manager or a registered nurse usually undertakes the pre-admission assessment to ensure that they are able to meet the residents care needs. Residents are provided with a contract of terms and conditions on admission to the home, a signed copy is available within the residents care file. Residents and a relative spoken to during the inspection stated they were very pleased with the home and its facilities. All residents appeared content and the staff were assisting them respectfully. Coach House Nursing Home DS0000004104.V333355.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The care plans reflect the residents care needs, and were being reviewed frequently. The home has the facilities and expertise to meet the needs of the residents. Medication management was well organised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care documentation for three residents was reviewed at the time of the inspection. The care records had sufficient detail to assist nurses and carers to deliver care appropriately. The care record also showed evidence of being regularly reviewed and updated by the nurses. For some residents, their Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 11 relatives have been included with the review of the care plan and a record is maintained of this review. Potential risks have been identified and a risk assessment developed and care plan to minimise the risk have been completed. Since the last inspection the home has updated their bed rails risk assessment for any resident where they are required. It was recommended that the home review and update their risk assessments format to provide a more up to date model. The management of medication was well organised, and audits confirmed that no errors had occurred. All residents who responded confirmed that all staff were most respectful and they were satisfied with the level of care provided at the home. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Visitors are welcomed and there are links with the local community. Limited activities are available though they are not suitable for all residents. The dietary needs of residents are appropriately catered for; residents are encouraged to make choices about what they wish to eat and where they eat it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not employ specific staff to organise social activities. The home provides limited activities for those residents who are able to participate. All care staff assist and encourage residents to maintain their preferred interests. The manager informed the inspector that the residents are very dependant at Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 13 the moment and enjoy listening to music and watching television. When the weather permits residents enjoy being assisted to go outside in the grounds. Relatives are welcome to visit at anytime. A relative spoken to confirmed that the staff were always welcoming. Feedback received about the food from, relatives, residents and staff stated how good it was. The meals are prepared and cooked in the main house and carried to the Coach House on trays. The home is currently planning to have the kitchen in the Coach house upgraded so that meals can be prepared and cooked in the Coach House. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good The home has a clear policy on how to deal with complaints and the staff, residents and relatives are aware of this. The home has a policy in place for protecting vulnerable adults, staff receive training and it is part of their induction training. This judgement has been made using available evidence including a visit to this service. 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 complaints records maintained in the home demonstrate that the home had followed their complaints policy, and the outcome was recorded. A procedure for responding to allegations of abuse is available. Staff have received training and are confident that they would report any concerns with poor practise immediately. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24 and 26 Quality in this outcome area is good. The home continues to ensure that a high environmental standard is maintained, creating a comfortable and homely environment for those living there and visiting the home. The home is clean and free from odours, with good laundry facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides accommodation for all residents on the ground level. It also provides two lounges, and dining area for the residents to use. The accommodation for residents is available in 5 shared and 7 single bedrooms. At the moment the home is using a shared bedroom for one resident. The home Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 16 stands in spacious well maintained grounds providing a pleasant outlook. Garden furniture is provided for residents to use when the weather permits. Since the last inspection the home has replaced some of the chairs in the lounges for a more suitable type for them. It also assists the staff in transferring the residents from the chairs. The resident’s bedrooms were observed to be personalised with some of residents’ own furniture and other personal possessions. The standard of decoration is good providing residents with an attractive and homely place to live. Residents and relatives confirmed that they appreciated the physical environment and were pleased with their bedrooms. The quality of the bed linen and the residents clothes appeared good this is reflects the quality of the laundry. All areas of the home were clean and tidy; no odours were evident in any part of the home this is commended. The home employs a “handyman” who undertakes maintenance, gardening and decorative work. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. The recruitment records show that the home complete appropriate checks prior to commencing new staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas evidenced that the home is providing staffing levels appropriate to meet the needs of the residents. For the sixteen residents the home as 1 nurse with 3 carers from 0700am until 1800pm. From 1800pm until 2200pm 1 nurse and 2 carers cover the home. Nights are 1 nurse plus 1 carer. The manager is supernumerary to the duty rota. The home has a committed staff team with little staff turnover. Staff and residents confirmed that the staffing levels were appropriate to meet the care needs of the residents. The home maintains cover for the home without using Agency staff. Residents and relatives were complimentary about the staff and their commitment to their work. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 18 Three staff files reviewed during the visit 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. In addition some staff had also attended dementia, protection of vulnerable adults and first aid training courses. The home complies with the standard of providing more than 50 of care staff with NVQ training, this is commended. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a first level registered nurse has been in post for many years. The residents and staff related easily to the manager, and she demonstrated a Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 20 good knowledge and understanding about the residents and their care needs. The manager has yet to complete the registered manager’s award. The manager and senior staff continue to maintain their staff supervision program and a record is maintained of the supervision meeting. Records inspected indicated that regular health and safety checks are carried out including fire safety checks. Risk assessments are in place to ensure the safety of the residents and staff at all times The home is not responsible for the resident’s finances this is managed by their relatives or friends on their behalf. The home’s quality audit includes questionnaires to residents and relatives to ensure that assists them in ensuring that they are meeting the resident’s needs. It is recommended that the audit be extended to monitor the homes performance against the national minimum standards. Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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. 2. OP8 Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 23 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coach House Nursing Home DS0000004104.V333355.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!