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Inspection on 26/06/06 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 26th June 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

Being a small home, it provides a very homely environment. The bedrooms are personalised by the resident to their preferred choice. Feedback received from relatives and residents expressed their satisfaction with the home. Comments about the quality and choice of food were excellent. The environment is maintained to a high standard and in good decorative repair throughout. All staff are up to date with training and regular training sessions are provided for the staff.

What has improved since the last inspection?

Staff supervision records have further improved since the last inspection. A quality audit system has been implemented. Activities for the residents have been reviewed.

What the care home could do better:

A heated food trolley would assist staff in ensuring the meal and pudding is kept hot. The furniture in the lounges should be reviewed for more appropriately suitable to meet the needs of the residents and assist staff with moving and handling. The activities for the residents could be further developed.

CARE HOMES FOR OLDER PEOPLE Coach House Nursing Home Broome Clent Worcestershire DY9 0HB Lead Inspector Chris Potter Unannounced Inspection 13th June 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.V305057.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.V305057.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 Hilda 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.V305057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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. The fees charged at this home range between £495.00 to £595.00 per week. Coach House Nursing Home DS0000004104.V305057.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 and took place for the day on the 26th of June 2006. The inspection lasted a total of 6 hours. On the day of the inspection the home was accommodating 15 residents. Feedback from relatives, residents and professionals was most complimentary about the homes, staff and facilities. During the visit relatives and residents who were spoken to confirmed that the home was meeting their needs and they have no problems. Many reported they were not aware of the homes complaints policy, so it was recommended that the home forward a copy to all relatives. What the service does well: What has improved since the last inspection? Staff supervision records have further improved since the last inspection. A quality audit system has been implemented. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 6 Activities for the residents have been reviewed. 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.V305057.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.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Resident’s individual needs are assessed prior to them moving into the home in order to establish the homes ability to meet those needs, and to ensure appropriate care is provided. EVIDENCE: Feedback received from relatives prior to the inspection confirmed that they had been provided with the relevant information prior to admission. The care documentation for 3 residents was reviewed these contained the preadmission assessment. This is undertaken prior to the resident being accepted into the home. The manager or registered nurse usually undertakes the preadmission assessment. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 9 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. The Statement of Purpose and Service User’s guide are updated to reflect any changes. Residents and relatives spoken to during the inspection stated they were very pleased with the home and its facilities Coach House Nursing Home DS0000004104.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are reflective of the resident’s care needs. EVIDENCE: Feedback from relatives and residents received prior to the visit, confirmed they were pleased with the level of care provided. One comment received on the feedback stated they did not feel all information was passed onto them. Any issue should be discussed with the manager or the nurse in charge at the time of the visit. The manager was advised about this comment and would be happy to discuss any issue with relatives. The care documentation for 3 residents was reviewed. The care plans had appropriate risk assessments in place and were evident of regular review and update. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 11 Staff spoken to also confirmed that the care practises in the home were excellent. The manager has implemented a system to review the resident’s care with their relatives. This assists them in ensuring they are meeting the residents needs fully. The management of medication was well organised, and audits confirmed that no errors had occurred. It was recommended that the medication in the primary boxes is dated on opening to assist with auditing. Coach House Nursing Home DS0000004104.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: The home does not employ specific staff to organise social activities. The home provides limited activities for those wishing to participate. All care staff assists and encourage residents to maintain their preferred interests. Residents are very dependant at the moment and enjoy listening to music and watching television. The home provides mobility plus exercises every Friday and arrange outings alternate weeks for those able to join in. 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. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 13 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. It was recommended that a heated trolley be provided to assist staff in keeping the food hot. Coach House Nursing Home DS0000004104.V305057.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints policy is provided to residents on admission to the home. A vulnerable adults policy is available to ensure an appropriate response is followed to any suspicion. 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. Given some comments from relatives stating that they were unaware of the complaints procedure, it was recommended that the home send a copy of the policy out. 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.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service 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 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 2 shared bedrooms as single. 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.V305057.R01.S.doc Version 5.2 Page 16 Given the high dependency of the residents it was recommended that the chairs are reviewed and a selection provided more appropriate for the residents needs. This would also assist staff in moving and handling the residents. The resident’s bedrooms were observed to be furnished with residents’ personal possessions, reflecting the resident’s personality. The standard of the environment within the home 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 was 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.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: The duty rotas evidenced that the home is providing staffing levels appropriate to meet the needs of the residents. The manager confirmed that the home is fully staffed and currently has no vacancies. 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. 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. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 18 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.V305057.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. 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 has yet to complete the registered manager’s award. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 20 The manager and senior staff continues to maintain staff supervision 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 was well organised in respect of records and registers required to be maintained. Some maintenance records were not available, these shall be observed at the next inspection. Coach House Nursing Home DS0000004104.V305057.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 N/a 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 4 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 3 3 3 x 3 3 3 Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 22 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. Timescale for action 20/08/06 Remains outstanding from the last inspection 2 OP12 13 The home must review their provision for activities for the residents and this should be based on the individuals needs and clearly documented. 30/09/06 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 2 Refer to Standard OP9 Good Practice Recommendations The home should date the primary container on opening to assist with the auditing of medication. A heated food trolley would assist staff in ensuring the OP15 Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 23 meal and pudding is kept hot. Coach House Nursing Home DS0000004104.V305057.R01.S.doc Version 5.2 Page 24 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. 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