Inspection on 26/01/06 for Coach House Nursing Home The

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Coach House Nursing Home The 06/03/07

Coach House Nursing Home The 16/11/04

Coach House Nursing Home The 11/08/04

Coach House Nursing Home The 01/03/04

Coach House Nursing Home The 27/08/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Coach House Nursing Home The Sharow Cross Sharow Ripon North Yorkshire HG4 5BQ Lead Inspector Mrs Anne Elaine Prankitt Unannounced Inspection 26th January 2006 10:10 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 The DS0000028026.V252739.R02.S.doc Version 5.0 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 The DS0000028026.V252739.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coach House Nursing Home The Address Sharow Cross Sharow Ripon North Yorkshire HG4 5BQ 01765 600541 01765 600189 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) Mr Allan Broadbent Mrs Glennis Carolyn Broadbent Mrs Jill Taylor Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 5 day care places Age range 60 years upwards Date of last inspection 18th May 2005 Brief Description of the Service: The Coach House is a care home providing nursing care for up to 42 service users. It is a large detached house that was previously a coach house, and which has been tastefully converted to its present use as a care home. It is located in the village of Sharow, which lies on the outskirts of Ripon. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and took approximately six hours. Three hours preparation took place prior to the inspection. The registered manager and administrator were available during the course of the inspection. Feedback was provided to the registered manager at the close. As part of the inspection, some service users and staff were spoken with, care practices in the home were observed where appropriate, some care plans were looked at, two staff recruitment files were inspected, and discussion took place about staff training and also quality assurance systems that have been developed at the home. A tour of all communal areas, and a random sample of service users’ bedrooms was also undertaken. What the service does well: The home provides warm, comfortable and attractive accommodation for residents. Residents are able to sit outside in the garden, which is well tended. Residents can bring in their own belongings to make their bedrooms more homely. Residents know the registered manager and the administrator well. They are available and accessible on a daily basis. They appreciate the input that they provide at the home. Residents said that the food was of good quality, and was plentiful. They are also provided with a choice of menu. Each resident has a care plan which explains to staff about the care that they need, and how it is to be provided. The help of outside professionals, such as doctors and other specialists, is sought where this is needed. Residents are given choices about how they wish to spend their time. Staff undertake a range of training to assist them in looking after the people who live at the home. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 The DS0000028026.V252739.R02.S.doc Version 5.0 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 The DS0000028026.V252739.R02.S.doc Version 5.0 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): EVIDENCE: None of the standards were assessed at this inspection. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 9 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 Staff are given information to help them to look after service users, who are enabled access to outside professionals who assist in their health needs being met. EVIDENCE: The care plans seen provided good information for staff. One service user spoken with was very clear that they had been involved in the development of their care plan, and they felt that the care provided met with their needs. The plans seen were regularly reviewed, and updated with additional information where required. There was information available to support that links have been developed with outside professionals, such as the tissue viability nurse, dietician and speech therapist. Risk assessments were in place where individual risk had been identified. The registered manager has explained that the dietician has provided a nutritional assessment tool. This is not completed for all service users on her advice, but, where nutrition becomes an issue, the relevant documentation is completed, included within the care plan, and the service user concerned referred to the dietician. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 10 Written information about social needs has been developed within the care plan, and it was evident that the information that has been collected was being used in order to assist in them being met. Care staff spoken with were aware of specific needs of service users. They stated that they are provided with good information at each handover, and it was evident that they were kept fully informed where health issues resulting in the need for robust infection control practice was required. Service users were happy that they had access to health services. The registered manager stated that there are no service users at the home who choose to self medicate. All medication is handled by trained staff. The administration records seen were clear and up to date. There is a fridge available for the storage of medication which needs to be kept cool, and records are kept on a daily basis of the temperature of the fridge. A random audit of controlled drugs evidenced that records kept tallied with stock held. It is recommended that the receipt, administration and disposal of Temazepam be recorded in the controlled drugs register. The home has organised safe disposal of medication, and two staff sign when medication is disposed of into the receptacle provided. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 11 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): 14 Service users’ right to make choices is protected. EVIDENCE: Service users spoken with were very happy with the amount of choice that they were afforded in order that they may live their lives as independently as possible. One service user stated that trained staff set good standards by their ‘hands on’ approach, and that care staff learn by their example. There are no restrictions on rising and retiring times. Residents may spend time in their own rooms should they wish to do so, and they were happy with the flexibility with regard to visiting arrangements. Bedrooms are individually decorated, and contained personal possessions belonging to the occupant. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 12 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): EVIDENCE: None of the standards were assessed at this inspection. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 13 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): 22 Thought is given both before and after admission about the individual abilities of service users in the environment in which they live. EVIDENCE: The premises have not been assessed by an occupational therapist. However, the administrator explained that both he and the registered manager assess each service user prior to admission to the home. Should it be deemed that the premises are not suitable for the prospective service user, the admission would not take place. Subsequently, aids are provided for individuals following admission where these are assessed as being needed. Those service users whose opinion was sought were satisfied that they were able to access areas of the home either independently, or with the assistance of staff, whom they stated were available when required. Hoist equipment is readily available on each floor of the building to assist staff in safe moving and handling of residents. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 14 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): 28 and 29 Ensuring that Criminal Records Bureau checks are completed by the home for all staff who work there would better protect service users from unnecessary risk. EVIDENCE: Two staff at the home are NVQ assessors, and it is planned that a third member of staff will undertake the training in order to provide continued support to the rolling programme of training to NVQ Level 2 and above. Currently, five staff are undertaking the training, while six already hold the qualification. The registered manager explained that they now apply for a POVAFirst check for all staff prior to their deployment at the home. She confirmed that staff who are deployed on this basis are supervised until such time that a satisfactory Criminal Records Bureau check is returned. Two staff recruitment files were inspected. Within one file, the CRB check available had been completed previously by another establishment, and not by the home. Therefore, the copy available was that received by the applicant. The registered manager explained that they believed that this practice was acceptable. However, a Criminal Records Bureau must be completed by the home for all staff who are deployed there. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 15 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): 33, 35 and 38 Safety systems need to be further looked into to ensure that service users are protected from unnecessary risks associated with fire. EVIDENCE: The registered manager and administrator carry out a number of audits at the home which have not yet been formalised into one quality assurance system. In addition to this, both the administrator and registered manager are accessible on a daily basis, and it was evidenced that service users know them well. The administrator estimated that he sees 90 of service users each day. In addition to this, he stated that visitors know both himself and the registered manager. A number of letters of commendation evidenced that people were satisfied with the care that was provided at the home. A decision has been made that residents meetings will not been organised. A residents’ questionnaire has been produced, but has not yet been issued to all service Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 16 users. It was agreed that it would be useful should residents be asked within the questionnaire whether they would find meetings beneficial. The home does not handle monies on behalf of service users. The sluice room was unlocked on the day of the inspection. It contained an unregulated supply of hot water, and also hazardous chemicals. The fire officer last visited the home 16 September 2005. The administrator stated that all matters within the subsequent report had been dealt with, and a follow up visit made by the fire officer. On the day of this inspection, there were a number of bedroom doors which were wedged open. The administrator explained that the wedges are removed, and the doors closed, during the night. Staff consulted confirmed that this was the case. The Commission cannot give permission for doors to be held open in this way. However, the administrator explained that the fire officer has given verbal confirmation that this arrangement is acceptable, but that written confirmation has not been provided. The fire safety risk assessment was not readily available at the time of the inspection. The responsible person must update the fire safety risk assessment: • • To include the decision made by the responsible person to wedge fire doors open by unauthorised means, the associated risks, and how the safety of all service users has been considered. To clearly state all rooms where door wedges are used, and to explain how staff will be made aware at all times where this is the case. In addition: • • Where risks to service users are identified, these must be eliminated wherever possible. The risk assessment must be discussed with the fire officer, and confirmation sought that the practice decided upon is acceptable. The registered manager explained that bed rails are checked by staff when they are first fitted, and then each week when they are cleaned. There is currently no system for recording that they have been checked and deemed safe and fit for use. The registered manager agreed to introduce a system whereby this could be evidenced. Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 17 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 X X X X 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 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X 3 X X X X STAFFING Standard No Score 27 X 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Version 5.0 Page 18 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 OP29 Regulation 19 Requirement Timescale for action 26/01/06 2 OP38 13,23 In all future appointments, a Criminal Records Bureau check must be applied for by the home for all staff prior to their deployment. In exceptional circumstances where the registered manager has made the decision to deploy a staff member pending return of the CRB disclosure, the registered manager must complete a POVAFirst check, which must be returned prior to the deployment of the staff member. Arrangements must be made for 09/02/06 the sluice room to be kept locked when not in use. In the interim, service users must be kept safe from unnecessary risk. Bedroom fire doors should not be held open by unauthorised means. Where the responsible person has made the decision to deviate from this, the fire safety risk assessment must be updated: • To include the decision made by the responsible Version 5.0 Coach House Nursing Home The DS0000028026.V252739.R02.S.doc Page 19 • person to wedge fire doors open by unauthorised means, the associated risks, and how the safety of all service users has been considered. To clearly state all rooms where door wedges are used, and to explain how staff will be made aware at all times where this is the case. In addition: • Where risks to service users are identified, these must be eliminated wherever possible. The risk assessment must be discussed with the fire officer, and confirmation sought that the practice decided upon is acceptable. • Written evidence must be kept to confirm that bed rails are checked on a regular basis. 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 OP33 Good Practice Recommendations It is recommended that the receipt, administration and disposal of Temazepam be recorded in the controlled drugs register. The quality audits carried out at the home should be further developed to seek the views of those with an interest in the home, and which should be used as part of the development of a quality assurance system. DS0000028026.V252739.R02.S.doc Version 5.0 Page 20 Coach House Nursing Home The Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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