Inspection on 05/01/07 for The Old Coach House

This inspection was carried out on 5th January 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Coach House 03/03/08

The Old Coach House 24/11/05

The Old Coach House 12/05/05

The Old Coach House 10/02/05

The Old Coach House 22/09/04

The Old Coach House 29/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Old Coach House 20 Wychall Park Grove Kings Norton Birmingham West Midlands B38 8AQ Lead Inspector Peter Dawson Key Unannounced Inspection 5th January 2007 10:00 Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 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 Old Coach House DS0000016807.V326128.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 Adults 18-65. 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. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Coach House Address 20 Wychall Park Grove Kings Norton Birmingham West Midlands B38 8AQ 0121 451 2779/1433 0121 451 1433 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Vacant Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 24th November 2005 Brief Description of the Service: The Old Coach House is a spacious, detached house along a drive between houses in a residential area of Kings Norton. There are shops nearby and reasonable access to public transport. Accommodation is provided for up to five adults with dual sensory impairment and additional learning disabilities. All the bedrooms are single. Two of the bedrooms are on the ground floor and three are on the first floor. There is no lift. There are two bathrooms one on the ground floor and one on the first floor. Both are domestic in style and have no aids or adaptations. There are two additional toilets on the ground floor. An office is available on the first floor of the house. The home has a large lounge with a separate large dining area. The garage has been converted into additional communal space and used as a sensory/activity room. The premises are adequate in size and furnished/equipped to a good standard. There is a secluded garden to the rear of the property much used in the summer monthls and has a range of good seating/eating facilities. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector in one day from 10 a.m. – 5.30pm. The Acting Manager was off duty. Because the 3 staff on duty were required to assist the residents going for a horse-riding visit the Assistant General Manager was contacted who came to the home and assisted with the inspection. She had detailed knowledge of the service and individual residents. A pre-inspection questionnaire had been provided prior to the inspection but was limited in information. There was no written feedback from relatives or other visitors. There was an inspection of the physical environment and documents relating to the inspection process including care plan, risk assessments, fire records, medication records and records relating to staffing. None of the five residents were able to verbalise their views about the service. Observations and communication with staff provided a basis for assessment of the service. Communication symbols, objects of reference and tactile expressions were used by staff in communication with residents. All residents have their own communication symbols etc. that they carry with them externally. Positive exchanges were observed between staff and residents both having a clear understanding of non-verbal communication methods. Staff approached residents in a sensitive and caring way who responded positively. The three members of staff on duty were involved in the inspection process and provided helpful information. There were 21 requirements made at the time of the last inspection. Sixteen have been satisfactorily addressed. Five are repeated in this inspection report. Two relate to medication practice, one relates to staff training and two relate to care plans and risk assessments which have been partially met. What the service does well: The Old Coach House is quite spacious with very large lounge, separate dining area and good communal facilities. All bedrooms are for single use and very spacious, well furnished and personalised to reflect individuality. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 6 There is a large, secluded and very pleasant garden area with good seating/eating facilities. This is used considerably during the summer months residents enjoying the facility to sit or to wander as they wish. There is level access from the lounge area. Transport is now readily available with adequate numbers of drivers. There is also nearby access to shops and individual access to taxis when large group activities are not appropriate. Staff spoken to on duty were relaxed and committed to resident care. Good communication facilities appropriately assessed and positively used were evident. What has improved since the last inspection? There has been considerable improvement in the cleanliness and presentation of the home. Additional domestic hours have been provided and there has been redecoration of some areas. Some carpets and soft furnishings have been replaced. Greater involvement in community facilities has been facilitated. Transport is more readily available with additional drivers. Holidays have been provided for most residents and others will be arranged. Mealtime guidelines for each person have been assessed and compiled providing clear information to staff in supporting residents. Additional staff have been appointed resulting in drastic reduction in the number of agency staff employed. COSHH items are now stored securely at all times in locked cupboard to ensure safety of residents. Some progress has been made in updating and reviewing care plans and risk assessments and this continues. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 7 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. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose must be updated. Good pre-admission procedures were evidenced concerning a recent admission. EVIDENCE: The Statement of Purpose requires updating to record changes at the Coach House. A new resident was admitted on 14/08/06 having been transferred from another Sense home which closed. The person visited with her mother and social worker on at least 3 occasions prior to admission and staff from The Coach House went to her previous placement several times to observed her routines and needs and to facilitate a smooth transition to her new home. She appears to have settled well into The Coach House. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 - 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Progress is being made in updating and review of care planning information and risk assessments. This task requires completion. There was evidence of consultation with residents in daily routines. EVIDENCE: Two previous requirements have been made to ensure care plans are updated. Some information had been dated, additions had been made but plans not updated. This has improved since the last inspection. A sample of care plans was seen. There is considerable information relating to each resident and much work has been done to update that information. A system to swiftly identify specific information sought is needed. This is a considerable task and remains ongoing. The work is split between the homes Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 11 staff and the Practice Development Worker (PDW). In a care plan sampled Vision & Hearing guidelines had been updated in August 2006 and Communication reviewed and revised by the PDW in October. A previous requirement to further develop risk assessments with evidence of review was made at the last inspection. It was clear on this visit that some areas still require action. Risk assessments had not been reviewed as required. Core team meetings are held monthly and allow the staff team to discuss individual residents progress and care. Observations during the inspection indicated that where possible staff consulted residents about daily routines and activities. Staff were sensitive and supportive in their approaches to residents. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11 and 13 - 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service Community participation has been greatly improved and previous requirements met. Contacts with relatives/families should be promoted. Food provision is satisfactory. EVIDENCE: Two previous requirements have been made to increase participation in the local community for all residents. This has been done. There was previously a shortage of drivers for the homes vehicle, this has been addressed. The number of drivers has been increased. Additionally some residents walk to local shops, taxis are used and the homes Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 13 vehicle has been changed and will now accommodate all 5 residents and up to 3 staff. On the day of inspection residents were taken out in the mini-bus for a morning outing and later in the day to the shops, calling at café for light tea. The facilities provided at the Sense locations in Birmingham are used providing a range of therapeutic and occupational activity. Residents contribute 60 of their DLA (mobility) payments to Sense towards transport costs. Transport is now more readily available to them. There is an activity programme for each resident, some involving group or individual activities. These are discussed in detail at core team meetings to ensure still appropriate and that adequate activities are provided. Daily recording for each resident indicates the activities for the day with relevant comments. A sensory room has been created in the former garage area, which is reported to be used more. The area has been cleared of unused equipment giving more space. There is a suspended hammock-bed used by several residents, comfortable seating where people can take “time out”. During the inspection a resident used the room in the morning choosing his music from the radio at a volume appropriate for his hearing. Opportunities for personal development are promoted. A new resident has her own kettle in the kitchen to make drinks. Another enjoys preparing food with assistance from staff. Activities are documented and risk assessments in place. Links with families are tenuous in some instances. Some families are involved on a regular basis, some visit monthly or six monthly. Distance, age and personal circumstances limit the contacts of some families. Some are in regular contact by telephone with the home. It was concerning that although there had been visits from families prior to Christmas – there had actually been no family visitors during the Christmas period. There appear to have been no home visits for sometime. A resident used to go home to her family but no longer does so. This was discussed during the inspection and it was felt that the home could take positive steps to facilitate and re-establish family contacts. No feedback forms were received by CSCI prior to the inspection. A requirement to provide annual holidays for residents was made at the last inspection. Four residents have since had holidays provided. An example is a long-weekend for a resident at Hoar Cross Hall where she was “pampered” and enjoyed all the facilities – she enjoys massage at the Old Coach House, where she has her own massage bed. Sense will provide a budget of £300 for each person for holiday purposes. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 14 Two previous requirements have been made to provide clear guidelines for staff concerning the required support for all residents at mealtimes. This has been done – revised guidelines seen on care plans inspected. Food provision appears good. Menus reflect an adequate and nutritional diet. The mid-day hot meal was sampled during the inspection and was to a good standard. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 - 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Whilst some aspects of healthcare recording and action has improved, others have not. Medication in the home is poor – several requirements are made, additionally staff require specific training. Work is required to improve this outcome area. EVIDENCE: There were 4 requirements made in these outcomes at the time of the last inspection. The requirement to review residents personal routines has been addressed with some improvements. Although it was noted that there was some conflict in information recorded relating to a persons night time care needs. A requirement to review guidelines for epilepsy care and review by a health Professional has not been met. One person with severe epilepsy is not longer Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 16 at the home, another resident has infrequent seizures, has been on Epilim for several years. This has not been reviewed and will be reviewed with the GP/Consultant swiftly. A requirement to provide protocols for PRN medication has not been met, this was highlighted in the inspection of medication. A requirement to provide staff with accredited training in medication administration has not been met. 5 staff still require training and this must be provided. Two further requirements are made in relation to medication arising from this inspection: Written information on MAR sheets must be avoided – where there is no alternative information must reflect prescriptions and must be checked and signed by 2 staff. It was not possible to reconcile the amount of remaining Epilim for a resident from information given on MAR sheets. There should be a count of medication to complete the audit trail for all medication. Health care records have been improved and updated although the outcomes of a physiotherapy assessment of a resident had not been clearly recorded in the care plan – specific daily actions/exercises were required. It was not possible to locate weight records for most residents on the day of the inspection (in the absence of the Acting Manager). One record did show a resident had been weighed only twice since July. The chart in relation to a resident with very low weight was not in place. All residents must be weighed monthly and where there are concerns about weight loss this should be weekly. All must be recorded. There was evidence of involvement from GP’s, Consultants and other health care professionals. Specialist services had been accessed from “Greenfields” (PCT and Learning Disability unit). All 5 residents have dual sensory impairment of sight and hearing. All have a learning disability and none have speech for verbal communication. The dependency level of the group is therefore high. All have comprehensive communication assessments and guidelines in place. All have symbols and objects of reference to provide communication of their needs and to facilitate the daily living situation in the home and engagement with staff. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for this group of residents to make complaints. Virtually all staff have received training in the protection of vulnerable adults. The home could consider future use of independent advocates. EVIDENCE: Whilst there is a complaints procedure in appropriate form for residents, it was agreed that none of the current resident group could reasonably be expected to understand and use the procedure. – What other safeguards are in place? Residents do not access day facilities outside the Sense organisation. Family contacts in some instances are very limited. The importance of staff awareness of changes in mood or behaviour of residents, or indications of dissatisfaction are vital. It is reassuring that only one member of staff has not had training in the protection of vulnerable adults. Perhaps the home should consider some use of independent advocates? A copy of the complaints procedure is not available to visitors in the home and this should be provided. A copy should also be given to all relatives. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 18 A vulnerable adults referral was made earlier this year and resulted in strengthening the medication procedures. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 - 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been considerable improvements to the environment and also to the cleanliness of the home. Presentation is now good. The building is homely, comfortable and provides a good standard domestic environment for the five residents. EVIDENCE: There has been considerable improvement in the cleanliness and presentation of the home. Cleaning routines are in place and additional domestic hours have been allocated to improve cleanliness. There has been redecoration of some areas and carpets, blinds, curtains replaced. The four requirements of the last report have been actioned. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 20 At the time of this inspection the presentation of the home was good, all areas were clean and hygienic and the environment replicated a good domestic environment. The only area requiring action was cleaning of the kitchen cupboards/units. All bedrooms were seen. All were spacious, well furnished and personalised reflecting the individuality of residents. Furnishings, fittings and equipment were good. Many bedrooms had double beds still providing adequate space for residents to move safely. A wash hand basin had been removed from a bedroom due to the alleged challenging behaviour of a person moved from a home outside the Sense organisation. The behaviours have not manifested themselves whilst resident at The Coach House and the home are considering re-installation of the wash hand basin in his bedroom. The garden area is secluded and affords considerable enjoyment for residents during the summer months. It is easily accessed from the lounge area. It was noted that several concrete slabs on the patio area were very uneven, presenting a potential trip hazards for the residents. These should be levelled as soon as possible and any interim access supervised by staff. The COSHH cupboard in the laundry area was locked safely on this visit. (previous requirement). Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 - 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff training is poor and must be provided as soon as possible. Recruitment documentation requires improvement. Staff supervision is regular and good. Positive relationships were evident between residents and staff. EVIDENCE: There are 3 staff on duty throughout the day, there is additional cover from the PDW (Practice Development Worker) and Manager. There is one waking night care assistant and one person sleeping-in and on call. The staffing rotas were not inspected/discussed on this visit. The staffing levels appear adequate for perceived dependency levels of the current resident group. At the time of last inspection there were 2 full-time vacancies in the home and considerable use of agency staff. This situation has changed, new staff have Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 22 been appointed and there is a current vacancy for 0.5 staff member. The use of agency staff is now minimal. There are many areas of staff training which have not been provided and this includes statutory training. Currently training is required in the following areas: First Aid, Moving & Handling, Food Hygiene, Communication, Challenging behaviours, Medication and protection. Currently all courses provided by Sense in these areas are fully booked, arrangements must be made for early training in these areas. The home should provide a training matrix to identify training needs. Staff files were sampled and although CRB checks has been obtained as required for new staff, other documents required under Schedule 2 had not been obtained. Missing documents included: photographs, birth certificate, passport, medical questionnaire and proof of identity. These are required. The home must have the required information on each staff member who is employed as detailed in Schedule 2. Supervision records were seen and there was evidence of regular (monthly) supervision for all staff. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 40 - 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new Registered Manager must be appointed. Interim arrangements for management of the home are satisfactory. Many improvements to the service have been made over the past year. EVIDENCE: A new Registered Manager was approved since the last inspection but left the home in September 2006. A temporary manager has been appointed but no application made to Register made with CSCI. This must be done as soon as possible. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 24 It was therefore not possible to asses the competence, leadership and management approach of the home. The home is overseen by an Assistant General Manager from Sense and the arrangements for interim cover pending the approval of a Registered Manager are satisfactory. It is nevertheless clear that many improvements have been made in many aspects of the service over the past year, since the last inspection. A requirement to secure COSHH items made in the last report has been met. The COSHH cupboard was locked and secure. Fire records were inspected. Regular checks of alarms and equipment had been carried out. However it was noted that the last fire drill was 7 months ago. A requirement is made that all staff have regular fire drills. It was positive that individual evacuation procedures had been compiled for all residents and that the fire risk assessment was in place and had been reviewed. Regulation 26 visits had been made on the required monthly basis to the home and copies of reports left in the home and also forwarded to CSCI. The Regulation 26 visits were particularly detailed and helpful. Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x X X X 3 2 2 X Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? 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. 2. Standard YA1 YA6 Regulation 4(1) 15(1 (2) Requirement The Statement of Purpose must be updated. The home must ensure that each person has an up to date care plan, reviewed at least 6 monthly. Previous requirement not met. Risk assessments must be further developed with evidence of review. Previous timescale not met. Re-establish & facilitate family contacts where possible. All residents must be weighed monthly or weekly where there are concerns about weight loss. Review epilepsy medication with GP/Consultant Written information on MAR sheets must be avoided. Where there is no alternative information must reflect prescriptions and checked and signed by 2 staff. Count & record medication to complete the audit trail of medication. Protocols must be in place for all PRN medication. Previous DS0000016807.V326128.R01.S.doc Timescale for action 31/01/07 31/03/07 3 YA9 13(4) (c ) 31/03/07 4 5 YA15 YA19 16(2)(m) 12(1) 31/03/07 06/01/07 6 7 YA19 YA20 12(1) (2) 13(2) 28/02/07 06/01/07 8 9 YA20 YA20 13(2) 13(2) 31/01/07 31/01/07 Old Coach House Version 5.2 Page 27 timescale not met. 10 11 12 13 14 15 16 YA20 YA22 YA24 YA34 YA35 YA37 YA42 18(1)(c () 22 13(4) 19(1)(b) Sched 2. 18(1)(c ) 8(1) 23(4)(a)(b) Staff must receive accredited training in medication. Previous timescale not met. Provide copy of complaints procedure in the home for visitors. Paving slabs in patio area to be levelled to reduce risk to residents. All documents required under Schedule 2 must be provided for all staff. Staff must receive training in all mandatory areas. Previous timescale not met. Application must be made to appoint a Registered Manager All staff must receive regular fire drills. 28/02/07 31/01/07 06/01/07 31/01/07 31/03/07 31/03/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Old Coach House DS0000016807.V326128.R01.S.doc Version 5.2 Page 29 - 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!