Inspection on 01/02/07 for Olde Coach House The

This inspection was carried out on 1st February 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.

Other inspections for this house

Olde Coach House The 05/12/05

Olde Coach House The 06/09/05

Olde Coach House The 08/02/05

Olde Coach House The 05/08/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Olde Coach House The 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW Lead Inspector Diane Wilkinson Unannounced Inspection 1st February 2007 09:30 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 Olde Coach House The DS0000019753.V329875.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. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Olde Coach House The Address 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW 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) 01482 645094 01482 643363 Dema Residential Homes Limited Mrs Elaine Bismor Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (29) of places Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: The Olde Coach House is a privately owned care home that is registered to provide care and accommodation for 29 older people, including those with dementia. The accommodation is provided in 15 single rooms and 7 shared rooms; 2 of the single rooms have en-suite facilities. Information about the home is provided to service users and others in the home’s statement of purpose and service user guide. Fees paid range from £372.80 to £410.00 per week and there is an additional charge for hairdressing, chiropody/foot care, newspapers, a service user’s own telephone and alcohol. The building is a conversion/extension of two adjacent houses with parking space for staff and visitors. There is an inner courtyard and small garden area where residents can sit out in fine weather. All areas of the home are accessible to service users via the provision of stair lifts and ramps. The home is situated within easy reach of local amenities in the town centre of Hessle where shops, churches, public houses and a range of community facilities are available. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the registered person, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 1st February 2007. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.45 pm. The site visit consisted of a tour of the premises and examination of documentation, including four care plans. On the day of the site visit the inspector spoke on a one to one basis with three residents, three members of staff and the registered person, as well as chatting to other service users and a relative. Prior to the day of the site visit the inspector sent surveys to six GP’s, seven health and social care professionals and eight relatives. One was returned from a GP, who stated, ‘very good overall level of care offered to residents’. Three surveys were returned from social care professionals and seven were returned from relatives. Three surveys were sent to staff following the day of the site visit and two have since been returned. Comments from surveys and from one to one discussions with service users and staff will be included throughout the report (anonymously). The inspector would like to thank service users, staff, relatives and the registered person for their assistance on the day of the site visit, and to everyone who spoke to the inspector or responded to a survey. What the service does well: Service users and relatives express satisfaction with the care provided by staff at the home. Staff speak to service users in a sensitive manner and privacy is promoted when assistance is offered with personal care. One relative stated, ‘you gave my relative love, care, understanding and most of all dignity…….’ All service users spoken with told the inspector that the food at the home is good – one service user said, ‘The cook is excellent and I can have anything I choose’. Relatives and visitors are made welcome at the home – all service users spoken with told the inspector about their regular visitors and how they are made welcome; this was apparent on the day of the site visit. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 6 The Olde Coach House provides a pleasant homely environment for the people who live there, with a high standard of décor throughout the home. A relative said, ‘The accommodation itself is always extremely clean and I never experienced on any of my visits any unpleasant odours that I have so often found when visiting other residential homes’. The home is well organised and managed, and staff are well trained and supported. 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. The summary of this inspection report can be made available in other formats on request. Olde Coach House The DS0000019753.V329875.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 Olde Coach House The DS0000019753.V329875.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): 2 and 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to their admission to the home and only admitted if this evidences that their current care needs can be met. EVIDENCE: The inspector observed in service user records that there is an appropriate statement of terms and conditions or contract in place between the home and the service user that defines the care that will be provided by the home. Contracts are signed by service users or their representative. The inspector examined the records for two newly admitted service users. These evidence that a needs assessment was undertaken prior to the service user being admitted to the home. In discussion with the inspector, the Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 9 registered person confirmed that service users are visited at home or in hospital by themselves or the deputy manager, and that this is when the assessment of the service user commences. Some service users told the inspector that they attended the home for day care or respite care prior to their admission on a permanent basis, to assist them in making a decision about their long-term care; records in the home support this. A Community Care Assessment is obtained from Care Management when they are involved in the service user’s admission; the inspector noted that this was sometimes a few weeks after the service user had been admitted to the home. Olde Coach House The DS0000019753.V329875.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. This judgement has been made using available evidence including a visit to this service. The health and social care needs of service users are being met by staff that respect their privacy and dignity, although the care provided to service users is not recorded thoroughly in some instances. Medication systems are good but more care must be taken with accurate recording. EVIDENCE: In most instances, a service user plan is generated from a needs assessment that has been completed by the home and, where appropriate, Care Management. However, one service user had been in the home for a week and there was no care plan and no risk assessments in place, although a needs assessment had been completed. There should be a care plan in place from the time that the service user is admitted to the home to record the action that needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 11 Care plans are reviewed on a monthly basis and the inspector saw that care plans are updated as necessary. Any changes made to care plans are dated; this is good practice. There are appropriate risk assessments in place for areas such as mobility, including the risk of falls and the use of bed rails. Annual reviews are held by Social Services if they are involved in the placement, or by the home. Service users sign some of their care planning documentation to evidence that they have been involved in this process. Care records evidence that the health care needs of service users are met. There are appropriate arrangements in place to ensure that service users do not develop pressure sores; this includes checking that skin is intact and the use of pressure care equipment. A record is maintained of all contacts with health care professionals, including the reason for the contact and the outcome; this includes GP’s, dentists, chiropodists and opticians. Nutritional screening takes place; food and fluid intake is monitored and recorded where this is an area of concern and all service users are weighed on a regular basis. The inspector observed that a service user’s psychological health is monitored – in some instances a chart is used to monitor changes in mood and behaviour. The inspector observed the administration of medication at lunchtime. This was carried out in a satisfactory manner, although the inspector noted that, on some occasions, the medication administration record was signed before the service user took the medication. The registered person confirmed that this was normal practice at the home for such medication as food supplements. However, one of the drugs administered was not a food supplement. The service user was in their bedroom and not in a communal area, so the risk of another service user taking this medication by mistake was minimal. The registered person was reminded that medication administration records are signed to evidence that the service user has taken prescribed medication, not that it has been handed to them. In one instance, medication had been prescribed for a service user after the usual delivery of medication from the Pharmacist. The medication administration sheet did not record the date that the medication had been received and there were no signatures to evidence that the medication had been given or not given. In other instances, medication sheets did not record whether or not a service user had been given prescribed medication. The registered person explained that the service users’ GP’s had advised that this medication should be given if the service user was well enough to take it, but that it was not imperative. This had been recorded in care plans, and the medication had been removed from the medications trolley, but the information had not been recorded on medication administration records; this could lead to confusion. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 12 Medication is held securely; none of the current service users have been prescribed controlled drugs but there are suitable storage and recording facilities should this occur. The registered person informed the inspector of various medication training courses attended by staff that administer medication and assured the inspector that these training programmes were accredited. The inspector observed on the day of the site visit that a service user’s right to privacy is respected. Staff speak to service users in a sensitive manner and privacy is promoted when assistance is offered with personal care. One relative recorded in a letter that was sent to the home, and copied to the inspector, ‘you gave my relative love, care, understanding and most of all dignity…….’ However, the inspector noted that some very frail service users who are primarily cared for in bed are accommodated in shared rooms. On the day of the site visit one service user was eating their lunch in the bedroom whilst another was being looked after in bed; the need for a single room for these service users should be considered. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities both inside and outside of the home, visitors to the home are made welcome and individual choice is promoted. Meal provision at the home is good. EVIDENCE: Care plans include information about a service users previous life history, lifestyle and social/leisure interests; in some instances this information has been written by a family member. Any activities undertaken by service users and any visitors seen or outings taken are recorded in daily diary records, and in monthly summaries recorded by key workers. The inspector observed on the day of the site visit that service users are supported to be as independent as possible, and that some undertake tasks within the home, such as setting the tables. There is no activities coordinator employed at the home, but care staff spend time with service users on a day to day basis; there was a ‘sing song’ on the day of the site visit. The monthly activities planner records such activities as ‘ladies enjoyed church service’, ‘physio. today’, ‘hairdresser’ and Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 14 ‘slide show’. The home employs a Physiotherapist who visits the home on a regular basis to support service users with exercise. One service user told the inspector that there are not enough activities on offer, whereas another service user told the inspector that there is plenty to do ‘if you are a mixer’. One member of staff stated that there ‘could be more for service users to do during the day’. All seven relatives that returned the survey recorded that they are kept informed about important events regarding their relative, although two of the three social care professionals that returned a survey stated that the home does not always notify them of significant events. The survey form returned by a GP records that the home communicates clearly and works in partnership with them. They state, ‘Very good overall level of care offered to residents’. All relatives said that they are made welcome at the home at any time. This was observed by the inspector on the day of the site visit, and a relative told the inspector that this is ‘the best home in the area’. Service users stated, and the inspector observed, that they are encouraged and supported to make decisions about their daily routines and life choices. Details about advocacy services are displayed in the home. The inspector observed the serving of lunch. Some service users congregate in the dining room and the inspector observed that meal times are promoted as a social occasion. Those service users that need assistance with eating and drinking have their meals in one of the lounges or in their bedroom; these service users have their meals before the other service users to enable staff to have time to spend with all service users. ‘Soft’ diets and diets to suit diabetics are provided for service users that require them. The inspector observed that service user are asked each day about their choice of meals for lunchtime and tea-time, and service users confirmed that they are always offered a choice of meal. Food supplements are obtained for service users if there is concern about their food intake. All service users spoken with told the inspector that the food at the home is good – one service user said, ‘The cook is excellent and I can have anything I choose’. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is understood and used by service users and others. Service users are protected from abuse by the policies and procedures that are in place. EVIDENCE: The complaints policy and a form to record any complaints are given to service users or their representative at the time of admission, along with the statement of purpose and contract. A pack containing this information was seen by the inspector on the day of the site visit ready to hand to a relative. No formal complaints have been received by the home or by the CSCI since the last inspection of the home; this is recorded in the Quality Assurance log. Some service users told the inspector that they would complain if they were not happy with the service provided, and feel that the registered person and other staff would listen and that their complaint would be dealt with in a professional manner. The GP and three social care professionals that returned the surveys stated that they had never had to deal with any complaints about the home. One relative stated that they were not aware of the home’s complaints procedure, but all relatives said that they had never had to make a complaint. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 16 The diary is used to record ‘staff grumbles’ and ‘resident’s grumbles’ – the inspector observed that these comments are dealt with by senior staff, and that this information is transferred to the homes quality assurance system as part of a monthly monitoring system. There are appropriate policies and procedures in place that are designed to protect vulnerable service users from abuse. Senior staff at the home have attended ‘Manager’s Awareness Adult Protection’ training and most care staff have done appropriate training. Staff spoken with by the inspector had an understanding of adult protection issues, including whistle blowing. Some care staff have undertaken Challenging Behaviour and Dementia Awareness training; the registered person informed the inspector that there are plans in place for more staff to undertaken Dementia Awareness training this year. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortable, well-furnished and well-maintained environment, although arrangements for protecting service users from the risk of scalding and burning are not robust. EVIDENCE: The inspector toured the premises and observed that all areas of the home are well maintained. The registered person informed the inspector that she would be developing a maintenance programme for 2007/8 shortly, but that this had been delayed due to planning permission being sought to convert an unused area of the home into three en-suite bedrooms. The daily diary records any repairs or maintenance needed that is observed by staff ‘on their rounds’ – the Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 18 registered person informed the inspector that the handyman ticks these diary entries when the work has been completed. All areas of the building were clean, bright, well furnished and pleasantly decorated, and furnishings and fittings are domestic in nature and of good quality. Some bedrooms have French windows that open out on to the enclosed courtyard garden. The large dining room/conservatory allows ample access to sunlight and enables service users to view the front of the property and the courtyard garden. The inspector observed that most radiators have been fitted with covers. However, a few remain unprotected and this work must be completed to ensure that service users are protected from the risk of receiving burns. The inspector saw records completed by the handyman when water temperatures have been tested in bathrooms. These evidence that the water temperature is cool; the registered person informed the inspector that a plumber is currently dealing with this issue and that it should be resolved shortly. Water temperatures are not currently tested in washbasins in bedrooms – this is recommended as a measure to control the risk of scalding for service users. The registered person agreed to this and designed a form to record this information on the day of the site visit. There are appropriate policies and procedures in place to ensure the health and safety of service users, including infection control. The home was clean and hygienic on the day of the site visit, with the exception of the strong odour in one bedroom (recorded in the Health and Personal Care section) that was dealt with immediately. Separate domestic and catering staff are employed at the home; on the day of the site visit the inspector saw an NVQ assessor at the home who was meeting with staff that are undertaking ‘housekeeping’ qualifications. Service users told the inspector that they are happy with the laundry service offered by the home. One relative said, ‘Clean, pleasant surroundings. No ‘institution’ smell’, and another said, ‘The accommodation itself is always extremely clean and I never experienced on any of my visits any unpleasant odours that I have so often found when visiting other residential homes’. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment practices and staff training ensure that suitable well-trained staff are employed in sufficient numbers to ensure that the needs of service users accommodated at the home can be met. EVIDENCE: There are appropriate staff rotas in place that record the role of each member of staff. This evidences that there are four care staff plus a senior carer on duty each morning and three care staff plus a senior carer on duty each afternoon. There are only two care staff on duty from 8.00 pm, when night staff commence work. This was discussed with the registered person, who said that most service users are in bed by this time, and that this is their choice. Two of the seven relatives that returned a survey said that there are not always enough staff on duty. Some staff are employed as room care assistants; as they are under the age of 18 they are not able to undertake personal care tasks and the registered person has ensured that these members of staff sign a ‘restricted activity agreement’ that records this. One member of staff was under the age of 16 Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 20 when she commenced work at the home and an ‘Employment of Children’ form was completed by the registered person. The pre-inspection questionnaire records that seven care staff have achieved NVQ Level 2 in Care. Another three care staff have enrolled for this training so the home are almost on target to meet the 50 qualification requirement; there should be an action plan in place that records how the home will ensure that 50 of care staff will achieve NVQ Level 2 in Care, and how this level can be maintained once achieved. Recruitment and selection records for two care staff were examined by the inspector and these evidence that safe practices were followed; a POVA first check and two written references were in place before staff commenced work at the home. The registered person is reminded that a POVA first check should be used only in exceptional circumstances. In normal recruitment situations a CRB check should be obtained prior to someone commencing work at the home. Staff records include details of induction training, and there are individual training records in place as well as a training and development plan that records training achievements for the full staff group. Staff undertake basic training (food hygiene, first aid, moving and handling and health and safety) as well as more specific training such as Bereavement Awareness, Parkinson’s Disease, Challenging Behaviour, Dementia Awareness and Diabetes. The home employs a number of junior care assistants and junior room care assistants. The inspector noted that some of these staff undertake no training other than induction training. All staff should undertake fire, health and safety, food hygiene and infection control training. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, including the handling of service user monies. Service users and others are able to affect the way that the home is operated. The health, welfare and safety of service users and staff is protected with the exception of fire safety concerns. EVIDENCE: The registered provider of the home is also the registered manager. She is a Registered General Nurse and has achieved NVQ Level 4 in Management; she has owned and managed the home for eighteen years. The registered person Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 22 informed the inspector that she has recently updated her medications training and has retained her registration with the Nursing and Midwifery Council. Staff and service users told the inspector that the registered person is very approachable and that she listens to suggestions and concerns and acts upon them. The inspector observed on the day of the site visit that the registered person, senior staff and other staff work well as a team. There is an effective quality assurance system in place. This includes monthly audits of the systems in place, an analysis of any complaints received and minutes of staff meetings and relatives meetings held. Quality audits are collated and the outcome is fed back to staff, service users and relatives at relevant meetings. Policies and procedures are updated appropriately. Personal allowances are held for some service users and the inspector was informed by the home’s administrator that these are held securely. The inspector checked the monies and associated records held on behalf of three of the service users that were case tracked. These were found to be an accurate record of transactions made on behalf of service users; receipts are retained and records include a ‘running total’. It is no longer a requirement for the registered person to write reports under Regulation 26 of the Care Homes Regulations 2001, as the registered manager is now the sole registered provider. Equipment and systems had been appropriately serviced, including the nurse call system, the fire alarm system, the passenger lift, hoists, portable appliances and gas appliances. There is information in place to record safe working practices, including risk assessments, and there is a fire risk assessment in place. The inspector examined the records for in-house fire tests and drills. It was noted that a fire drill only takes place every 2 months – the inspector recommends that this should be monthly. On the day of the site visit the records evidenced that the most recent fire drill took place on the 22nd November 2006. Following the inspection, the registered person forwarded a document to the inspector that records that a fire drill that took place in January 2007. In-house tests of the fire alarm system took place on a regular basis until the 22nd November 2006; the registered person informed the inspector that these should take place every 2 or 3 weeks. Fire tests must be undertaken consistently and the inspector recommends that a fire test should take place every week. Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 1 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13 Requirement Those radiators that are not yet satisfactory must be guarded or have guaranteed low temperature surfaces to protect service users from the risk of receiving burns. Fire tests must consistently take place on a regular basis. The inspector suggests that this should be weekly. Timescale for action 30/04/07 2 OP38 23 01/02/07 Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations There should be a care plan in place from the time that the service user is admitted to the home to record the action that needs to be taken by care staff to ensure that all care needs are met. The registered person should consider the need for very frail service users who are care for in bed to be accommodated in a single room. More care should be taken to ensure that medication administration records are a true record of medication administered/not administered to service users. The registered person is reminded that medication administration records are a record of medication that has been taken by service users, not handed to them. Water temperatures should be tested in washbasins in bedrooms as well as bathrooms to control the risk of scalding for service users. There should be an action plan in place to evidence how the minimum requirement to have 50 of care staff trained to NVQ Level 2 or equivalent will be achieved. All staff should undertake basic training to enable them to undertake their role safely and effectively. 2 3 OP8 OP9 4 5 6 OP25 OP28 OP30 Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Olde Coach House The DS0000019753.V329875.R01.S.doc Version 5.2 Page 27 - 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. 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