Inspection on 06/09/05 for Olde Coach House The

This inspection was carried out on 6th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Olde Coach House The 01/02/07

Olde Coach House The 05/12/05

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 The Olde Coach House 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW Lead Inspector Sarah Urding Unannounced 6 September 2005 9:30 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 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. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Olde Coach House Address 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW 01482 645094 01482 643363 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dema Residential Homes Limited Mrs Elaine Bismor Care Home 29 Category(ies) of OP Old Age (29) registration, with number DE(E) Dementia - over 65 (29) of places The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th February 2005 Brief Description of the Service: The Olde Coach House is a privately owned care home that is registered to offer accommodation for 29 people with dementia and/or old age. The accommodation provided is in 15 single rooms and 7 double rooms; 2 of the single rooms have en-suite facilities. 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. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five and a half hours and was unannounced. The inspector looked round the building and inspected a number of records and policies. Twelve of the twenty-nine service users and three staff were spoken to. A relative of a service user was also spoken to. What the service does well: What has improved since the last inspection? What they could do better: Minor additions to the care plans of service users are required to evidence that foot and optical health care needs are being addressed by the home. The use of a shared bedroom for treatment of all service users in the home is not appropriate as this compromises infection control. The recruitment of staff needs to be consistently robust so that service users are safeguarded. Activities provided in the home are not meeting the needs and interests of all service users. A number of service users say that “there isn’t much to do” and one service user said “ we get bored with ourselves”. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 6 Service users and relatives felt that the home was short staffed at times. Whilst staffing levels are assessed as appropriate, the layout of the building or deployment of staff may lead to this perception. This should be reviewed. Some environmental recommendations are made so that service users remain protected. Hot water pipes must be covered and the registered person must provide evidence that the boiler and central heating system have been serviced. 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 Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 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 standard(s) 1, 3, 6 Service users are well informed by the home’s statement of purpose and service user guide. The assessment that the home carries out on service users prior to admission is not comprehensive enough to ensure that all of their needs will be met. EVIDENCE: On admission the home provides comprehensive information to service users and their families about the facilities on offer so that they can make an informed choice about where to live. The recommendation made at the previous inspection to include the views of service users about the home in this document is not yet in place but the home is in the process of compiling this. One service user who had only been in the home for two weeks did not recall having seen the brochure about the home. She said that her daughter had been given all of the information. A copy of the service user guide should be given to service users also and be revisited on a regular basis by staff so that service users are familiar with this document. The assessment of service users covers most aspects identified in standard 3.3. However this does not include reference to how dental, foot and optical care needs will be met. In order to ensure that these basic needs are met for The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 9 all service users, reference should be made to these aspects of care, however routine. The home does not offer intermediate care to service users. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Service users health care needs are being met although evidence of this is lacking in one care plan inspected. Service users are respected and treated with dignity by staff. EVIDENCE: The majority of service users records indicate that care plans are clearly set out to meet all aspects of care. The care plan of one service user did not demonstrate to staff how foot and optical care needs were to be met. In discussion with the deputy manager it became clear that the service user took responsibility for meeting these aspects of care herself. Whilst it is positive that the home encourages service users to remain as independent as possible, this must be reflected in the care plan to evidence that this area of need is being addressed by the service user. It was clear from records inspected that the health care needs of service users are being fully met by the home. Service users are able to register with a GP of their choice and access to specialist services is made available. One area of practice requires review. A number of service users currently see the chiropodist in one of the shared bedrooms. This is unacceptable as it could lead to cross infection. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 11 A clock in the living room, displaying the date and time was not correct. This could lead to confusion for service users and must be repaired or replaced. The home has a comprehensive medication policy and trained staff administer medication to service users. Records kept were clear and concise. All service users spoken to spoke warmly about the staff in the home. They consistently stated that staff respect them and their dignity is upheld during personal care tasks. Staff were observed to knock on service users doors prior to entering and were aware of the sensitivities involved while carrying out personal care. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 The home does not offer all service users the opportunity to experience activities suited to their needs. The lives of service users are enriched by family and friends being able to visit the home. Meals are nutritious and balanced and offer a healthy diet for service users. EVIDENCE: The home offers some activities on a regular basis including slide shows, hairdressing and “sing a longs” but an activities plan is not available for service users to refer to. Some service users spoken to said, “There isn’t much to do”. One service user said “ we get bored with ourselves”. It was clear from speaking to service users that the existing range of activities is not sufficient to meet the needs and interests of everyone. The home must address this by providing activities for all. A regular plan of varying activities would enable service users to have more choice in this area. Service users spoke positively about staff taking them for walks in to Hessle. Contact with service users friends and family is promoted well by the home. Service users said that they are able to see friends and family when they wish. One relative spoken to said that she was made to feel welcome when visiting. Relationships between staff and service users were positive and mutually beneficial, with staff speaking positively about the service users they care for. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 13 One service user said, “Staff are very kind”. Independence is promoted by the way in which staff work with service users on a daily basis and a range of advocacy services are made available to service users in the home’s brochure. Service users are given choice around where to have their meals. Staff ask service users daily what they would like to eat at lunch and teatime. Service users were clear about what was on offer, demonstrating good levels of consultation and communication. The home provides healthy and wellbalanced meals for service users who said that meals are “very good”. One service user commented on the fact that her meals “could be hotter”. This was passed on to the deputy manager to address. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Arrangements for complaints and the protection of vulnerable adults are handled well and ensure that service users feel listened to and protected. EVIDENCE: Service users spoken to said that they had no complaints about the home but felt confident to raise issues of concern if they arose. Complaints are recorded in the diary and addressed by the manager. They are then reviewed at the end of every month as part of the quality assurance system and recorded appropriately. The home has a clear complaints procedure in place. The home has an appropriate policy in place for the protection of vulnerable adults. The local authority guidelines for the protection of vulnerable adults are also in place. Staff spoken to were clear about reporting procedures should a service user make an allegation and around the indicators of abuse. Training for some staff has been on an in house basis and it would be good practice if all staff received the local authority training on the protection of vulnerable adults. Service users spoken to said that they felt safe when being looked after by staff. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25, 26 Generally service users live in a safe and well-maintained environment however some outstanding areas require attention so that the service users are not placed at risk. EVIDENCE: The home is clean, well presented and homely. A planned programme of maintenance is in place and work is ongoing to further improve standards in the home. There is evidence in reviews that service users are regularly consulted about their wish for locks on doors and lockable storage space. This is good practice and was a recommendation made at the last inspection. This standard is now met. Currently, the work identified at the last inspection regarding the need for radiator covers is being carried out. The covering of hot water pipes has not yet taken place. This must be addressed with priority. Water temperatures are monitored on a regular basis and “caution” signs have been placed where there is a risk to service users and staff from hot water. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 16 Policies for the control of infection are in place but as mentioned previously in this report practice around the use of a shared bedroom for treatment must be reviewed. Service users spoken to were positive about standards of cleanliness in the home. Laundry facilities in the home are appropriate and meet the needs of the service users. Service users commented on the cleanliness of their clothes on the return from the laundry. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Service users needs are met by the good level of staffing and training provided in the home. The procedures for the recruitment of staff have improved and offer protection to people living in the home. However there are some shortfalls in this area which could place service users at risk. EVIDENCE: The home is well staffed at all times. Three/four care staff are on duty at all times throughout the day supported by a cook, two housekeepers and a laundry assistant. Two staff are on duty at night. In addition one/two senior members of staff are on duty at all times supported by the manager. Despite the good staffing levels it is a perception of some service users and relatives that the home is often short staffed. This may be due to the layout of the home and/or the deployment of staff. This should be looked at by the registered manager. Recruitment practice in the home has improved and service users are safeguarded. CRB checks and references are in place prior to staff starting work. However there was one instance where a member of staff had started work prior to her CRB check being received. The manager explained that the member of staff was inexperienced and had been started in order to provide her with some experience. This was in addition to the rota and she was supervised at all times. In this instance a POVA First check was not in place and must be when CRB checks are outstanding. The CRB check for this member of staff has been subsequently obtained. One reference is still The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 18 outstanding for a member of staff. The registered manager must address this. Staff are appropriately trained and undergo induction and foundation training. As identified previously in this report it is recommended that local authority POVA training be provided to all staff. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, 38 High levels of consultation and regular reviews by the manager ensure that service users are looked after in an environment that is both safe and inclusive. Some minor areas require attention in order to ensure that service users are safeguarded in all aspects of care. EVIDENCE: The home operates an effective quality assurance system that seeks the views of service users and staff on a regular basis. There is a monthly audit system in place that looks at key areas aimed at improving standards. This is good practice. Service users are protected by the financial procedures of the home. The home does not act as appointee for any service users and looks after money appropriately. Written records of all transactions are accurately maintained. The home has detailed policies and procedures in place. Most records are kept The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 20 appropriately. Some elements of service users records are not in place. Photographs of service users are not kept by the home and must be as specified in schedule 3. The registered person is not compiling reports in respect of regulation 26 and must do so. Copies of these reports must be sent to CSCI for information. Generally the home operates in the best interests of the health and safety of service users and staff. All safety checks are carried out within the specified time frame and policies are in place for safe working practice. One area requires attention so that service users continue to be safeguarded. The gas safety certificate was not available for inspection so it was unclear if the system has been serviced. The registered person must provide evidence that this has taken place within timescale. All staff receive health and safety training. The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 2 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 2 2 The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 22 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 3 7 Regulation Requirement Timescale for action Oct 31st 2005 Sept 30th 2005 3. 25 4. 8, 10, 12, 26 5. 29 6. 37 7. 37 12, 13, 14 The assessment of service users must cover all aspects of standard 3.3. 12, 13 The care plan for one service user must evidence that all health care needs are being addressed by the home. To include optical and foot care. 13, 23 The registered person must ensure that pipework is guarded or has a guaranteed temperature(previous timescale 1/4/04 not met). 12, 13, 23 The registered person must make proper provision for the treatment of service users. The use of a shared bedroom for chiropody treatment must cease. 19 The registered person must ensure that new staff are confirmed in post only following completion of a satisfactory CRB check and two written references. 17 The registered person must keep all records identified in schedule 3. To include photographs of service users. 17 regulation 26 reports must be completed by the home. Copies of this must be sent to CSCI. J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Nov 30th 2005 Immediate and on going Immediate and ongoing Oct 31st 2005 Oct 31st 2005 Page 23 The Olde Coach House Version 1.40 8. 38 12, 13, 23 The registered person must ensure that the gas system is serviced within timescale. A copy of the certificate must be sent to CSCI for information. Sept 30th 2005 9. 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 1 Good Practice Recommendations Service users views should be put within the service user guide to the home. Staff should ensure that all service users are familiar with the guide for the home. A reference copy should be made available to service users at all times. The clock in the lounge should be repaired or renewed. An activities plan should be made available for service users reference. Local authority POVA training should be made available to all staff. The registered manager should review the deployment of staff in the home. 2. 3. 4. 5. 8 12 18 27 The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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. Extracts may not be used or reproduced without the express permission of CSCI The Olde Coach House J53_s19753_Olde Coach House_v247070_060905_Stage 4.doc Version 1.40 Page 25 - 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!