Inspection on 11/08/06 for The Coach House

This inspection was carried out on 11th August 2006.

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

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

Other inspections for this house

The Coach House 10/06/08

The Coach House 30/01/06

The Coach House 22/08/05

The Coach House 30/11/04

The Coach House 09/07/04

The Coach House 19/02/04

The Coach House 04/12/03

The Coach House 19/09/03

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

CARE HOMES FOR OLDER PEOPLE The Coach House 67 Keyhaven Road Milford-on-Sea Lymington Hampshire SO41 0QX Lead Inspector Isolina Reilly Unannounced Inspection 11th August 2006 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 The Coach House DS0000011880.V303490.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. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 67 Keyhaven Road Milford-on-Sea Lymington Hampshire SO41 0QX 01590 642581 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) Mrs D L Fry Mrs D L Fry Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (17), Old age, not falling within any other category (17) The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Currently has three service users under 65. No future admissions in this category 30th January 2006 Date of last inspection Brief Description of the Service: The Coach House is a care home providing personal support and accommodation for up to seventeen older people with the following needs, old age, dementia or mental health. The home is owned and managed by Mrs Donna Fry and is situated in a quiet residential area of Milford On Sea with local amenities are a short walk from the home. The Coach House consists of a three story building with thirteen bedrooms, nine are single and three of the four double bedrooms are en-suite. There is a dining room and lounge with conservatory overlooking the homes enclosed garden. A stair lift provides access to the first floor, thereafter stairs provide access to the third floor, which comprises of two wings, one with service users bedrooms and the other provides private accommodation for two staff. The provider makes information available about the service, including a statement of purpose and service user guide and the commission’s report to prospective residents on request. Copies of these documents are available at the home and may be sent out by post on request. The home states in the pre-visit information questionnaire completed by the manager on 29th May 2006 that the fees range from £385.21 to £446.00 for residential care. There are additional charges for hairdressing, chiropody, newspapers and toiletries. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over one day. The inspector looked around the home, viewed records and procedures, spoke with residents, a relative, staff and observed the interaction between them. The manager helped the inspector during the visit. Information has also been taken from the pre-visit questionnaire filled in by the manager and other correspondence with the home. The commission has received no written questionnaires from residents or visitors. What the service does well: The home is good at assessing if it can meet the needs of residents before they come to the home and makes good records. The residents and relative spoken with stated they had useful information about the home when making the decision to stay. Everyone spoken with confirmed that staff are caring, respectful and mindful of peoples need for privacy and dignity. There are reasonable records kept by the home to help carers look after individuals. The carers are aware of residents’ needs and how to care for them. The residents have access to health care professionals either those that visit the home or by going out to see them. The home has various themed activities each afternoon with external entertainers visiting regularly. A mobile library stops outside the home and the local church provides regular visits including communion for those who wish to take part. The home has an open and good process in place for dealing with complaints, concerns and compliments. The staff team at the home is skilled and receive regular training to be able to care for the residents. The home has a logical and detailed process for recruiting new staff. There are good systems in place for making sure that the service is run in a safe manor for residents. The residents stated they all feel safe and comfortable at the home. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Coach House DS0000011880.V303490.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 The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good admission process, giving residents and their families clear information regarding the service that meets the needs of the individual. The home does not provide intermediate care. EVIDENCE: The residents spoken with explained that family members were able to visit the home before making their decision to stay. The relative spoken with confirmed this. The manager visits the prospective client and undertakes an interview with them and their family or carer. She completes a full assessment of needs and aspirations. Records of these completed assessments were seen on the files tracked. One out of the four residents records seen had a copy of the Adult Services care management assessment and the instructions to care staff mirrored those The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 9 needs. Another residents file had a copy of a health care assessment prior to admission. The manager confirmed that all new residents undergo a full assessment of their needs to establish if the home is able to meet their needs. These cover the necessary areas including, personal care, physical well-being, dietary preferences and records of regular weights. Information was seen on each file that described issues with sight, hearing, mouth and foot care. There was information on the level of mobility and dexterity and a history of falls, continence and behaviour. There were records of life history and relationships including likes, dislikes and preferences. The relative spoken with said that the home asked lots of relevant questions and looked after the residents well. Three residents spoken with were able to recall their admission stated that they were made very welcome. One said “This is good place and has become my own home.” The four residents records seen contained a signed contract that were informative and contained all the necessary information. The relative spoken with confirmed that the contract had been explained to them when they first came to the home. The manager confirmed that the home does not provide ‘intermediate care’. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records of care within the home hold sufficient detail for staff to meet residents’ personal and health care needs. The home promotes residents’ privacy and dignity. However, confidentiality of information held at the home needs to be tightened. Medicine is stored and handle appropriately but administration records have gaps in them, which need to be addressed. EVIDENCE: Three out of the four resident files were discussed with each individual resident who confirmed that they recognised the records and the staff have discussed their needs and care with them. The relative spoken with confirmed this. The care plans contained written risk assessments and instructions to staff on how to look after the individual. The records also included names of relatives, friends, health care professionals and social services care managers who are involved in supporting the individual. All files seen had been recently reviewed by staff and signed by each resident. There were details of monthly reviews and changes to care instructions recorded. However, one care plan had yet to The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 11 be up dated to reflect the determination and subsequent change in care needs of the individual. The manager amended the care plan on the day of the inspection to reflect the additional care needed. Three staff spoken with were aware of this individual’s changing care needs and the resident had been receiving the necessary care. The staff stated that they did use the care plans and found them particularly useful when new residents arrive at the home. One resident confirmed that they regularly like to go out for walks to the local shops and down to the park. The manager and staff were aware of this and felt that the individual’s safety was not at risk. However, a written risk assessment had not been recorded in the individual’s care plan. The manager stated this would be completed as a priority. Records of doctor and nurse visits and information on outpatient, dental, optician and chiropractic appointments were seen on the files. Various residents stated that a visiting dentist and optician had seen them. The recent treatment and corresponding medical notes were present in the file. The residents spoken with felt they are being well looked after by the home. They described staff as caring, helpful and appeared to know what they are doing. They also said everyone was respectful, mindful of their privacy and dignity. Four residents spoken with stated that they choose and wear their own clothes. The inspector observed the residents appropriately dressed. The inspector observed the staff interacting with the residents and found them attentive, caring, respectful and have a good understanding of individual’s needs. Refreshments and snacks for both residents and visitors were offered regularly throughout the day. A staff member was observed administering medication appropriately and there is a good medication policy and procedures. The home administers from ‘single blister pack system’ provided by the local pharmacist and correctly stores in a locked cupboard in the kitchen. The home’s medical room and cupboards stored were clean and reasonably orderly with medication stored correctly in date and in sufficient quantities. However, medication kept loose in the kitchen fridge and could have been accessed by a confused resident. The manager as a temporary solution provided a lockable container and locked the medication in the tin returning it to the fridge. She stated that the home would invest in a small fridge just for the storage of refrigerated medication. Currently no residents are self administering their own medicines. The manager and a senior carer order and check all medicine received at the home recording name, quantity and sign for them. The records were seen and found to be satisfactory. The home uses the ‘Medicine Administration Record Sheets (MARS) system for recording the administration of medication. Each resident’s record also has a recent photograph. It was noted that there were several signature gaps in the administration records for one out of the fifteen records seen. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 12 Medication that is in need of disposal is returned to the local pharmacy and a record is kept by the home that is signed on receipt by the pharmacist. This record book had been left at the pharmacy and a carer went to collect it from them during the visit. On return of the book, the records seen were satisfactory, although it was noted that a resident’s contact information sheet had been used as a piece of card to lean on whilst completing the record. This card had been accidentally taken with the book to the pharmacist. The concern was that personal details regarding a resident had not been kept confidential. This was discussed with the manager who gave a verbal undertaking to ensure that all staff are reminded of their obligations under data protection and the home’s confidentiality policy to ensure this does not happen again. The carers stated they have received training in the safe handling of medication. The manager stated that all staff have received instruction on the safe handling of medication and she has accessed their competency. She confirmed that all staff are have or are in the process of completing an external training course in the safe handling of medicines. Staff training records seen confirmed this. The Coach House DS0000011880.V303490.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 at least once during a 12 month period. 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. The residents experience a stimulating and varied life at the home with visitors made welcome. The meals in this home are good and residents are given a choice. EVIDENCE: The inspector observed residents reading large print books, daily newspapers and magazines. Two residents stated that thy enjoy reading and look forward to the mobile library visits to change their books. Several residents spoke with stated that “in the mornings there was not much going on”. This was confirmed by the staff spoken with stated that in the morning they were generally busy providing personal care and other health and personal care associated tasks. Five of the residents spoken with stated that they prefer to do their own thing and were not keen on the organised activities that the staff undertake in the afternoon but enjoyed the sing songs and musicians that visited the home. The manager confirmed that they had The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 14 organised various external activities from arts and crafts to exercise but the residents had chosen not to join in which was not effective use of the visiting activities people’s time. The home has asked the residents what their preference is and devised an activities plan for each afternoon. The plan is available on the notice board in the dining room and the staff office. Activities include themed arts and craft such as beach huts, art and music around the world, the past through pictures, indoor gardening, different eras in history, comedy and changing environment. Activities within these themed days include painting, building mosaics, card games, picture slide shows, discussions and quizzes. Three residents and the relative confirmed that clergy visit the home regularly. Two residents stated that they had received communion the day before. Information about residents’ religious preferences and cultural aspiration were seen on file. The relative spoken with feel the clients are well cared for and that they are made very welcome and part of the home. The inspector observed that the relative visiting that day had been offered refreshments. There were cold drinks available all day in the communal areas, hot drinks, biscuits and cake was taken around regularly throughout the day. All the residents stated that the day routine is flexible and a meal can be put aside should they wish. The inspector was able to speak to kitchen assistant and found there are reasonable systems in place for cleaning, hazards and risk assessments. The menus are kept in the kitchen and on the notice board in the dining room. The menu does not include an alternative but staff and residents confirmed the carers go around and ask if they want an alternative. Individuals’ likes, dislikes and special diets were recorded and a list kept in the kitchen. The inspector viewed the four-week menu and found it to be variable, balanced and with written amendments and no alternatives listed except for the lunchtime meal. The records of food provided by the home showed that alternative meals were provided on a regular basis and the kitchen staff were aware of individuals preferences. The residents and visiting relative felt the food was fine and of good quality. The residents were very happy with mealtime experiences and felt they were not rushed. The meal was observed by the inspector and found to be relaxed, unhurried and the food attractively presented. Daily records of foods served and temperatures of hot probed meals and freezers and fridges are kept by the cooks and found to be satisfactory. Environmental Health Officer last visited the home in May 2006 and made one requirement that has been addressed by the home. The Coach House DS0000011880.V303490.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 inspected at least once during a 12 month period. 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. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues that protects residents from potential abuse. EVIDENCE: The residents and relative spoken with stated that they would go straight to the manager if they had a concern or complaint. They confirmed that the staff are good and listen to their concerns. The relative felt that the staff were patient, caring and willing to listen and the inspector observed this during the day. The staff spoken with were aware of the home’s complaint procedure. The home’s complaint procedure includes the address for the Commission and that all complaints will be dealt within 28 days. A copy of the home’s complaint procedure is displayed in reception. The home has received one complaint in the last twelve months, which were resolved promptly. The complaint log was seen and found to be satisfactory. The manager confirmed that detailed records of each complaint are stored separately. All the residents spoken with stated that they always felt safe at the home and the relative also confirmed this. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 16 The staff spoken with confirmed that they have received instruction and are aware of the protection of vulnerable adults from abuse. They have had training on recognising and reporting of concerns or suspicions. The staff spoken with were clear about their responsibilities regarding protection of vulnerable adults. The manager confirmed that all staff undertake instruction in adult protection and abuse on induction and are able to refresh their understanding by watching an educational video. Also a further six staff have attended external training on the protection of vulnerable adults. There has been one allegation of abuse at this home. The allegation was promptly and appropriate reported and records kept. The home has an copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure from 2003. The manager was advised to ensure she has the latest copy and is aware of amendments. The home also has it’s own policy and procedures reflecting the guidelines from Hampshire County council’s own policy. All the staff spoken with stated that there was an open and encouraging ethos to speaking up when things are not quiet right and issues being dealt with promptly. The Coach House DS0000011880.V303490.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home presents as a clean, homely, comfortable and suitable environment for the residents. However, the home is having an on going problem managing offensive odours. The standard of the décor within the home is good with evidence of on-going maintenance and improvements but infection control practices can be improved. EVIDENCE: The residents stated that the home is clean, warm and in communal areas no offensive odours were detected. They also confirmed that there has been on going decorating. In the main the inspector observed this on the tour of the home. But there was an offensive odour problem in bedroom 3. The management of offensive odours have been an on going problem for the home and a requirement was raised at the last two inspections. The offensive odour problem on the ground floor corridor outside the manager’s office and resident’s bedroom has improved greatly with soft furnishing and the carpet The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 18 being replaced. But bedroom three still has a problem. The manager stated that sift furnishing and the carpet will need replacing to improve this. The manger confirmed that there has been substantial redecorating and refurbishment throughout the home where carpets have been replaced in four bedrooms, five new beds in three bedrooms and one further bedroom fully redecorated. All the residents spoken to like their bedrooms. The home’s radiators and pipe work are safe ensuring that potential hot surfaces are kept to low temperature. A random selection of the bedrooms where seen on a tour around the home and were found to be clean, bright and warm, furnished to the individuals taste and most had been personalise. Ten residents’ spoken with felt there were enough toilets and bathrooms. The bathroom on the first floor is awaiting new flooring as the lino was damaged during a water leak. During the tour of the home, the inspector noted that all baring one communal hand sinks had liquid soap for washing hands and disposable paper towels, which promoted good hand hygiene. There were gloves and plastic aprons available in different places around the home, including the laundry, toilets and bathrooms. The residents and relative stated that the staff do use them and the inspector observed this during the visit. The staff confirmed that they have received regular training on infection control. The laundry room is small and accessed from outside the house. There is one domestic size washing machine and a tumble dryer seen working. The manager confirmed that the home has a contract with a company who launders all bedding and towels. One residents and relative spoken with stated that they were happy with the laundry service provided. The inspector noted that residents’ clothing had been hung up to dry along the perimeter rough wood fence outside the laundry room. This was discussed with the manager due to the risk of wood splinters getting into the clothes and becoming stained. The manager stated that she would invest in a new washing line as a matter of urgency to replace the one that had broken recently. The Coach House DS0000011880.V303490.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 at least once during a 12 month period. 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. The staff at the home are well trained, supported and employed in sufficient numbers to meet the residents needs. There are satisfactory recruitment procedures that ensure residents are not put at risk. EVIDENCE: The residents spoken with described the staff as ‘caring, friendly, helpful and around when you need them.’ All residents stated that the staff were always polite and had no complaints. Ten of the residents spoken with stated that they were happy at the home. All the residents and relatives spoken with said there was sufficient staff around and that the staff know what they are doing. The rotas showed that a minimum three carers during the day, two carers in the evening and one awake carer each night. These figures exclude the manager. The rota shows a mix of experience and new staff and the manager confirmed that all staff are over eighteen years of age. This was confirmed in the written information provided by the home for this visit. The home also employs one-kitchen assistants and is in the process of recruiting for a cook. Currently the manager or the kitchen assistant are cooking the meals. The home also employs a cleaner who undertakes some menial maintenance. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 20 The staff spoken with felt there was a good skill mix within the staff team and they worked well together as a team. The staff asked had received a copy of the General Social Care Council’s code of practice and extra codes were available in the office. The manager explained that she had also secured copies of the General Social Care Council’s code of practice in the native language of the overseas workers at the home. The manager confirmed that she is working towards increasing the number of carers with qualifications in care. Currently due to staff leaving 58 of carers hold a qualification in care. Out of the twelve carers employed by the home two have a National Vocational Qualification (NVQ) level two in care and one NVQ three in care. The manager confirmed that four overseas staff hold equivalent qualification to NVQ three in care. The staff spoken with felt that the recruitment process within the home is thorough. The inspector was able to see three different staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. Other records seen on file include signed contract of employments, job descriptions and criminal record bureau and protection of vulnerable adults register checks. The manager explained that she is responsible for identifying training needs and securing training for the staff. The records of training were seen and found to be detailed. These included copies of certificates. The staff spoken with stated that the induction programme run by the home was useful and detailed. The files seen held records of the individual staff induction training covering the key areas with the signatures of the staff member and trainer. The manager confirmed that the home’s induction programme meets the recently amended Skill For Care standards for induction. The home’s training records shows that external and internal training is done. The staff confirmed that they undertake training regularly and the inspector viewed copies of individual staff training certificates and other records of instructions. The staff have received training in the necessary health and safety subjects such as fire safety, first aid, moving and handling, health and safety, infection control and food hygiene. Other training courses attended by staff include dementia, abuse training and principles of care. The Coach House DS0000011880.V303490.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 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 run well by an experienced owner manager. There is an informal system for involving residents in the day-to-day running of the home that needs to be formalised and an appropriate, auditable quality assurance system implemented. The home is not involved in monitoring or handling residents’ money. The residents’ health, safety and welfare are well promoted by the home with systems that ensure everyone is protected within the home. EVIDENCE: The owner manager has many years experience in this business. She is a registered nurse and holds a National Vocational Qualification (NVQ) level 4 Registered Manager’s Award. She undertakes regular up date training with the The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 22 staff and has recently completed training in Food hygiene, fire safety and risk analysis. The staff spoken with confirmed that there is a clear line of authority within the home. All the staff, residents and relative spoken with found the management supportive and approachable. The home has a programme of one to one monthly supervisions that has recently lapsed, annual appraisals and various staff meetings that are minuted. The manager stated that she would restart the supervision sessions to ensure staff receive a minimum of six supervisions in a twelve month period. The residents stated that their family or financial appointees rather than the home look after their money. The manager confirmed they do not hold residents’ money in the homes safe. The manager explained that she is not an appointee for any client. Regular risk assessments are undertaken and recorded to ensure that the safety within the home room by room. These were sampled and found to be satisfactory. The managers explained there is an informal quality assurance process that feeds but there are no records of audits are done. The residents spoken with stated that they felt their opinions were valued within the home. The staff felt they were included in the day-to-day decision making within the home, stating that changes and or issues are discussed and actions agreed at regular staff meetings that are minuted. The minutes were available from the offices for reference. The manager shared with the inspector surveys completed by residents and relatives regarding if individuals were able to understand staff from overseas. The responses were positive and undertaken as a direct response to a complaint made at the home. However, residents, relatives and other stakeholders have not been involved in quality survey for some time. The manager stated that she would restart this practice. Since the last inspection, the home has produced accidents, injuries and incidents, illness or communicable disease records and appropriately reported to the commission under The Care Homes Regulations 2001, regulation 37. Evidence of this was seen across the four care records tracked that correspond with the commission report received and from speaking with staff and the manager. This was an outstanding requirement from the previous two inspections. Records were sampled of maintenance undertaken on equipment within the home and it was evident that regular maintenance is undertaken. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 23 All the residents and relatives spoken with stated that they felt safe at the home and some confirmed that the fire alarms are regularly tested. The manager explained the recording system for fires safety maintenance, training, evacuation and visual checks. The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals to ensure the safety of the residents. The home has at past inspections had a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being utilised within the home. However, on this visit she was unable to find the file. This was discussed with the manager who agreed that it would be safer to have various copies around the home one for the cleaner, the kitchen and the main file held in the office. The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 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 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 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 16, 2(k) Requirement The care home is kept free from offensive odours. THIS IS A REPEAT REQUIREMENT FROM 22/10/05 The responsible individual must undertake and maintain a system for reviewing and improving the quality of the service provided at appropriate intervals. This must include a formal system for securing service users and their representatives’ views. Timescale for action 30/09/06 2. OP33 24(1) (2)(3) 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Coach House DS0000011880.V303490.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Coach House DS0000011880.V303490.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. 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!