Inspection on 12/08/08 for The Coach House

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Good service.

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

The Coach House 04/12/07

The Coach House 07/11/06

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Coach House 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU Lead Inspector Joy Hoelzel Key Unannounced Inspection 12th August 2008 10:00 X10029.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 DS0000067681.V370085.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU 01902 343 000 01902 331000 goldthorncourt@btconnect.com 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) Select Health Care (2006) Limited Susan Margaret Jones Care Home with Nursing 70 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 70 Both of places Dementia (DE) 70 Both The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing – Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia – Code DE (70) Mental Disorder, excluding learning disability or dementia – Code MD (70) 2. The maximum number of service users who can be accommodated is: 70 Date of last inspection 4th December 2007 Brief Description of the Service: The Coach House is a purpose built care home providing accommodation, nursing and personal care for up to seventy people of all age groups. In June 2006 the home was registered with Select Healthcare Ltd as new providers for the service. The home has a variety of communal lounge and dining areas, all bedrooms are single occupancy with en suite facilities. The home is located at Goldthorn Hill, Wolverhampton and is within easy walking distance of the local shops and amenities. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have been revised and are readily available. The service user guide states the weekly fees range from £600.00. The reader may wish to obtain more information of the differing level of fees from the care service. Commission for Social Care Inspection reports for this service are available The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 5 from the provider or can be obtained from www.csci.org.uk The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection took place over five and a half hours on Tuesday 12th August 2008 Twenty three of the thirty eight National Minimum Standards for Care Homes for Older People and twenty one of the forty three standards for Care Homes for Adults (18-65) were inspected as they are viewed as key standards for services. Sixty three people are currently living at the home and during the inspection were observed to be accessing all areas of the home. The registered manager, Sue Jones, was on the premises and was supported by the deputy manager, two registered nurses, eight care staff, a social activities coordinator, domestic and catering staff. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. Discussions were held with people living, visiting and working at the home. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to us within a given timescale. The registered manager completed this document and returned it to us. Comments from the AQAA are included within this inspection report. Have Your Say surveys were distributed to people living, working and visiting the home prior to this inspection. The comments from those that were completed and returned are included in this report. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations have been made following this inspection. All evidence points to a service that has developed systems to provide good quality outcomes for people living at the home. The continuity and effectiveness of the recent changes will be determined in due course. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 8 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. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6. YA 2. Quality in this outcome area is good. Admissions are not made to the home until a needs assessment has been undertaken by a senior member of the staff team, this ensures that the home is confident that all assessed care needs of the individual can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of the service provision are available in the statement of purpose and service user guide; both documents have recently been updated are available The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 11 on request at the home. The service user guide includes details of the current level of fees, the services that are provided and includes photographs of the environment and garden. The case file of the person who recently moved into the home was looked at to see if information had been sought regarding this persons needs prior to moving into the home. Information had been gathered from various outside agencies and an assessment of care needs had been conducted by the home. This gathering of information ensures that the service can be confident that the care needs of people can be satisfactorily met. This person was unable to fully comment on the admission and assessment process but looked settled, at ease, comfortable and well cared for. Other case files selected and looked at contained similar sources of information and included a full assessment of needs completed by the home prior to offering a placement. The Annual Quality Assurance Assessment completed by the manager records and describes the admission procedures ‘Service users are initially admitted on a trial basis following a full pre admission assessment including liaising with multidisciplinary teams, attending meetings, speaking to families and any other person. The prospective service user is invited to visit the home as often as they feel necessary’. The home does not provide an intermediate care service. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10. YA 6,9,16,18,19,20. Quality in this outcome area is good Each person has a plan of care that, whenever possible, is written with the individual, or their representative, and includes a range of information and details of their care needs. Implementation of the revised care planning documentation should focus on an individual’s particular needs in a person centred way. This judgement has been made using available evidence including a visit to this service. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each person living at the home has an individual plan of care based on the information gained prior to admission. The plans, whenever possible are discussed with the person and/or their representative. Each plan is reviewed at least monthly or when a change of need has been identified. A full review of the care plans and documentation is currently receiving attention to ensure that the documents being used are fully suited and appropriate to the client groups. The manager explained the work in progress and the anticipated time scales for completion. When completed the new files should give a complete person centred picture of the care needs of the individual. Thereby ensuring that health, personal and social care needs can be fully met. Two case files from each unit were selected for inspection and were looked at in depth. Several more case files were selected throughout the course of this inspection to determine that the care being delivered and the assessed care needs corresponded. Inspection of these files, observation of working practice and discussions with people living and working at the home suggest that satisfactory care is being delivered. The Have Your Say comment cards received from six service users and one relative indicated that generally they get they care and support they need • • My relative is given the care and attention she needs. I think we usually get the help from the carers most of the time. The Annual Quality Assurance Assessment completed by the manager discusses the ways that equality and diversity are promoted within the service by – ‘Staff are actively encouraged to be proactive and offer person centred care to cater for all our service users individual needs’. During the past twelve months the manager explained some improvements that have been made – ‘Service users are far more involved in their plan of care’. Changes have been made to the pharmacist supplying the medications for the service with the pharmacist carrying out regular audits. The deputy manager continues to audit the medication on a monthly basis to ensure that an accurate system is maintained. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 14 The registered nurses administer the medications, the Medication Administration Record appears to be fully completed, and no gaps in the recording sheet were seen in the selection viewed. Observation of staff working practice and during the tour of the premises evidences that the privacy and dignity of people is upheld at all times. Staff were very respectful when speaking with residents and it was obvious that very good relationships had been developed and maintained. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15. YA 12,13,15,17 Quality in this outcome area is good People are involved in daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 16 The service has a full time coordinator to arrange and facilitate social, leisure and recreational activities. A full programme of events is available each month and is displayed on the notice boards around the home. Community meetings are held each week, chaired by service users and offer people the opportunity to discuss the content, frequency and preferences of the activities. A group of people went on a days outing to the seaside and stated that this had been a very enjoyable event. Other trips out to local places of interest have been arranged. A variety of activity is arranged for the people who are unable or unwilling to go out of the home. Many people were enjoying singing along to well known tunes, reminiscing and participating in board games. Other people were reading the daily papers or interacting with staff and visitors. The activities coordinator discussed the opportunities for religious observance and the many faiths of people living at the home. The coordinator and staff were observed to be particularly efficient in including and persuading people with complex cognitive difficulties to participate in various pastimes. Other activities recently introduced into the home are slimming and exercise class/group and gardening. The service has recently purchased of a greenhouse and exercise videos to assist with this. The Annual Quality Assurance Assessment describes the challenges with some people being very reluctant to take part in any social activity and records ‘We are always looking for new ways to encourage reluctant service users to participate in activities’. It goes on to record – ‘More activities are taking place both in groups and individually, some service users that are quite withdrawn are showing more of an interest’. The responses in the ‘Have Your Say’ surveys completed by people living at the home indicated a mixed view that always, sometimes or never were activities arranged. Friends and relatives are able to visit at times suitable to the resident. Any restrictions for people visiting are clearly recorded in the care plan and agreed with the person and the multi agency teams. The main entrance doors are kept locked for security purposes, a number keypad is used to for entry and exiting of the premises. There is restricted access between the units with a number keypad being attached to the doors. Other doors within the home which are locked include some private bedrooms, kitchenette, and offices. The revised documentation in the care plans includes an assessment on any restriction of liberty and a person’s capacity for decision making. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 17 During the tour of the premises some of the bedrooms had been personalised and contained the photographs, pictures and other items belonging to the person. Meals are served in the dining areas of the units and people are encouraged to sit at the table to eat. However, people are able to choose where they wish to eat. The dining tables are prepared in advance of the mealtimes, and people are asked their meal preference at the time of the meal and then are served their preferred choice by the staff. A selection of British, Caribbean and Asian food is provided. People stated that the food is good and that they enjoy the meals that are provided. It was noted that improvements and an attempt has been made for dining to become a more social occasion. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18. YA 22,23 Quality in this outcome area is good The complaints procedure is displayed in a number of areas and is available to help anyone living at, or involved with, the service to complain or make suggestions for improvement. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of how to make a complaint are included in the statement of purpose and service user guide and a copy of the procedures is displayed in various areas around the home. The manager stated that she had received one complaint about the service that she had looked at using the homes own procedures. This has been fully logged and a satisfactory conclusion was reached. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 19 We, the commission, have received one concern from a person living at the home. We have spoken with this person who is now reasonably satisfied with the care they are receiving. Since December 2007, six concerns have been referred to the Safeguarding multi agency team to be looked at under their procedures. Four have reached a conclusion with two still to be concluded. A meeting is arranged with the Safeguarding team and the registered manager to discuss these referrals. The manager discussed her involvement with the team and has offered her fullest cooperation during the process. Policies and procedures are available for reference in the event of any safeguarding issues. Staff demonstrated a good knowledge of the action they would take if they had any suspicions of wrong doings or potential abuse. Two out of the six ‘Have Your Say’ surveys completed by people living at the home stated they did not know how to make a complaint about the service. Others indicated that they would speak with a member of staff if they any concerns. No changes have been made to the procedures for the safe keeping of a person’s money. A selection of records relating to this were seen, each transaction is recorded, two signatures are obtained and receipts are kept. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,26. YA 24,30 Quality in this outcome area is good People stay in a safe and well-maintained home that is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 21 The Coach House is situated in a residential area of Wolverhampton and is purpose built as a care home. There are two main units each providing care for older and younger adults. Improvements to the environment have been continuing with the redecoration and refurbishment of private and communal rooms. The large smoking room is currently being divided into two. This will provide an additional quiet room with desks and computers but which can then be used as another meeting room if needed. The main corridors have benefited from replacement floor coverings and the walls have been decorated. The manager discussed other planned improvements for the coming year. People spoken with indicated a satisfaction with their own bedrooms, one person stating it was an ‘ ok place to live’. All areas of the home were clean and hygienic. A recent infection control audit conducted by the Primary care Trust resulted in a good standard being awarded. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30. YA 32,34,35 Quality in this outcome area is good There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A duty rota is maintained each week to indicate the staff on duty at any given time. The manager explained the staffing complement and the staff allocations, with each unit being staffed separately. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 23 General observations of staff working practice and home life, discussions with people living and working at the home suggests that the staffing complement is satisfactory for the needs of the current resident population. The Annual Quality Assurance Assessment completed by the manager documents that of the 33 permanent care staff 14 have been accredited with National Vocational Qualification level 2 or above. A further 10 staff are working towards the qualification. The home has achieved a ratio of 72 of trained care staff this ensures that suitably qualified, competent and experienced staff are working at the care home at all times. The recruitment of care staff is ongoing with interviews currently happening. The manager and administrator demonstrated and discussed the robust recruitment procedure that is in use. Both stating that it is crucial for the service to get the ‘right person for the job’. Staff personnel files were selected for inspection and contained references, criminal record bureau disclosures and confirmation of identity. An audit of all personnel files has recently been carried out to ensure that the necessary checks have been made. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 25 OP 31,33,35,38. YA 37,39,42 Quality in this outcome area is good The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve services. The manager leads and supports a strong staff team who have been recruited and trained to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Sue Jones is the registered manager for the service and has made many changes to the service provision. Throughout this inspection she discussed the improvements made and the plans for further developing the service. Clear lines of accountability have been established with Ms Jones leading the staff team effectively and efficiently. Health care professionals visiting during the inspection discussed the improvements made to the service and offered positive comments about the management team. One resident stated ‘ very satisfied with all aspects, managers and staff are excellent, I inform the manager if I feel anything needs improving’. Quality assurance and monitoring of the service continues with regular audits and review of systems, meetings for service users and staff and satisfaction surveys being distributed to stakeholders. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. A lockable drawer is provided in each bedroom for the safe storage of cash or valuables belonging to the individual should a person wish to use it. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept and available for inspection. Staff receive regular training and updates for all safe working practices including moving and handling, fire safety awareness and infection control. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 26 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 3 2 X 3 3 4 X 5 X 6 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 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 3 34 X 35 3 36 X 37 X 38 3 The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 27 No 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. Standard Regulation Requirement Timescale for action 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 DS0000067681.V370085.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. The Coach House DS0000067681.V370085.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!