Inspection on 18/07/06 for The Coach House

This inspection was carried out on 18th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Coach House 04/11/08

The Coach House 24/01/08

The Coach House 05/01/06

The Coach House 10/08/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Coach House Trevaylor Manor Newmill Road Nr Gulval Penzance Cornwall TR20 8UR Lead Inspector Stephen Baber Key Unannounced Inspection 18th July 2006 09:30 18/07/06 The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 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 DS0000063988.V292756.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Coach House Address 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) Trevaylor Manor Newmill Road Nr Gulval Penzance Cornwall TR20 8UR 01543 414222 Swallowcourt Limited Annette Margaret Reynolds Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: The Coach House is a brand new purpose built care home offering ground floor and first floor accommodation for 9 adults with physical and complex needs and who experience a learning disability. The registered provider is Swallowcourt an organisation that provides specialist care for people with special needs and owns three large nursing homes. Mrs Annette Reynolds is the manager and is registered with the Commission. The manager explained the aim of the home is to provide specialist support in a homely environment where residents can experience a quality of life with the support and care of the staff. The home is located in Newmill and is within the curtilege of the grounds of Trevaylor Manor, which is registered as a nursing home. The facilities are separate with the home having its own entrance, parking to the front for several cars and beautiful walled gardens, which are safe for the residents to use. Penzance town is 2 miles away and a bus service passes the home twice a day. The Coach House shares transport with its sister homes in Penzance. All the residents have their own ensuite bedrooms and special locks have been fitted to give greater privacy if it is required. The home has communal space, including a lounge/dining room, and further conservatory, which is much, enjoyed by the residents and looks out over the walled gardens. There is a small fully equipped kitchen and additional bathrooms and toilets on each floor. There is a shaft lift that serves the two floors and there are two waking night staff on duty to offer care and attention to the service users. Weekly fees range from £800 to £1100. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focus on the experience of people using services and focus on providers to ensure quality. This was an annual key inspection, which took place over two days and was unannounced. It lasted for approximately 14 hours. The Commission received information about the home in the form of the pre inspection questionnaire and this was taken into account when planning the inspection. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved talking with them and observation of the daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of service users and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight as to how service users needs are being met in the home. At this inspection, two of the service users were case tracked. There was evidence of ongoing improvement in care standards at this inspection and work is continuing to improve it further to provide service users with a safe and comfortable home. What the service does well: The manager and staff work very closely with all healthcare professionals to provide a high standard of care to the service users. Specialist nurses visit almost once a week and give in-house training in their specialist areas to the staff. The service users in the home have lived there for over a year now and appeared and happy settled at The Coach House. The house is homely and comfortable and maintained to a high standard. There is a very large walled The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 6 garden to the side of the property, which was being fully used by the service users over the two-day inspection. There was a large inflatable paddling pool and different equipment to play with. There were tables and chairs for people to sit out in the glorious sunshine we were experiencing The service users enjoy a wide range of activities inside and outside of the home, including trips out in anyone of the three mini buses owned by the company. Family visit daily and are kept fully informed about the welfare and care of their children or relative. Many of the service users have complex needs and it was difficult to hold a conversation with them but I could see how happy they were in their interactions with the staff. Two service users I spoke with said that they liked living at the home and that they were very happy. Observations made by me on the days of the inspection were that the service users were supported by the staff to look nice and feel clean and comfortable. Most of the staff working at the home either have or are working towards obtaining formal vocational training qualifications and benefit from training provided by the company to support the specialist needs of the service users. Records are well maintained, securely stored and ensure that service users’ confidentiality is protected. The home is well maintained and kept safe for service users, with regular tests and checks of safety equipment and systems and risk assessments to protect them from fire and other hazards. What has improved since the last inspection? What they could do better: The Coach House is one of seven homes owned and managed by the company. The company have issued corporate policies and procedures over a year ago that are common throughout the company. The policies and procedures should be personalised to suit the home and a system should be set by the company The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 7 to keep under review the policies and procedures. Some of the documentation inspected was incorrect and needed to be brought up to date E.g. adult protection and reference to The National Care Standards Commission throughout some of the policies and procedures. The home’s manager should undertake multi-agency training on the protection of vulnerable adults from abuse, neglect and self-harm, which they should them cascade to all staff working in the home to ensure that they are fully informed and confident in working together with other agencies locally to protect service users from harm. This matter is going to happen in the near future. The staff training will further ensure that service users are protected from harm and abuse. The home’s written procedures to guide staff on the protection of vulnerable adults from abuse should be reviewed and updated, to fully reflect current and best practice and enhance existing in-house training provided to them. The registered manager should complete the home’s annual development plan, to include the views of service users and their representatives in the ongoing plans for development of the home and services provided there. The company should review and update all its written policies and procedures to guide staff in their day-to-day work with service users in the home. This work should be completed so that staff are fully informed on how to work effectively with service users, in accordance with best care practices. The home’s practice with regard to management of service users’ medication needs to be improved. One member of staff was observed to sign for medication before it was given to the service user. When challenged on this the member of staff knew the correct procedure. Better evidence of fire training for staff should be recorded with the name of the trainer and trainee. The updating training is intrinsic in the responsibilities staff hold throughout the night and when the manager is not on duty. 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 DS0000063988.V292756.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service No new service users have been admitted since the last inspection. Service users currently in the home were assessed prior to their admission to the home to ensure that their needs could be met there. EVIDENCE: The two files case tracked provided evidence of very clear and thorough assessment information on their files. Due to the complex needs of the service users it would be difficult to retain their concentration for a period of time. Information was shared with them but it was at a pace that suited them. The files evidenced clear indications of their immediate, intermediate and longterm needs and sufficient information including valuable input from other professionals. The manager works extremely well at fostering good effective working relationships with all professionals. The assessments guide, direct and inform staff about the care needs of the service users and are clear about the purpose of their placement in the home. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Evidence of good practice was found at the home. The home works closely with external professionals and specialists for advice and support. Positive arrangements have been established to provide care plans that are user lead and provide staff with clear information, guidance and direction about the service users needs, choices and preferences. More detail is required in the care plans on how the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. The management of risk has improved and guidance is provided to staff when required. The arrangements to assess risk are not satisfactory and suitable records of the assessments need to be completed. EVIDENCE: Each of the service users case tracked at this inspection has a written care plan addressing their personal; social and physical care needs including needs relating to their religious, cultural and ethnic backgrounds. Care plans address their needs, risks and set out specific goals. More detail is required in the care plans on how the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 11 achieve goals. At present in some areas there is a reliance on tick boxes where greater explanation would paint a better picture for the staff to follow. Representatives of service users should be encouraged to participate when reviews of their care plans take place and to sign care plans as evidence of their participation and agreement. Daily care records evidence how service users’ care plans are carried out on a day-to-day basis but an action box on the daily sheet should be included so that management can initial the action taken when staff have recorded issues for follow up. Service users have personal written risk assessments, but these should be further developed to record identification and management of risks. Environmental risk assessments should also be written to safeguard and protect service users from harm. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a wide range of activities in and out of the home in accordance with their assessed needs, preferences and written care plans. They are encouraged to maintain contact with their families and develop relationships with others in accordance with their abilities. The manager and staff work hard to meet the varying needs of the service users EVIDENCE: Service users enjoy a broad range of activities in accordance with the home’s statement of purpose and their individual needs and preferences, in and out of the home. The manager said their daily activities are planned and gave examples of how she and the staff have assisted them to further develop their daily activities in and outside of the home. The manager and staff organise social functions and take service users to pubs, restaurants, places of interest in the local community and local shops. They help service users to maintain The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 13 family links and develop friendships and relationships in accordance with their individual risk assessments The service users I spoke with said that they enjoy the meals and I observed the staff offering sensitive intervention with those people who required help with their meals. Service users are encouraged to eat healthily. Staff take service users shopping for household food and will enjoy a coffee at the superstore. They are able to access the kitchen at all times and have a ready supply of healthy snacks, including fresh fruit. Dietary advice is sought from external professional sources as necessary and service users’ weight is monitored. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service The health needs of service users are well met with evidence of good multi disciplinary working taking place. The staff have a good understanding of service users support needs. This is evident from the conduct of the staff and the positive relationships that have been formed with service users. The medication at the home is managed satisfactorily and promotes good health but staff need to follow the procedures correctly at all times. EVIDENCE: This is an area of the manager’s responsibility that she manages very well. The records indicate the staff at the home takes careful account of service users health needs. Detailed records have been established that note any specific or particular health issues an individual may experience. This information is also included in the individuals care plan. If any concerns arise the individuals relatives or representatives are consulted as well as a general practitioner when this is required. During the inspection one service user was unwell and the inspector noted the positive and attentive manner in which the staff provided care and support. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 15 The personal support provided to service users is individualised and this can be evidenced from the information provided in the service users care plans. It is also evident that staff treat each person as an individual and make sure they provide care in a satisfactory manner to the person concerned. Service users are not hurried or rushed to complete a particular task and during the inspection the staff consistently provided clear advice and guidance to me during any interaction with a service users. Medicines are kept safely and appropriate records are maintained. The policy and procedure for the storage and administration of medicines has recently been reviewed and meet the required standard. The staff administering medicines has been suitably trained but I observed one member of staff signing the medication sheet in advance of giving the medication. This was discussed with her and she said she knew the correct way this should be carried out. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ views are heard in a variety of ways and acted on, where necessary. There are systems in place to ensure that service users are protected from abuse, neglect and self-harm. Policies, procedures and staff training that underpin protection of service users from abuse, neglect and self-harm would benefit from amendment and improvement. EVIDENCE: The home’s formal complaints procedure is communicated to parents and representatives through the home’s service users’ guide. The views of service users are heard in a variety of ways and acted upon. The complex needs of the service users disadvantages them when they cannot read or understand the procedures. I did talk with two service users and they said if they were unhappy they would say. This was observed throughout the two-day inspection. Service users are encouraged to maintain contact with their parents and representatives from outside of the home. Their parents and representatives and placing authority representatives are invited to attend their care plan reviews, which set out their needs and goals at least every six months. The company’s procedures for the protection of vulnerable adults from abuse need to be reviewed and updated to ensure that they reflect the role of the multi agency policies and procedures including the involvement of the police and passing on concerns to the C.S.C.I. in accordance with the Public Disclosure Act 1998 and The Department of Health guidance No Secrets. The The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 17 home’s manager is going to attend multi-agency training and cascade this to all staff working in the home so that they are fully informed of the action they should take if they suspect a service user is being abused. Through in-house training the staff are familiar with actions that they are expected to take in this respect? Service users have regular contact with a range of professionals and relatives from outside of the home and Swallowcourt’s senior managers are in frequent attendance at the home. Some of the service users’ personal finances are being managed by the company learning disability manager who is having a difficult task in setting up individual financial accounts for them. In the meantime no service users are going without any comforts. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a comfortable, homely environment that is safe, clean and hygienic. All residents have en suite bathrooms with lockable doors to ensure their privacy and dignity. There are suitable systems in place to protect them from the risks of infection. Specialist equipment is provided so that the residents can maximise their independence EVIDENCE: All of the service users have en suite rooms so that their personal care needs can be met in private. I have spoken to some relatives who said they were very pleased with the high standard of accommodation and cleanliness of the home. All of the bathrooms are lockable from the inside and there are facilities for staff to over-ride locks in an emergency. It was very hot in the sun lounge on the days of the inspection and there was no protection from the sun through the sunroof. It is recommended that the company fit blinds to the roof to prevent the sun lounge becoming unbearably hot. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 19 The home was clean and tidy throughout at the time of the inspection. Staff are routinely provided with training in infection control. The home’s laundry facilities are sited away from areas in which food is cooked, prepared and eaten and there are stocks of dissolving sacks for heavily soiled laundry and special sacks for clinical waste to ensure that infections are contained and not spread throughout the home. All staff undertakes training from induction in The Control Of Substances Hazardous to Health (C.O.S.S.H.) and Infection Control. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staff team is effective in supporting service users. The arrangements for training and personal development of staff are satisfactory and ensure that the individual and joint needs of service users are met. Recruitment practice protects the well being of service users. EVIDENCE: Most of the home’s staff are qualified to at least NVQ level 2 or are in the process of undergoing training to achieve qualifications to at least this level. The company are committed to providing the staff with updating and ongoing training. All new staff undergoes structured induction training, with records kept. The home’s recruitment policy is clear and detailed and ensures that staff are recruited on the basis of equal opportunities and that only people who are suitable to work with vulnerable adults in a care setting are employed. This is backed up with thorough recruitment records relating to staff working in the home. The manager is making full use of the annex four documents that was provided by the Commission to assist management to record recruitment details and training. There was written evidence in the home that staff have undergone enhanced CRB checks and Swallowcourt has taken up two references prior to their starting work in the. A staff member said they feel well supported by the manager and have had good access to training and knowledge to support The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 21 service users with very complex needs. There are always two staff on duty day and night to offer support and reassurance to the service users. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s manager is qualified and competent and discharges her duties in a clear and transparent manner. The home’s quality assurance programme must be carried out so that service users, parents and representatives are confident their views underpin all self-monitoring and development by the home. All staff must receive ongoing fire training to protect service users. EVIDENCE: The home’s manager is very experienced and has worked for the company for eleven years. The manager is a qualified nurse and has obtained her registered manager’s award. She undertakes regular training to update her knowledge and skills. The home is well managed by her. The Responsible Individual for the company submits to the Commission monthly regulation 26 reports on the conduct of the home. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 23 There is some evidence that service users and representatives have been consulted on the quality of the services provided to them and quality assurance questionnaires have been prepared to carry out the annual quality assurance. Discussion took place with the manager on the exercise encompassing the views of external stakeholders such as relatives, advocates and placing authorities, linked to an annual development plan for the home. This needs to be done so that service users and their representatives can be confident that their needs are paramount in the ongoing planning and development of the home. The manager carries out regular staff familiarisation with the policies and procedures of the home and regular testing and servicing of alarms and fire safety equipment and completion of the home’s fire safety risk assessment. However fire training to day and night staff is not at the recommended intervals recommended by the fire authority. This must be rectified immediately. Staff have good access to ongoing training so that they know how to keep service users safe. There are safe and secure storage facilities in lockable filing cabinets in an office that is kept locked when not in use. There is a policy on accident reporting and the inspector examined the accident records. Records were satisfactorily completed. The record complies with the Data Protection Act 1998. There are no concerns regarding the financial viability of the home and an appropriate Insurance Policy is in place. The registration and Insurance certificates are publicly displayed in the office. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 x The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 25 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. 1. Standard YA9 Regulation 13 Requirement Personal and environmental risk assessments must be in more detail and must clearly identify the actions, outcomes and risk management strategies to safeguard and protect seervice users. Fire drills and fire training for staff must regularly take place according to the good practice guidelines as recommended by the fire authority.. Timescale for action 30/01/07 2 YA42 23(4) (d-e) 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations More detail is required in the care plans on how the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. Swallowcourt should update its written procedures to guide staff on how to protect service users from abuse and DS0000063988.V292756.R01.S.doc Version 5.1 Page 26 2. YA23 The Coach House 3 4. YA24 YA39 ensure that they are trained and aware of their responsibilities in relation to the local multi-agency procedures. Blinds should be fitted to the roof of the sun lounge so that the room does not get unbearably hot for the service users. A formal review of the quality of the services of the home should be undertaken based on service users’ views, stakeholders and those of their representatives. The Coach House DS0000063988.V292756.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000063988.V292756.R01.S.doc Version 5.1 Page 28 - 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. 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