Inspection on 19/01/06 for The Coach House

This inspection was carried out on 19th January 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 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 09/11/09

The Coach House 07/06/07

The Coach House 21/06/05

The Coach House 16/12/04

The Coach House 09/06/04

The Coach House 02/03/04

The Coach House 13/12/02

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Coach House 58 Lidgett Lane Garforth Leeds West Yorkshire LS25 1LL Lead Inspector Sean Cassidy Unannounced Inspection 19th January 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 DS0000033650.V276094.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 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 DS0000033650.V276094.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Coach House Address 58 Lidgett Lane Garforth Leeds West Yorkshire LS25 1LL 0113 2320884 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 Claire Louise Buckle Mrs Alison Jayne Green Mrs Victoria Thompson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: The Coach House is a care home providing accommodation and services to older people; it is situated in a residential area of Garforth and is close to the amenities of the town and public transport. It has been recently purchased by the current providers who have started a programme of improvements in respect of the general facilities and internal appearance and to operational and organisational matters. It provides accommodation for up to nineteen men and women in both single (the majority) and shared rooms, although plans are being considered to reduce the ratio even further. There is a range of communal sitting and dining areas, bathrooms and toilets on both floors and passenger and stair lifts to different parts of the upper floor. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector and lasted a full day. The purpose of the inspection was to make sure the home was operating and being managed to a satisfactory standard. The inspector spoke to several service users and members of staff. A number of documents were examined which included care plans, policies and other records. What the service does well: What has improved since the last inspection? The care plans are written with the involvement of the residents and their relatives, if needed. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 6 Staff have received training in Adult protection. Residents are provided with copies of the Service User Guide. Residents are consulted regarding their recreational interests and hobbies and assistance is provided to try and provide for these. Improvements have also been made with the environment of the home. These include: • • • • • A new nurse call system is in place. A new laundry is being completed. A new heating system is being provided. Two residents rooms and a bathroom have been redecorated. A Gazebo has been built at the back of the home so residents can access the garden. 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 DS0000033650.V276094.R01.S.doc Version 5.1 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 DS0000033650.V276094.R01.S.doc Version 5.1 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): 1,3 Residents and their families are provided with information that assists them to make a choice of moving into the home. But, the Statement of Purpose and Service User Guide do not provide all the necessary information. All prospective residents are assessed prior to moving in. EVIDENCE: Relatives confirmed that they were provided with sufficient information prior to accepting an offer of a room. The manager has now placed Service User Guides in all the resident rooms. Residents spoken to said that they are aware of these documents and had read them. The Statement of Purpose and Service User Guide were reviewed by the Inspector and it was identified that some of the required information was not contained in the documents. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 9 The documentation of the most recent resident was inspected and it was identified that the home ensures each prospective resident is assessed prior to moving in. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 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): 7,9 The home ensures the health, personal and social care needs are clearly set out in a good system of care planning. Residents are assisted to self medicate whenever possible. EVIDENCE: The manager has continued to make improvements with the care planning documentation. All care files inspected showed that each individual had been assessed and a plan of care had been developed for those areas in which a need was identified. All care plans and risk assessments inspected showed evidence that the resident or their relatives have been involved with their development. The care plans are reviewed monthly and altered when needed. Care home staff administers the medications. The manager is undergoing advanced medication training and twelve members of the staff team have completed or are in the process of completing a medication training programme with a local college. The medication charts were examined and these were properly filled in. There is a self medication policy and this has been used previously. Residents are assisted to self medicate where possible. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 11 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 Residents spoken to expressed contentment with the provision of activities and recreational opportunities provided by the home. Residents are enabled to maintain contact with families and friends. Residents are involved with making decisions that assist them with controlling their own lives. EVIDENCE: The care files of residents’ inspected showed that improvements have been made regarding the assessment and provision of activities to residents. Residents spoke to praised the home for providing them with a good standard of entertainment and activities. Records are kept of what entertainments and outings are provided. The home has an identified activities co coordinator who keeps a record of residents’ likes and dislikes and attempts to provide for them wherever possible. There are no time restrictions placed upon visiting in the home. The manager attempts to promote visiting at every opportunity as she recognises the benefits to the individual residents with maintaining contact with their family and friends. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 12 The home attempts to involve the residents with making choices regarding decisions about their own lives within the home. Regular resident meetings are held and residents do regularly express their views regarding issues that are important to them, food and activities being the popular talking point. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 13 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): 18 The residents could be more thoroughly protected by the Adult Protection process adopted by the home. EVIDENCE: Staff now receive Adult Protection training to assist them with protecting the residents living in the home. There is an ongoing Adult Protection issue at present. It was identified from the incident records that this is continuing to be a problem. The inspector noted a number of recent incidents had occurred that should have been brought to the attention of the Adult Protection team. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 14 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): 25 Work is ongoing to ensure the residents living at the home will be safe and warm. EVIDENCE: On the day of the inspection work was being carried out to replace the existing heating system of the home. This has been a large undertaking, as the boiler could not properly control the temperature of some parts of the home. It was hoped the work would be completed in another one to two weeks. Residents said they were happy with the heating at this present time, though they did say that at times it was very hot. The home was extremely warm on the day of the inspection and the owner had to turn the heating down manually. Assurances were given that when work is completed the heating system will be in good working order. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 15 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): 27,30 Residents care needs are met by suitable numbers of appropriately trained care staff. Residents were confident that the care team are able to meet their needs. EVIDENCE: The staffing numbers and skill mix on the day of the inspection were appropriate for the assessed needs of the residents. The manager stated both the owner and she work the outstanding shifts when they arise. It is very seldom that an agency staff member would be brought in. Staff are provided with an induction booklet when they start work. The manager works with each individual and signs the document at the end to show that it has been completed. Staff receive an appraisal on a yearly basis that helps identify areas of training that may be required. Residents spoken to praised the staff team and were very confident that they are able to meet their care needs. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 16 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): 31,33,35,38 Residents benefit from a well managed home. Appropriate quality assurance tools are used to improve the quality of care provided in the home. The system for managing residents’ monies in the home is good. The home must improve the systems used to protect the health and safety of the residents. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 17 EVIDENCE: The home is managed and run to a good standard. The registered manager has recently completed her Registered Managers award. Residents and relatives praised the way in which the home was managed and spoke highly of the registered manager. A number of different quality assurance tools are used by the manager to improve the quality of care in the home. Relatives and residents are provided with questionnaires on a regular basis to obtain their views of the home. It was recommended that the manager record the improvements that have been made as a result of these quality audits. The manager keeps some residents monies locked away in the home safe. This is money that has been provided by relatives to obtain necessary items. The records and receipts were in good order for these monies kept in the home. A number of health and safety issues were identified that must be rectified. The practice of transferring residents in wheelchairs without footrests places the resident at risk of injury. This was highlighted and the manager took action. Major works were being carried out within the home but the home had not taken appropriate measures to ensure the health and safety of the residents was properly protected.. This refers to the floorboards being lifted up on the first floor without having had a hazard analysis carried out. The manager has developed a system to ensure all staff have received the necessary mandatory training. The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 18 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x 2 x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 19 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 OP1 Regulation 4,5 Requirement The registered person must ensure the Statement of Purpose and Service User Guide contains all the necessary information. The registered person must make arrangements to prevent residents being placed at risk of harm or abuse. The registered person must ensure that heating suitable for residents is provided in all parts of the care home used by residents. (The previous timescale of 30/09/05 was not met.) The registered person must ensure residents’ health and safety is protected at all times. Timescale for action 28/02/06 2. OP18 13 28/02/06 3. OP25 23 28/02/06 4 OP38 13 28/02/06 The Coach House DS0000033650.V276094.R01.S.doc Version 5.1 Page 20 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 DS0000033650.V276094.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000033650.V276094.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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