Inspection on 21/01/09 for The Coach House

This inspection was carried out on 21st January 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Coach House 20/02/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

CARE HOME ADULTS 18-65 The Coach House Church Road Baschurch Shrewsbury Shropshire SY4 2ED Lead Inspector Sue Woods Key Unannounced Inspection 21st January 2009 10:00 The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 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 DS0000071103.V372277.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 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 DS0000071103.V372277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address Church Road Baschurch Shrewsbury Shropshire SY4 2ED 01939 260 150 01939 260 150 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 Daniel Andrew Brown Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 8 The maximum number of service users to be accommodated is 8 Date of last inspection 20th February 2008 Brief Description of the Service: The Coach House is a care home registered with the Commission for Social Care Inspection to provide personal care and accommodation for a maximum of eight adults with a learning disability. The Registered Provider of the home is Select Healthcare (2006) Limited and the registered manager is Mr Daniel Brown who is also the registered manager for The Old Vicarage, a care home on the same site. The home is situated in the village of Baschurch, Shropshire and is within walking distance of the post office, general convenience store and local pubs. The accommodation provided is very spacious and furnished to a high standard All bedrooms have spacious en suite bathrooms and additional bathing facilities are also available. Seven of the eight bedrooms are on ground level. One bedroom is accessed via a steep flight of stairs. The home is situated in wellmaintained extensive gardens. The home uses hoists, standing frames and other aids to help people with mobility problems. Information is shared with people who live at the home in the Service User Guide. Advocacy support is promoted and a quality assurance system is in place in the form of questionnaires for people who live at the home and The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 5 relatives. The cost of living at the Coach House is not included in the Service User Guide so the reader may wish to contact the home directly for details of fees charged. The Coach House DS0000071103.V372277.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 0 star. This means that people who use this service experience poor quality outcomes. The unannounced key inspection of the Coach House took place on 21st January 2009 with a further visit on 23rd January 2009 to look at medication arrangements within the home and to review concerns and complaints policies. The inspection lasted 11 ½ hours in total. The inspection reviewed all twenty two of the key standards for care homes for younger adults. Information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection we, the commission, met and spent time with four of the people who live at the Coach House. We also spoke with the four staff on duty, the registered manager and the newly appointed manager of the home. Over the two days, three care files were reviewed in detail and extracts were seen from others. Two staff files and other records referred to within the report were also seen. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection that took place on 20th February 2008. This included notifications received from the home (these are reports about things that have happened in the home that they have to let us know about by law), and an Annual Quality Assurance Assessment (AQAA). This is a document that provides information about the home and how the provider thinks that it meets the needs of people living there. What the service does well: People who live at The Coach House are supported by a team of staff who they like and who treat them with respect. The atmosphere within the home is warm and friendly. Staff were observed to involve people in carrying out every day tasks and enable people to make choices, for example what they would like to drink and what they would like to do. People all have their own rooms and the home is well maintained and people are encouraged to personalise their rooms as they choose. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 7 People are enabled to keep in touch with family and friends and staff know how important family contact and support is to the people living at the home. Staff enjoy working at the home and were described as ‘brilliant’ by one person who lives there. A visitor to the home said that people are supported by ‘an excellent staff team’. The home works closely with health care professionals to meet people’s needs. What has improved since the last inspection? What they could do better: When we last inspected the Coach House we found that record keeping within the home was poor. This continues to be an issue and this is now seriously affecting the quality of the service provided and thus the quality rating for the home. The home does not provide people who may wish to live at the Coach House with appropriate or accurate information about the service it provides. Nor can the home demonstrate that people are only admitted after a comprehensive assessment of their needs. Care plans are inconsistent in the way they are set out and the manager is now working to make them more about the person they belong to rather than them focussing almost entirely on their medical needs. Staff training is an area of concern for us as the manager could not show any evidence to suggest that staff have been adequately and appropriately trained to carry out a number of tasks that they are required to perform to meet people’s needs. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 8 Overall management arrangements are currently letting the home down. Managers do not appear to have the time, skills or the competencies to show that the home is well run or to carry out their roles properly. 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 DS0000071103.V372277.R01.S.doc Version 5.2 Page 9 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 DS0000071103.V372277.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1, 2, 5 Quality in this outcome area is poor People who may want to live at the Coach House may not receive accurate information about what the home has to offer and may move in and find that the home cannot meets their needs. People who move in to the Coach House may not have their individual needs met if the home doesn’t carry out appropriate assessments of those needs or obtain assessments carried out by health or social care professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at information provided by the Coach House that informs people who may want to live at the home what service is offered. The Statement of Purpose and the Service User Guide both contain some required information but other information is missing. Although both documents have been produced using symbols they were often misleading or did not reflect what the text was trying to say. Information was not available to tell the person interested in the home who the manager was and it said that the home is still trying to recruit staff, which is inaccurate. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 11 We looked at all information available belonging to the last two people to move to the Coach House. One person had moved in permanently and one person was staying for respite. The home could not show that proper assessments and been carried out on individuals prior to them moving in. Information for one person suggested that he had nursing care needs. On the two files that we looked at there was no evidence that a contract had ever been produced or agreed. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 Quality in this outcome area is poor People’s individual support needs are not always recorded in their plan of care making them vulnerable if staff do not know how to meet and respond to their needs safely. People are enabled to take responsible risks however formal assessments are not being reviewed or completed appropriately on all occasions making people vulnerable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection we looked at two care plans. One person did not have a care plan. The way that each care plan was set out was very different and the new manager of the home explained that she was looking to develop individualised plans that are ‘owned’ by the people they were written about. She had started The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 13 this process in one of the files seen. The manager had a lot of ideas of how to develop this further and was meeting later in the week with one person to agree his new plan. One person told us that the home was able to meet his needs and information that he shared was later seen on his care plan. This included his likes and dislikes as well as his care and support needs. Care plans, where available, were basic and there was a lack of guidance for staff to show how people’s individual support needs should be met. For example one person had special requirements in relation to how he received his food and this was not detailed. One plan told staff to read the instruction manual before using an identified piece of equipment suggesting that staff had not received appropriate training to carry out this task. The person at the home for a short “respite” stay was not being supported by plans or protocols to meet his support needs. This was of concern as staff said that he had quite complex support needs and the home could not show that they were being met safely or consistently. There was no assessment of need on his file other than one carried out by the registered manager and he was unsure how he had reached the conclusions of his ‘scores’. The lack of such information makes the person vulnerable to not having his needs met, not having them met in a way that he prefers and also being harmed as a result of unsafe practices being carried out. Risk assessments are in place and have been reviewed however they did not always accurately reflect information contained in the care plan or identify how identified risks were to be managed. This means that people may be taking risks that were placing them in unsafe situations. People who live at the Coach House are asked for their opinions on how the home is run and what they would like to do. People who are unable to communicate their needs and wishes verbally are supported by an advocate who knows them well and family are involved wherever possible. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13, 15, 16 and 17 Quality in this outcome area is adequate People benefit from supported family contact and involvement meaning that they are able to stay close to the people that matter to them. The home plans to develop a varied and nutritious diet. They also aim to plan activities in advance according to people’s identified wishes and needs. This will mean that the service will be more structured and everyone will have the opportunity to be involved in activities and access the community on a regular basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person told us that he takes part in cleaning tasks and is responsible for cleaning his room although he does not really like doing this. He said that meals are ‘nice’ and that if he could improve the service he received he would like to be offered more choice in relation to what he ate. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 15 People are involved in preparing meals within the home. On the day of the inspection one man was seen to be helping a staff member prepare the evening meal by cutting up the vegetables. A record of food eaten by one person showed that he enjoyed a varied diet but not necessarily a nutritious one given that he has to watch his weight. Over recent months the manager has started reviewing the house menu to take into account peoples likes and dislikes and also any special dietary needs that people may have. This was something that the home was asked to do last year when we inspected but had not been actioned. As a result people may not have been receiving a balanced or nutritious diet. People are supported to retain family contact as this is important to them. One person is supported to visit his family at their home and people have moved to the Coach House in order to be near to their family. One person told us that he had a girlfriend and he speaks to her regularly. One person is starting a new college course to develop his cooking skills and he said that he is really looking forward to this. He already attends college twice a week. The home has introduced an activities board that reflected what people were doing on the day of the inspection although one man was recorded as watching TV and did not appear to be doing anything else or having any significant interactions from the staff team. This observation was mentioned to the manager. Daily routines were seen recorded for one person living at the Coach house however was not seen in place for the two people whose care we looked at. The manager stated that they try to enable everyone to go out, at least one person each day. The current approach is that the staff do what they can with the resources available rather than focusing on the needs of the individual and planning and resourcing accordingly. This may mean that people may be missing out on activities that they would like to do as a result of staffing restrictions. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is poor People’s good health and wellbeing may be at risk if the home cannot show that they are supporting individuals safely to manage their health and personal care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the people living at the Coach House have complex medical and personal support needs. There is no evidence to suggest that these needs cannot be met within the home however there is insufficient guidance to support staff to carry out personal and health care tasks safely or consistently. Previous inspections have made similar findings. The lack of appropriate assessments of need and in one case the lack of a formal care plan place people at risk of having their care needs missed or not met safely. People who visit the home such as district nurses and other health and social care professionals speak highly of the staff team and observations at the time of the inspection reflect that staff care about the people they support. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 17 One man told us that the staff were ‘brilliant’ and met his needs within the home. Arrangements in place for the recording and storage of medication were generally satisfactory however the lack of protocols to support the administration of medication suggests that people may be vulnerable to mistakes happening. The home could also not demonstrate that staff have been trained to administer medication or been trained in carrying out specialist personal care procedures to support at least two people living at the home. Likewise no protocols were in place to support the safe storage or administration of oxygen, although general guidelines were in place. Following the inspection we spoke with health and social care professionals about these concerns and plans are now in place to review support protocols, practices and training within the home. One health care professional said that she felt that the home could safely support the people living there although there was an issue raised in relation to the home supporting someone with possible nursing care needs. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good People are protected by procedures in place for managing concerns and complaints and can be confident that their concerns will be listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House has a complaints procedure that is shared openly with relatives and advocates of people living at the home. One file seen contained a copy of the pictorial complaints procedure although this needs to be reviewed to ensure that the ‘pictures’ reflect the practice. Also some information given is out of date. Select Healthcare has policies and procedures in place for managing complaints and for protecting people from abuse. There have been no complaints received by CSCI or the home about the service provided at the Coach House. The new manager is aware of adult protection policies and guidance and said she would be confident to use them if necessary to protect people living at the home. There have been no referrals within these procedures. One person living at the Coach House said that if he had any concerns or worries he would speak with the staff. Other people who cannot communicate verbally are supported by an advocate who has been visiting them for a number of years. Some people have family members who would advocate for them meaning that their views and concerns will be raised. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 19 We looked briefly at arrangements for supporting people to manage their money. One person said he has his own money when he is out and the home looks after it when he is at home. The manager later confirmed this arrangement. We saw records showing that staff check the amount of money within the home is correct and that it reflects the records. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good People who live at the Coach House are provided with a clean, well-maintained and safe place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House opened in August 2007 and comprises of largely single storey accommodation. There are now four people living at the home and one person visits for regular planned respite. Only part of the home is being used on a regular basis. All areas were seen to be clean and ‘homely’. One person was happy to show us his room and other areas of the home. He told us that he cleans his own room and helps out with other cleaning tasks although he does not especially enjoy it. The maintenance worker was on site carrying out some major changes to access to an en suite bathroom in preparation for a future admission. He said that access to a budget for maintenance tasks has improved and he is now The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 21 able to make minor purchases. This has meant that he can make repairs sooner than in the past. The home is still in the process of installing fire exit signs and the manager was made aware that this should be prioritised to ensure that in the event of a fire it would be clear to people where the safe exits from the building were. The manager said that the home has applied for funding for a larger washing machine. There are plans to move the laundry room to a larger area within the home that will mean that more independent people living at the Coach House can access it. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 Quality in this outcome area is poor People living at the Coach House cannot be sure that they are supported by a qualified or competent staff team and as a result they may be at risk of harm during personal care tasks. There may not be sufficient staff on duty at all times to ensure that peoples personal and social care needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Everyone we spoke with at the time of the inspection said that they enjoyed working at the Coach House and felt well supported by management. One person said that she had been trained to do the job by the manager. A visitor to the Coach House commented on an ‘excellent staff team who really care about residents’. A GP and social worker both said that ‘staff are good’. A nurse manager told us that staff work well with health care professionals. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 23 The registered manager of the home told us that there are no records available to show that staff have received any form of formal training. The only evidence of staff being trained came in the form of some certificates awarded to named staff for attending a specified training course. It is of concern that the staff at the Coach House are expected to carry out some complex personal care tasks, some of which that remain the responsibility of the district nursing team, and there is no record to suggest that they have been trained to carry them out or that they are competent to carry them out safely. One staff member requested first aid training in April 2008. To date she has not received this. Likewise records of senior manager visits show that staff are still waiting for health and safety training. The registered manager said that formal supervision for staff has not happened recently as events within the home have affected morale. Staffing levels were seen to be one to one for the majority of the time however as records do not detail all staffing requirements it is now difficult to establish if levels are sufficient to support people to receive their basic care and support needs. The homes AQAA states two people require the support of two or more staff to support with personal care needs at night. Records showed, and the manager confirmed, that there is only one member of staff on site at this time. Sleep in support is provided if required from a senior staff member who sleeps at the care home on the same site. There is no evidence that staffing levels have been assessed as safe or adequate and this now needs to happen. Staff recruitment files contained all required information to demonstrate that pre employment checks take place however one of the two files seen contained references that were dated after the persons start date. The registered manager could not explain why this had happened but was aware of his responsibilities around safe recruitment practices. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 Quality in this outcome area is poor The registered manager has not made sure that the home can demonstrate through effective record keeping that people are kept safe and that staff are supported to carry out their roles safely or consistently. People using the service and staff carrying out complex procedures are vulnerable as a result. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House is not currently a well run home. Within the last three months Select Health Care (who own the home) have appointed a ‘nurse’ manager. However we discussed that the manager should not use her ‘nurse’ title as it may mislead people into thinking that the Coach House is a nursing home. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 25 The new manager has previous supervisory experience and the staff team speak highly of her skills and competencies to lead the home. The current registered manager is still working at the home although he now plans to step back and let the new manager take over. The registered manager has failed to address issues identified at the time of the last inspection of the home and as a result the quality rating for the home has again been affected. Record keeping is poor and there is no evidence to suggest that any improvements were made in this area prior to the new manager starting. The lack of appropriate records, assessment and other documentation referred to within this report means that the home cannot show how people are safely supported and protected. The new manager should review her work schedule to ensure that she has sufficient time not working on the rota to ensure that policies and procedures are implemented and record keeping is significantly improved. We also identified that there may be someone living at the home who requires nursing care and this is not something that the home can offer within its current registration. Placing authorities have been made aware of this as it may be that the safety of the person identified is being compromised. The home has recently requested that an independent advocate support the people living at the home to express their views of the service they provide. Outcomes were very positive and despite the shortfalls in management arrangements people like living at the Coach House and all said that staff treat them well and respect their privacy. The deputy manager is collecting all responses from the questionnaires and is reviewing the findings to look to improve the service in the future. Staff carry out regular safety checks to make sure that the home environment is safe and that everything is working as it should. Records completed by the maintenance worker were up to date and showed that, for example, in the event of a fire, people would be kept safe. Fire doors however were not identified and this may place people at risk. The health and safety officer, who was working at the time of the inspection said that health and safety arrangements are in place and up to date. For example he checks that chemicals used within the home are stored securely and used safety. Select Health Care have arranged for an external health and safety officer to visit the home and carry out an audit. This will further ensure that people are able to feel safe at the home. The Coach House DS0000071103.V372277.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 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 1 2 1 3 X 4 X 5 1 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 1 33 2 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 X 1 X 3 X 1 1 X The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Timescale for action 09/02/09 2 YA6 15 (2) (b) People must not be admitted to the home without having an assessment of care and support needs that enables the home to identify if that persons needs can be met at the home and that can inform a care and support plan. This is to make sure that that no one is admitted inappropriately putting them at risk of not having their needs met. 30/03/09 Care plans must be in place and accurately reflect people’s current and changing needs to ensure that people receive the care and support that they require and the home can demonstrate that it can meet those needs safely. Previous time scale 09/04/08 Not met. 3 YA20 13 (2) The home must ensure that systems are in place to support the safe storage and administration of all medicines (including oxygen) and protocols must support its administration when complex procedures are DS0000071103.V372277.R01.S.doc 16/02/09 The Coach House Version 5.2 Page 28 4 YA32 18 5 YA33 18 (1) (a) 6 7 YA35 YA37 18 (1) (c) (i) 9 (1) 8 YA41 17 (1 3) involved. This is to ensure that staff know how to store and administer medicines safely reducing the risks of harm to the people receiving it. The home must be able to demonstrate that staff are competent and qualified to carry out the tasks required of them. This is to ensure people receive care and support safely. Staffing levels must be reviewed and the manager be confident that there are sufficient staff on duty at all times to ensure that peoples care and support needs can be met safely. Staff must receive appropriate training to carry out their roles effectively and safely. The organisation must ensure that management responsibilities are carried out by a person who is competent to do so and with sufficient time dedicated to carrying out the role. Records must be accurate, available and up to date at all times to demonstrate that the people living at the home receive the care they require and that the home is operating safely and in the best interests of the people they support. Previous time scale 09/04/08 Not met. 16/02/09 16/02/09 30/03/09 30/03/09 30/03/09 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 DS0000071103.V372277.R01.S.doc Version 5.2 Page 29 1 YA1 2 YA1 3 4 5 6 YA5 YA9 YA11 YA24 7 YA22 The home should have a statement of purpose in place that accurately reflects the service that it provides. This to ensure that people or their representatives that may be interested in a place at the home have accurate and up to date information available to them to help with their decision-making. The home must have a service user guide in place that accurately reflects the service that it provides. This to ensure that people or their representatives that may be interested in a place at the home have accurate and up to date information available to them to help with their decision-making People living at the Coach House should have a contract detailing the terms and conditions of their stay. Risk assessments should be continually reviewed and updates as peoples needs change Activities should be planned around people’s individual needs and wishes rather than when there are enough staff available to facilitate them. The home should contact the local fire authority to discuss arrangements for having display signs to show people which doors are fire exits. The home should record and act upon their advice without delay. The complaints procedure should be updated to reflect changing contact details. The Coach House DS0000071103.V372277.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands Office 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 DS0000071103.V372277.R01.S.doc Version 5.2 Page 31 - 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. 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