Inspection on 21/06/05 for The Coach House

This inspection was carried out on 21st June 2005.

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 19/01/06

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 LS25 1LL Lead Inspector Sean Cassidy Unannounced 21 June 2005 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 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 J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Coach House Address 58 Lidgett Lane Garforth Leeds LS25 1LL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2320884 Mrs Claire Buckle Mrs Victoria Buckle Care home 19 Category(ies) of Old age (19) registration, with number of places The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 December 2004 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 J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 this inspection was to ensure the home was operating and being managed to a satisfactory standard for the benefit of the residents. The methods used in this inspection included discussions with service users, visitors and staff, examination of records including service users care plans and staff files, a tour of the home and indirect observation of care practices. The inspector spoke to several residents, relatives and members of staff. A number of documents were examined which included care plans, staff files and training files. What the service does well: What has improved since the last inspection? Care plans and risk assessments for residents have improved. The residents are better protected with the improved recruitment and selection process used by the home. Privacy and dignity of the residents has been improved with the provision of locks on all residents’ bedroom doors. Two residents said they felt this helped maintain their privacy. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 6 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 J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,5. The home ensures prospective residents and their families make an informed choice about moving in. This decision process is assisted by the provision of contracts and trial visits. Pre assessments are carried out by the home on all service users to ensure their needs can be met. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide, which meets with the standard. Relatives and residents spoken to said that they were provided with good amount of information, which helped them to make their choice. Residents spoken to said they had not received a Service User Guide which was confirmed by the manager. The evidence seen showed that the home assesses prospective residents before they are offered a place and trial visits are offered and taken before a final decision is to move in. Relatives confirmed that contracts and terms and conditions are provided by the home. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,10. Good progress has been made with the development of resident care plans. The home needs to ensure that a more consistent approach to obtaining consent to care is recorded. The privacy and dignity of the residents is well respected by the staff. EVIDENCE: A number of care plans were inspected and these were found to be of a good standard. Each file showed that residents are fully assessed and a plan of care is put in place for any identified problems. The care plans were reviewed on a monthly basis so that they are aware of the changing needs of the residents. The care plans and risk assessments do not show residents and relatives are consistently involved with the writing of these documents. This omission means documented consent is not being obtained for the care provision. The residents’ health care needs are reviewed regularly and the relevant health professionals are involved when needed. Evidence to show this occurred was found in the care files and from speaking to residents and their families. Those residents spoken to said that they were very pleased with the way in which their privacy and dignity was respected by the staff. Staff were observed to treat residents with kindness and respect throughout the inspection. All residents now have a lock fitted to their bedroom doors and keys are provided. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 10 Appropriate documentation was in place for those service users assessed as unable to have a key to their room. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 standard(s) 12,15. A more structured approach should be taken in relation to the provision of activities for residents living in the home. The meals provided are of a good standard. But more consultation is needed with residents to ensure that they meet their needs. EVIDENCE: Those residents spoken to about the food said that they enjoyed the majority of the food provided but they felt that there were areas where improvements could be made. Two people said that there were too many sandwiches served at teatime and not enough hot options were offered. The home is already looking at ways in which this can be improved and a new menu was produced to show that there would be more hot options offered at teatimes in the future. One resident felt that the meal times were far too early and the gaps between the meals were too short, which meant that you were not hungry when the meal arrived. The residents said they would raise this issue at the next resident meeting. Staff try to provide activities for the residents when they can. No structured activity plan was seen during the inspection and the residents were not aware that one existed. The care plans had no evidence that the interests and hobbies of the residents had been assessed and provided for. A small number of residents went on a recent excursion and another one is being planned for. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 12 Representatives from different religions come to the home on a regular basis to provide services for those who want them. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 standard(s) 16,18. Complaints are handled properly and residents felt confident that they would be listened to and acted upon. The omission of staff training in Adult Protection does not ensure that residents living in the home are protected from abuse. EVIDENCE: Residents and their families were very confident that any complaint that they did make would be thoroughly dealt with by the home. Each person spoken said that they were fully aware of how to make a complaint if they needed to. The complaint procedure was well displayed in the foyer of the home. There is an absence of training for all levels of staff with regards to adult protection and this was highlighted when the inspector identified an adult protection issue during the inspection. The home has an adult protection policy that includes whistle blowing and information informing staff as to what constitutes abuse. This policy and procedure has not been written with reference to the local Adult Protection Guidelines. The procedure used by staff to refer adult protection cases should be reviewed so that the appropriate names and telephone numbers are included. The provider said that adult protection training had been highlighted as a training need and that it was being arranged. Residents and relatives stated that they felt safe and protected by the home. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 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 standard(s) 19,25,26. Overall, the environment of the home is safe and comfortable for service users. But, the central heating failure and the noisy washing machine need urgent attention. EVIDENCE: The premises are well maintained and suitable for the needs of the residents living there. Some residents said that it was like home from home. All areas of the home were found to be very clean and tidy and the majority of people spoken to commented on this. Some bedrooms were very warm as the central heating system was not working properly and the heaters could not be turned off in all of these rooms. Two residents stated that the heat in their rooms was intolerable at times due to the combination of the heaters and the recent hot weather. I sent a letter to the provider about this matter. It asked her to look into this problem urgently and inform me of the outcome. The washing machine is unstable and noisy. One resident felt that the noise is sometimes “unbearable.” The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 15 A new maintenance man was has been employed recently and he has been carrying out the appropriate checks on the hot water systems and the equipment kept by the home. A maintenance book is in place for staff to highlight minor jobs but not for a rolling programme of routine maintenance. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The recruitment process used by the home properly protects residents living there. EVIDENCE: Three staff recruitment files were inspected and the standard of recruitment adopted by the home was good. All the relevant information was obtained for each employee before employment was commenced. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,38. The home is being managed to a good standard and both residents and staff are confident that there is an open and transparent management approach within the home. Residents and staff would benefit by having a moving and handling update. EVIDENCE: The manager is in the process of completing the NVQ Level 4 in Management course. She feels this has assisted her with her day-to-day management of the home. Staff spoken to felt very supported by the management structure and said that they would have no hesitation with speaking to the manager regarding any problems. Residents and staff spoke very highly of the manager and the provider and said they felt the home was “managed very well indeed”. Residents said that they had the opportunity to attend resident meetings on a regular basis to discuss any issues that they felt needed discussed. The minutes from these meetings were seen and are regularly held. The notice board in the main entrance is used to inform residents, staff and relatives of The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 18 any important management changes. Staff said they received supervision on a regular basis and this was evidenced in the records. Regular fire training and moving and handling training is given to the staff. It is recommended that the staff receive an update for moving and handling training, as staff were unsure of the processes and equipment used for this in the home. The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 1 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 3 x x x 3 x 2 The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 20 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 7 Regulation 15 Requirement The registered person must ensure that the care plan is written after consulatation with the resident or a representative has taken place. The registered person must make arrangements, by training or by other measures tp 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 registered person must ensure that each service user receives a copy of the Service User Guide. The registered person must consult service users about their social interests and make arrangements to enable them. the registered person must make suitable arrangements to provide a safe system for moving and handling service users. Timescale for action 30 September 2005 30 September 2005 30 September 2005 30 September 2005 30 September 2005 30 September 2005 2. 18 13 3. 25 23 4. 1 5 5. 12 16 6. 38 13 The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 21 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 Good Practice Recommendations The Coach House J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley 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 J52 S33650 The Coach House V233629 210605 Stage 4.doc Version 1.30 Page 23 - 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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