Inspection on 03/06/08 for The Coach House

This inspection was carried out on 3rd June 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Coach House 26/05/09

The Coach House 25/05/07

The Coach House 04/07/06

The Coach House 06/03/06

The Coach House 13/10/05

The Coach House 01/02/05

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 28/09/2008.

CARE HOME ADULTS 18-65 The Coach House Mythe Road Tewkesbury Gloucestershire GL20 6ED Lead Inspector Lynne Bennett Key Unannounced Inspection 3rd June 2008 09:30 The Coach House DS0000062579.V363213.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 DS0000062579.V363213.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 DS0000062579.V363213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address Mythe Road Tewkesbury Gloucestershire GL20 6ED 01684 299507 F/P 01684 299507 Thecoachhouse@kentwoodsupport.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Kentwood Ltd To be appointed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2007 Brief Description of the Service: The Coach House is part of a large house that has been divided in two to provide two registered care homes. The home provides care and support to service users who have challenging behaviours. The home is set in its own large grounds a mile outside the town of Tewkesbury. Accommodation is provided over two floors. The residents all have single rooms. There is a communal dining / lounge area and a small kitchen. A small staff office is provided but the manager’s office is located in the adjacent home. The home provides 24-hour care and support and also organises its own day care activities. There is a designated staff team supported by the Manager who is currently going through the registration process. The home is owned and run by Kentwood Care Limited and was first registered in July 2004. The home’s Statement of Purpose and Service User Guide provide information as to the services that the home provides. The current fee range for the home is £1600 to £2000 per week. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place in June 2008 and included a visit to the home on 3rd June. The manager was present throughout and the group manager was in attendance for part of the visit. People living in the home were observed and staff were spoken to about the care they provide. The manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing information about the service and plans for further improvement. A selection of records were examined including care plans, staff files, health and safety documents, medication administration records and quality assurance systems. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? What they could do better: The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 6 Not all contracts include a breakdown of the fees payable by each person and the services they are to receive. Where any restrictions are in place to people’s freedom of choice the reasons for these must be recorded. Staffing levels impact on the opportunities for people to regularly take up scheduled activities. The cleanliness of the home could be improved by replacing carpets and making sure that surfaces are kept clean. The home needs to be more robust with recruitment and selection, making sure that all information is obtained prior to employment and that the necessary records are kept in the home. Although systems are in place to monitor health and safety within the home not all records were being completed. 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 DS0000062579.V363213.R01.S.doc Version 5.2 Page 7 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 DS0000062579.V363213.R01.S.doc Version 5.2 Page 8 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): 1,2,4 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory admission procedures are in place that include obtaining a full assessment of the person’s needs. Visits enable people to make an informed choice about whether they wish to live at the home. More information needs to be included in the statement of terms and conditions provided to people so that they are aware of the level of fees payable and services provided. EVIDENCE: The home has a Statement of Purpose and Service User Guide that were displayed in the office. The manager said that these would be reviewed once she had completed registration. An interview had been scheduled. The AQAA indicated that this document was last reviewed in December 2007. On the files examined each person had a copy of their terms and conditions with the organisation although only one file provided additional information about the fees payable. Since the last inspection one person had been admitted to the home. There was evidence that the home had obtained a number of assessments from their previous placements, other healthcare professionals involved in their care and their placing authority. These were comprehensive and formed the basis of care plans and risk assessments in the home. The AQAA stated, “Any future service users will be assessed using the new pre admission assessment tool”. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 9 A copy of this was not seen on their file. A placement review had been held within three months and a mental health review was scheduled within six months. Admission information confirmed the person had visited the home and had an overnight stay prior to moving into the home. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are being assessed and they are being supported to make decisions about their lifestyles, which are reflected in their care plans. Risks are being managed safeguarding them from possible harm. EVIDENCE: The manager stated that new person centred plans were being introduced by the organisation creating greater consistency across all the homes. A copy of this was available for inspection confirming that each person would have an initial holistic assessment from which individual needs and hazards would be identified and care plans, risk assessments and guidelines put in place. In the meantime the old system of care planning was being maintained. Three people were case tracked including the recent admission to the home. This involved reading their care plans and associated documents, talking to staff about the care provided and observing people during the visit. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 11 Each person had a range of care plans in place reflecting their physical, emotional, intellectual and social needs. There was evidence of regular review, with the key worker producing a monthly summary sheet of how their needs were being met. Staff spoken with had a good understanding of the needs of the people they support. For instance they referred to communication profiles (which had been examined) and the way in which they use sign language, photographs and symbols to promote positive communication with people. Staff were observed using sign language during the visit and confirmed that further training in Total Communication had been arranged. For people who suffer from epilepsy care plans indicated the level of support required. Strategies for the safe use of listening devices and medical interventions were in place. Protocols should be in place when using listening devices indicating the reasons for use and how the privacy and dignity of people are promoted. Risk assessments were being developed as a result of incidents and new hazards as they were identified, which is good practice. They provided staff with guidance on how to support people to take managed risks and minimise any hazards identified. Staff described how they had reassessed hazards after one incident and had provided locks to wardrobes to safeguard the person’s possessions but also other people from possible harm. Any restrictions such as this must be recorded and the rationale provided. The manager and staff spoke about the Mental Capacity Act and implications for people living in the home. They had experience of working with an Independent Mental Capacity Advocate (IMCA) and holding a best interests meeting with other relevant health care professionals. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite an increase in social, educational and recreational activities, inconsistent staffing levels impact on the possibility of people participating in these on a regular basis. People are supported to maintain contacts with families and friends. EVIDENCE: There had been continued improvements in the range of activities and opportunities being offered to people living at the home. Unfortunately at the time of the inspection staffing levels were impacting on this. Some activities were being postponed due to not having enough staff. (See also Standard 33) During the visit some people were being supported to go out on a shopping trip as well as a visit to the Forest of Dean and lunch out. Those who spent time at home watched television, listened to music or played a keyboard. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 13 Daily diaries evidenced the range of activities available for some people including attending a day centre, sailing, ten pin bowling, watching football, car boot sales, walking and cycling, train rides and swimming. One person said they were looking forward to trying out a work experience at a farm. They also helped the maintenance person at the home. The AQAA indicated “a successful holiday for a group of service users and 1 service user with 2 staff members” were arranged last year and that the home needs to “develop a daily activity planning board, detailing the plans for staff and clients and a greater use of planned activities for all service users.” Indications were that increased activities both outside and at home were having beneficial effects on people. Staff reported that the number of incidents of challenging behaviour had significantly reduced and people were much calmer. It is important that these improvements are sustained. People were also being supported to help around their home with the laundry, cleaning, cooking snacks and making drinks and gardening. Daily diaries recorded people’s level of interaction. Staff commented that one person liked to be busy and they had identified that this was a way to distract them when they become anxious or angry. People were being supported to maintain contact with family and friends whether by visits or using the telephone. The home shares a chef with the home next door and meals were passed through a communal kitchen hatch. Staff were provided with a thermometer to test the temperature of hot food. It appeared that this had not been used for some time after the thermometer had become broken. (See Standard 42) A four-week menu was in place and staff were asked how this reflected the tastes of people living in the home. They said people were involved in meal selection and had a choice about what they ate. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 and 21. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication. EVIDENCE: The way in which people would like to be supported with their personal and health care needs were clearly recorded in their care plans. Staff discussed their understanding of the support people like and how they adapt to each individual. For example one-person likes touch stimulation to express their feelings and massage and reflexology have been arranged for them. Another person can only cope with one member of staff at a time when distressed, so other staff ensured this space was provided. One person living at the home was considerably older than the others and staff were able to explain how they make sure that their needs were being balanced with those of the younger people. Support from the local Community Learning Disability Team had also been requested to develop appropriate activities and methods of communication. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 15 Each person now has a Health Action Plan in place although the manager explained that a new version of this was being introduced across the organisation. It was clear that people were having access to a range of healthcare professionals with appointments being recorded and outcomes also noted. Systems for the administration of medication were examined and found to be satisfactory. A fan had been put in the room due to concerns about the temperature exceeding 25°C. If the temperature regularly exceeds this level consideration will need to be given to finding an alternative storage area. Staff had completed training in the safe handling of medication and four were completing an accredited medication course with a local college. An end of life care plan had been put in place for one person with the help of their relatives. Some circumstances in the plan had changed and the plan needs to reflect this. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place that enable complaints and concerns to be raised by people using the service or on their behalf. Procedures are in place to safeguard people living in the home from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure in place. A version using text, symbol and picture was available for people in the home. The AQAA stated there was an “increased use of signs and symbols for service users and a pictoral guide implemented to help service users communicate complaints.” Staff said that they would recognise from people’s behaviour and body language whether something was wrong and would attempt to discover the cause of this. The home had received two complaints and records for these were kept on file with a copy of the outcome of the complaint. Kentwood also monitor complaints. Staff complete training in CALM (Crisis and Anger Limitation Management) that teaches them a low arousal approach to the management of challenging behaviour. Staff discussed diversion and distraction techniques they used and the effectiveness of the programme of activities for each person. Records indicated that there had been a significant reduction in the use of physical intervention for some people. When physical intervention was being used protocols indicated this was as a last resort only and provided clear guidance on possible triggers, proactive and reactive strategies. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 17 Incident and CALM records were being used after the use of physical intervention and we were being sent notifications under Regulation 37. The terminology in some records indicated the use of floor restraint but when questioned staff clearly knew this was not to be used and the reasons why and explained that a seated restraint on the floor may have been used. The senior carer confirmed this. Staff confirmed that they had completed training in the safeguarding of adults and had a good understanding of their roles and responsibilities. Some staff had also completed Mental Capacity Act training. The financial records for the people being case tracked were examined. Records were being maintained for each person with evidence of regular checks by staff. Receipts were being obtained and could be cross-referenced with financial records. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is pleasantly decorated and fitted with good quality fixtures and fittings. The cleanliness of the home needs to be improved to ensure environmental standards are maintained. EVIDENCE: On arriving at the home we were shown into the lounge/dining room via the French windows. Other healthcare professionals had commented that this was the route favoured by people. This means any visitors disturb people who may be eating or using the lounge. The front door was situated next to the French windows and led to a hallway that provided access to the office or communal areas. Staff should encourage people to use this route. The home was pleasantly decorated throughout with good quality fixtures and fittings, which tend to be minimalist in both communal areas and some individual rooms as dictated by the needs of the people living there. However the communal carpets were dirty and were threadbare in places. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 19 Holes in the stair carpet had been noted in the monthly health and safety audit. Some of the paintwork such as banisters was dirty and sticky to the touch. When we entered the laundry some clothing was on the floor rather than being in laundry baskets. This was immediately rectified. There was a damp patch in the boiler room. Communal hand washbasins had liquid soap and paper towels and personal protective equipment was provided for staff. The manager confirmed that there was a system in place for reporting maintenance issues. These records were examined indicating that there were some outstanding issues to be dealt with such as the stair carpet and damp in the boiler room. Concerns expressed previously about the gravel in the driveway were being considered by Kentwood. The AQAA stated “we have reviewed the exterior with the view to removing the stones when affordability allows.” The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Improvements in recruitment and selection procedures will ensure that people are being safeguarded from possible harm. EVIDENCE: Since the last inspection there had been significant changes in the staff team. At the time of the visit the home had two full time vacancies and another member of staff had just handed in her notice. New staff had also been appointed during the year and additional staff were being recruited. There was some use of agency staff as well as staff in the home being asked to work additional hours. Staff reported that at times they were working with fewer than 3 staff on shift, which was, the minimum required at the time. The rota and daily diaries confirmed this. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 21 Staff spoken with expressed concerns over the staffing levels and the impact this was having on the quality of service provided to people. Although some felt that despite this the team had worked hard to make “the guys happy” and provide a consistent approach to their care. As a result of this the numbers of staff with a NVQ Award had significantly dropped to 33 with another 33 registered to do their awards. The AQAA had indicated that 83 of staff either had or were working towards their awards. Recruitment and selection files were examined for four new members of staff. The manager had not been involved in the recruitment of these staff. The following inconsistencies were found in these files: • • • • • One had no evidence of an application form, that references had been obtained or that a CRB was in place, the manager said that these would be at Head Office another file had no evidence that references had been received two application forms had gaps in employment history which had not been investigated one referee had not provided the reasons for the employee leaving their employment one file did not provide evidence that proof of identity or a current photograph had been obtained. The home has comprehensive systems in place to provide training to staff. There was evidence that staff complete an induction programme that includes mandatory training. Training specific to the needs of people living in the home such as Learning Disability awareness, Autism, Epilepsy, Total Communication and Mental Health was being provided. A mix of internal providers and external providers were being used. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An improvement in some management functions will make sure that people are living in a well run home which safeguards and protects them from harm. Quality assurance systems are in place, which do not appear to be as effective as they should be. EVIDENCE: The manager has been absent from the home since December 2007 due to temporary relocation to another home and sickness absence. The registered manager from the sister home, next door, and the deputy manager and senior carers in the home temporarily managed the home. Staff spoken with had concerns about the management support from the organisation during this period of time and the impact on the staff team as a whole. The inspection identified that some management functions such as recruitment and selection and health and safety had suffered as a result. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 23 An interview had been arranged by us as part of the process to consider the manager for the position of registered manager for the home. Kentwood had undertaken regular Regulation 26 inspections and these have provided action points for the home, although it was not clear how these were being monitored. Some actions were noted to be outstanding such as high fridge temperatures noted below. The group and area managers arrived on the day of our visit to conduct a Regulation 26 inspection. Reports for previous inspections were examined. Quality assurance audits were also being completed, again with feedback being provided to the Manager and staff team. Systems for monitoring health and safety within the home were examined and the following shortfalls identified: • • • • • Temperatures of hot foods were not being taken or recorded, the last records were for April fridge and freezer temperatures were not being recorded consistently, there were no records for May or June fridge temperatures when recorded frequently indicated they were above safe parameters – this had been identified in a Regulation 26 report first aid boxes were incomplete hot water temperatures were last tested in February. Fire equipment and alarms were being regularly tested and serviced and a fire risk assessment was in place. The manager stated that a new fire risk assessment was being put in place the week of the visit. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 3 X X 2 X The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 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 YA5 Regulation 5(1)(bb) Requirement Each person must be provided with information about the fees that are to be paid to the home. This is to make sure they have access to information they need about the services they are to receive. Where a person has restricted access to their possessions the reasons for this must be recorded, so that they are aware of the reasons for this. Carpets must be steam cleaned or replaced where threadbare. All areas of the home must be kept clean and outstanding maintenance issues dealt with. Staff must be employed in sufficient numbers to meet the needs of people living at the home so that they can participate in social, educational and recreational activities. Records must be obtained for new staff before employment such as two satisfactory references, proof of identity, a full employment history and written verification of the reason for leaving former employment. DS0000062579.V363213.R01.S.doc Timescale for action 30/07/08 2. YA7 17(2) Sch 3.3(q) 30/07/08 3. YA24 23(2)(b) 30/09/08 4. YA33 18(1)(a) 30/07/08 5. YA34 19(5)(d) Sch 2 30/07/08 The Coach House Version 5.2 Page 26 6. YA42 23(2)(c) This is to safeguard people from possible harm. Equipment such as electrical or taps and water outlets must be checked and serviced at regular intervals. This is to make sure that people are safe from possible harm. 30/07/08 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard YA7 YA17 YA20 YA21 YA23 YA24 YA24 YA39 YA42 YA42 Good Practice Recommendations Guidance for the use of listening devices should be included in care plans indicating when they are to be used and how they promote the dignity and privacy of people. The temperatures of cooked food should be taken and recorded. If the temperature of the medication cabinet regularly exceeds 25°C then alternative storage arrangements will need to be made. The end of life plan for one person should be reviewed. Terminology used in reports about physical intervention should be clear about the type of physical intervention used. The front door should be used as the main entrance/exit to the home. A system needs to be put in place to monitor maintenance requests to make sure they are dealt with. Review the way in which Regulation 26 action plans are being monitored. First aid boxes should be regularly checked. New stock should be supplied where needed. Where fridges do not operate within safe parameters this should be investigated and corrected. Staff should be provided with a reminder (on the record) about the safe parameters. The Coach House DS0000062579.V363213.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000062579.V363213.R01.S.doc Version 5.2 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. 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