Inspection on 30/01/06 for The Coach House

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

The Coach House 10/06/08

The Coach House 11/08/06

The Coach House 22/08/05

The Coach House 30/11/04

The Coach House 09/07/04

The Coach House 19/02/04

The Coach House 04/12/03

The Coach House 19/09/03

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

CARE HOMES FOR OLDER PEOPLE The Coach House 67 Keyhaven Road Milford-on-Sea Lymington Hampshire SO41 0QX Lead Inspector Tracey Box Unannounced Inspection 30th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Coach House Address 67 Keyhaven Road Milford-on-Sea Lymington Hampshire SO41 0QX 01590 642581 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs D L Fry Mrs D L Fry Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (17), Old age, not falling within any other category (17) The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: The Coach House is a care home providing personal support and accommodation for up to seventeen older people with the following needs, old age, dementia or mental health. The Coach House is owned and managed by Mrs Donna Fry. The home is situated in a quiet residential area of Milford On Sea, local amenities are a short walk from the home. The home consists of a three story building and comprise of thirteen bedrooms, nine are single and three of the four double bedrooms are en-suite, a dining room and lounge with conservatory overlooking the homes enclosed garden. A stair lift provides access to the first floor, thereafter stairs provide access to the third floor which comprises of two wings, one with service users bedrooms and the other provides private accommodation for two staff. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over four and a half hours. The people living at The Coach house prefer to be referred to as residents, therefore will be referred to as this throughout the report. At the time of the inspection seventeen residents lived at the home. The inspector witnessed lunch being prepared, fresh produce was used, resulting in a nutritious, home cooked meal. Two residents agreed that meals are always very good, and are home made as apposed to pre packed. Records were seen and the inspector asked residents and staff for their views and experiences of living and working at The Coach house. One resident stated “This is my home now, I like it here very much” Two residents, when asked, commented on how polite, helpful and friendly the staff are at the home. Staff were observed knocking bedroom doors and waiting for a reply before entering, two residents said that they felt staff respected their privacy and dignity. The manager showed the inspector the layout within and surrounding the home, including communal areas and a few bedrooms, all areas appeared clean and comfortable, providing a pleasant environment for residents. What the service does well: Staff morale is high resulting in an enthusiastic, multicultural workforce that works positively with residents to improve their whole quality of life. Two staff are working towards achieving a National Vocational Qualification (NVQ) award, levels 1, and 2, four staff have completed NVQ level 3 awards and one senior is completing her level 4 in care. The home benefits from the manager, who is the provider who works closely with staff, residents and relatives to provide a ‘homely’ atmosphere. Should the home have a vacancy in a double bedroom, part of the assessment process ensures prospective service users are fully informed of the fact that two people may be required to accommodate that bedroom. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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 DS0000011880.V280875.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. A comprehensive procedure for assessing the needs of potential new residents is in place to ensure the resident’s and the homes needs are met prior to admission. The Coach house does not provide intermediate care. EVIDENCE: The inspector saw two residents’ files that included a client assessment form completed by the manager prior to the residents admission to the home. The information included likes and dislikes, medical and family history and other relevant information to ensure the home is able to provide the care the individual requires. Family/representatives are invited to participate in the completion of the assessment to obtain as much information as possible The manager visits the prospective resident to assess their needs, with a social worker (if appropriate) with family / representative present, one resident recalled the manager visiting them prior to their admission, and that she visited the home to see if she liked it. The manager said it is the home’s policy not to provide intermediate care. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 9 The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10. Residents health, personal and social needs are set out in individual’s care plans ensuring the individual’s needs are fully met. Personal support within the home is offered in such a way as to promote and protect residents’ privacy and dignity EVIDENCE: The inspector looked at two care plans, both included pre assessment paperwork, the information in these assessments is used to compile each individual’s care plans and risk assessments. The care plans are comprehensive and include information about the individuals health, abilities, strengths, needs and wishes, any special requirements, mobility, religion and family details The manager reviews each care plan monthly, signed documentation showed this practice occurred. One resident said “staff care for me as I wish, all I have to do is ask”. Staff confirmed the care plans provide them with the information they need to satisfactorily meet the resident’s needs. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 11 Care plans included records of visits to the individual by their doctor, chiropodist, district nurse and other entries such as flu jab and admittance to hospital. The inspector witnessed staff address individuals in their preferred manner, as stated in individuals care plans. Staff were observed knocking bedroom doors and waiting for a reply before entering. One member of staff recalled privacy and dignity being part of her induction and foundation training. Two residents commented on how polite, helpful and friendly the staff are, and how they feel staff respect their privacy and dignity. Staff receive Dementia care training, one member of staff said the training helped them to understand peoples behaviour better, it made her more aware of why some people seem forgetful The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents feel the home matches their expectations and preferences, their social, cultural, religious and recreational needs are met. Contact with family/friends/representatives and local community is encouraged as the individual wishes. Practices in the home demonstrate that the home promotes individual choices and encourages residents to have control over their lives. Dietary needs of service users are catered for with a balance and varied selection of food available that meets individual’s taste, dietary requirements and choices. EVIDENCE: Individuals care plans explore contact with family, friends, representatives and social workers, as are individuals wishes to attend activities outside the home, one resident attends a local church, this was recorded in her care plan. A record of visitors to the home was seen, which showed family visits. The inspector witnessed lunch being served and eaten, all residents appeared to enjoy their meal, the inspector asked four residents sitting at one table for their opinion of the food. All agreed the food was nice. Staff gave each resident the choice between two options, one resident confirmed this practice occurs daily. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 13 The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents, their relatives and friends feel that their views are listened to and acted upon. EVIDENCE: The inspector saw the complaints procedure, which was displayed in the entrance hall for all to read. A complaints log included a record of one complaint received by the CSCI which the manager investigated to the CSCI’s satisfaction. The inspector asked one residents if they had made a complaint in the past, they replied “No, I haven’t ever needed to.” The inspector asked if they felt able to should the need arise, “I am know I would speak to the staff or the manager.” Two staff confirmed their knowledge of the correct procedure to follow, and said “the home is very open and friendly, we talk about things before they become an issue of concern.” The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Residents live in a safe, pleasant environment which is well maintained. The majority of the home was clean, pleasant and hygienic, however an offensive odour was present. EVIDENCE: The manager showed the inspector around the home, which appeared well maintained. One resident said “ if I notice anything that needs fixing or I want a picture hung, I ask and the job is as good as done.” One resident said their room was very pleasant, clean and warm, they were encouraged to bring their own personal belongings, furniture and pictures to make it feel like home. A random selection of bedrooms were seen, all were found to be clean, warm and furnished with personal items. One resident said “I feel safe here, as well as being free to come and go as I please”. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 16 The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are kept to low temperature. The garden is well maintained and residents enjoy using it, to walk around, sit in or look at from inside the home. The inspector witnessed an offensive odour in the entrance hall and two of the residents bedrooms, the inspector required the cause be investigated and eliminated. THIS IS A REPEAT REQUIREMENT FROM 22/10/05 The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The staff at the home are well trained, supported and employed in sufficient numbers to meet the residents needs. This has resulted in residents feeling safe and comfortable at the home. There are good recruitment procedures in place that ensure residents are not put at risk. EVIDENCE: At the time of the inspection, appropriate numbers of skilled staff were on duty, ensuring the residents safety, The rotas showed that there were sufficient staff on duty to meet the residents’ needs, staff confirmed this. The manager stated the home is fully staffed at present with no vacancies. Two staff told the inspector “I receive more than adequate training to enable me to carry out my role” “I am encouraged to do training, I really enjoy doing it, and working here”. One residents spoken with said “Staff do training, sometimes it is held here at the home, other times it is at colleges.” All the residents spoken with said there was sufficient staff around and that the staff appear to know what they are doing. All eight staff files and the homes training records showed that staff had completed the following mandatory training: Induction and foundation, moving and handling, food hygiene, first aid and fire training. Certificates showed all staff have attended training to cover abuse awareness and dementia care. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 18 The residents spoken with described the staff as ‘caring, friendly, helpful and there when they are needed.’ The manager explained the procedure for the induction of new staff, the inspector saw a written record of training received. Four staff files were sampled, all of which belonged to a staff member who were employed recently. The files contained photographs of the individual, along with other evidence of the individual’s identification. The inspector saw evidence that appropriate Criminal Records Bureau (CRB) disclosures had been completed, along with a record of POVA clearance. All evidence found in staff files ensure that staff are fit to work at the home. The staff spoken with felt that the recruitment process within the home is thorough and the induction programme run by the home was useful and very detailed. The files sampled held records of the individual staff home’s own induction training covering the key areas with the signatures of the staff member and trainer. The manager confirmed that the home’s induction programme has been assessed against the Skills for Care Council induction standards. The manager is positive and supportive of staff development and training, the inspector saw records which show staff receive regular supervisions, annual appraisals and various staff meetings that are minuted. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,38. The home is run and owned by a manager who is registered. Documentation had not been correctly forwarded to the CSCI, therefore Service users health, safety and welfare are not fully protected. EVIDENCE: The manager is the owner of the home and was registered with The CSCI in 1994, and has completed Registered Managers Award (RMA) and is a registered nurse. Whilst looking through the accident record and copies of the homes regulation 37 documents, it was apparent that seven accidents had been documented in the homes accident book, however, the CSCI were not notified under regulation 37. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 20 The home is required to ensure all accidents, injuries and incidents if illness or communicable disease are recorded and reported to the manager and the Commission for Social Care Inspection CSCI under Regulation 37. THIS IS A REPEAT REQUIREMENT FROM 22/10/05. The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 22 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 OP26 Regulation 16, 2(k) Requirement The care home is kept free from offensive odours. THIS IS A REPEAT REQUIREMENT FROM 22/10/05 The home must ensure all accidents, injuries and incidents, illness or communicable disease are recorded and reported to the CSCI under Regulation 37. THIS IS A REPEAT REQUIREMENT FROM 22/10/05 Timescale for action 30/03/06 2. OP38 37 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Coach House DS0000011880.V280875.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000011880.V280875.R01.S.doc Version 5.1 Page 24 - 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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