Inspection on 04/12/07 for The Coach House

This inspection was carried out on 4th December 2007.

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 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 12/08/08

The Coach House 07/11/06

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Coach House 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU Lead Inspector Joy Hoelzel Key Unannounced Inspection 4th December 2007 09:30 X10029.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 DS0000067681.V356367.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 Older People and 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 DS0000067681.V356367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU 01902 343 000 01902 331000 goldthorncourt@btconnect.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) Select Health Care (2006) Limited Vacant Care Home 70 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number disorder, excluding learning disability or of places dementia (70), Mental Disorder, excluding learning disability or dementia - over 65 years of age (70) The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate 12 people with a mental disorder who may have a learning disability in a specific unit within. The home can accommodate 12 people with a mental disorder who may also have a physical disability in a specific unit within the home. People accommodated at the home who are over 65 may also have a physical disability. 7th November 2006 Date of last inspection Brief Description of the Service: The Coach House is a purpose built care home providing accommodation nursing and personal care for up to seventy people of all age groups. In June 2006 the home was registered with Select Healthcare Ltd as new providers for the service. The home has a variety of communal lounge and dining areas, all bedrooms are single occupancy with en suite facilities. The home is located at Goldthorn Hill, Wolverhampton and is within easy walking distance of the local shops and amenities. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have been revised and are readily available. The service user guide does not include information on the current level of fees for the service. The reader may wish to obtain more information from the care service. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours on Tuesday 4th December 2007. It was conducted by two Commission for Social Care Inspection personnel. Twenty three of the thirty eight National Minimum Standards for Care Homes for Older People and twenty one of the forty three standards for Care Homes for Adults (18-65) were inspected as they are viewed as key standards for services. Fifty eight people are currently living at the home and during the inspection were observed to be accessing all areas of the home. The acting manager was on the premises supported by four Registered nurses, eleven care staff and ancillary personnel. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. Discussions were held with people living and working at the home. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with the CSCI areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. The registered manager completed this document and returned it the commission. Comments from the AQAA are included within this inspection report. What the service does well: The home has good procedures in place for arranging and offering people a placement, providing a good standard of accommodation, dealing with concerns and complaints and recruitment of staff. The manager and staff have a good knowledge of the individual care needs of people living at the home. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 6 The cleanliness of the home is maintained to a high standard. People living at the home commented – • • • ‘ Look after me very well’ ‘They [staff] all try to do their best’. ‘Ok place to live’. What has improved since the last inspection? What they could do better: Whenever possible people and/or their representative should be involved in the care planning and review processes. The care plans should be improved and developed to ensure that staff have the full details of the assessed needs of a person, of the care that is to be delivered and the expected outcomes for the person. The monthly audits conducted by the senior staff should be sufficiently robust to reduce the potential risk of errors occurring. A ratio of 50 of trained care staff (National Vocational Qualification in care level 2) should be achieved to ensure that suitably qualified, competent and experienced staff are working at the care home at all times. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 7 The dining arrangements are very functional and routine; consideration should be given to improving this practice to enhance the social occasion of dining. For the safe use of bedrails, regular checks should be conducted to ensure the rails are correctly fitted and compatible with the beds and that the rails are fit for the purpose. Records of these checks should be maintained and available for inspection. 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 DS0000067681.V356367.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6. YA 2 Quality in this outcome area is good. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. Generally admissions are not made to the home until a full needs assessment has been undertaken with prospective individuals given the opportunity to spend time in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 10 Details of the service provision are available in the statement of purpose and service user guide; both documents have been reviewed in February 2007, and are available on request. These documents were not inspected in depth on this occasion but on general observation the service user guide does not include information on the current level of fees for the service. To comply with the regulations the service user guide must include information about the fee levels and what are and are not included in the fees. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the home specifies that whenever possible people are invited to visit the home prior to making the decision to move in. The manager described the admission process and the assessment documents used by the home to obtain a persons care needs. This documentation is currently under review. Pre admission information is stored separately from the case files but is used to generate a plan of care at the point of admission to the home. One person stated that the social worker arranged the placement but was satisfied with service and that it was ‘ an ok place to live’. The home does not provide an intermediate care service. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10. YA 6,9,16,18,19,20, Quality in this outcome area is adequate Each individual has a care plan but practice of involving people who use the service in the development and review of the plan is variable. The plan includes basic information necessary to deliver the resident’s care but is not detailed or person centred. The care plan is not used as a working document and does not consistently reflect the care being delivered. This judgement has been made using available evidence including a visit to this service. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 12 EVIDENCE: All people living at the home have a plan of care that is based on the information gained prior to admission the plan is then reviewed on a regular basis. Four case files were selected for inspection and each contained a variety and assortment of documents and assessment tools. Many of the assessment and monitoring tools were duplicated for example in one file there was three different falls risk assessments and two different moving and handling assessments. Some documentation in use relates to the previous providers of the home. Where a potential risk had been identified a care plan had not been developed, for example a moving and handling assessment had identified a medium risk to the person, a plan of care had not been developed to ensure that the action needed to be taken by staff to reduce the risk of injury was documented. Nutritional risk assessments had been completed but there was no information to ensure that good nutritional status is maintained. The records of the fluid and food intake completed by staff for some people are not in sufficient detail to determine that a satisfactory diet has been prepared, offered and taken. Where the use of bedrails had been identified for maintaining a persons safety in bed the assessment document or consent for use had not been completed. There was no evidence in the case files selected to suggest that people or their representatives were being fully involved with the care planning process. The AQAA documents that ‘ the service user is encouraged as much as possible to contribute to their care plan’. The statement of purpose indicates ‘We work with the individual and or their representative to draw up a written plan of care. This document will be signed by the admitting nurse, the resident and their representative’. It is acknowledged that some people may not wish to or are unable to contribute to the process but efforts should be made to ensure that the plan of care is discussed and agreed with the individual. The home operates a twenty eight day prescribing regime for the administration of medication using a monitored dosage system with the additional use of boxes and bottles of medicines. The registered nurses administer the medications, the Medication Administration Record appears to be fully completed, and no gaps in the recording sheet were seen in the selection viewed. Peoples consent to medication has not been obtained there is no record of this is in the care plan. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 13 The deputy manager and registered nurses conduct monthly audits to ensure the accuracy of medication procedures and systems. However these checks do not appear to be robust as on checking one person had been prescribed an external preparation for a skin condition, the care plan had not been updated to detail this instruction and another Medication Administration Record indicated that a certain medication was not being given at the instructed time. The people living and working at the home appear to have developed good relationships with each other there was lots of chatter and discussions occurring. Staff were observed to be offering many choices and carrying out interventions in a calm, efficient and competent manner. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15. YA 12,13,15,17. Quality in this outcome area is adequate People using the service are given the opportunity to take part in a variety of activities within the home and some say that the food and meals are satisfactory but this process could be improved to ensure that a persons expectations and preferences are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 15 The acting manager stated that arrangements have been made to recruit a specific person for arranging and facilitating social, leisure and recreational activities. During the morning of the inspection a community meeting was held in the lounge on Poppy unit with much discussion regarding the Christmas festivities, the replacement of the payphone and the purchase and choice of furniture for the lounge. The meeting is chaired by a person using the service, with the minutes of the content of the meeting made by a staff member. People in the other areas around the home were observed to be generally occupied, listening to music, watching television and chatting to staff. Some people stated that they would like to go out of the home more often and one person stated that they would like to go to college. One person was clearly unhappy that they had been cajoled into doing some artwork they stated that they did not want to and was unable to do it. Relatives and friends are welcome to visit the home at times suitable to the person living at the home. The AQAA completed by the acting manager indicates recognition that improvements and development of the social side of life at the home is required within the next twelve months with the possibility of a holiday next summer. Meals are served in the dining areas of the two units. People are encouraged to go to the dining rooms but can have their meals in other areas if they prefer. Observation of the midday meal in the large dining room indicated that it was a very functional occasion with little opportunity for the meal to be a social or pleasing experience. Staff appeared to be very tense and rushed. The cook explained that cultural diets are catered for with English and Asian type meals prepared each day. Other cultural diets for example Jamaican food is served once a week. It was not possible to establish if the different meals are offered to all people or just to a minority of the people. The AQAA completed by the acting manager states – ‘The menu is varied including afro-Caribbean and Indian food as some of our service users are from these countries’. There was little evidence to suggest that people are offered a true choice – one person requested fresh fruit salad for desert but was told this was only for people with a specific dietary need. Most people however appeared to enjoy the meal with some people stating that the food was – ‘alright’. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 16 In the ‘Have your say’ survey completed one person thought the meals had improved within the last six months. The AQAA completed by the acting manager states‘Service users are encouraged to bring in personal possessions with them as far is appropriate in order to personalise their rooms’. This was evidenced in a selection of the bedrooms looked at during the tour of the premises. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18. YA 22,23 Quality in this outcome area is good. The service has a complaints procedure that is clearly written and easy to understand and is displayed in a number of areas within the home. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the statement of purpose and service user guide and a copy is displayed at the entrance to the home. The acting manager has a good knowledge of the safeguarding and the protection of vulnerable adults procedures and has recently made a referral to the multi agency team following an alleged incident between staff and service users. This incident has yet to come to a satisfactory conclusion. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 18 The AQAA completed by the acting manager indicates that improvements have been made within the last twelve months with ‘staff more aware of abuse and protection of vulnerable adults’ and identifies that further improvements could be made with ‘clearer documentation recording any incidents separately for immediate reference’. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,26. YA 24,30 Quality in this outcome area is good The Coach House is a very busy, large home that provides a physical environment that is appropriate to the specific needs of the people who live there. It is comfortable, and has a programme to improve the decoration, fixtures and fittings to further enhance the standard of the accommodation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 20 Some private and communal areas have recently benefited from redecoration and refurbishment, discussions with the acting manager revealed an ongoing renewal programme relating to further improvements including the interior décor, new floors, painting, and furniture. The newly named Primrose unit now has a separate entrance from the main building with plans for additional communal space to be provided with a conservatory at the rear of the premises. The garden has been improved and now provides a safe and secure area for people to enjoy. The local fire safety officer and environmental health officer have both made recent visits to the home, the acting manager confirmed that the recommendations following these inspections would be complied with. The whole of the premises was clean and hygienic with staff demonstrating a good knowledge of infection control procedures. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30. YA 32,34,35. Quality in this outcome area is adequate. There appear to be enough staff available to meet the needs of the people using the service, with the staffing structure based around delivering outcomes for the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager described the staffing levels for the two units (each staffed separately) and the desired number of staff on shift at any given time. General observations and discussion with staff confirmed that staffing numbers and skill mix enable a service provision, which meets the care needs of the people living at the home. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 22 Staff were observed to carry out their duties in an enthusiastic and professional manner. The AQAA completed by the acting manager identifies some difficulties with assisting people with personal hygiene ‘ People can present many challenges as some service users do not want to bathe/shower or have their hair cut. Staff are continually looking for ways to encourage people to meet their hygiene needs’. Many service users looked well groomed and it was obvious that where the staff assisted people high standards of personal care are achieved. The Annual Quality Assurance Assessment completed by the manager documents that of the 44 permanent care staff 13 are working towards accreditation with National Vocational Qualification in care at level 2 or above. The training matrix supplied by the acting manager indicates that only four staff have the award at Level 2. The home should by now have achieved a ratio of 50 of trained care staff to ensure that suitably qualified, competent and experienced staff are working at the care home at all times. Four staff personnel files were looked at; the records examined showed they contained all the necessary information, which demonstrates potential staff are well screened before they are deemed suitable to start work at the home. Certificates and accreditations of training are included in the files; the training matrix indicates that training in the core topic areas (moving and handling, fire safety, first aid) have been accessed, together with some specialist areas (Dementia awareness, mental capacity act etc). The acting manager confirmed that all new starters follow an induction programme; however two staff files looked at did not contain any information relating to this. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 24 OP 31,33,35,38. YA 37,39,42. Quality in this outcome area is good. The acting manager has the required qualification and experience, is competent to run the home and has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager Mrs Sue Jones has been in post since May 2007 and still has to make a formal application to us for registration. Mrs Jones is a first level nurse and has experience with the management of care homes and throughout this inspection demonstrated a sound knowledge of the individual care needs of the people living at the home. She is in process of a clearly thought out restructuring exercise and is providing direction and leadership which staff and service users understand and relates to aims and purpose of the home. Mrs Jones has implemented strategies for enabling her deputy to take on a more explicit management role with other staff and service users. Two staff members indicated that the home and provision of the service has improved since Mrs Jones has been employed. Quality assurance and monitoring of the service continues with weekly, monthly and annual audits conducted with the findings actioned. Satisfaction surveys are distributed to staff, service users, visitors and contractors on a regular basis to obtain an overview on how the service is operating. There are regular staff and service users meetings and numerous opportunities for informal discussions. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. The policy and procedure relating to the safekeeping of peoples monies does not include a maximum amount for any one person for which the home takes responsibility. It was recommended to the acting manager that the policy be amended to include this information with any surplus money being placed in an individual interest bearing savings account or returned to the local authorities Weekly, monthly and annual testing of the equipment and premises are conducted with records kept and available for inspection. The manager The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 25 confirmed that safety checks are made on a regular basis for the use and fitness of the bedrails, the recording documents were unavailable for inspection. The Coach House DS0000067681.V356367.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 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 2 X 3 3 4 X 5 X 6 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 2 36 X 37 X 38 2 The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 27 Yes 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 OP8 Regulation 15(1) Requirement All risk assessments, identified risks and care plans must be fully completed and set out in detail the action to be taken by staff to ensure all care needs are fully met. Previous requirement timescale of 30/11/06. Not met. Timescale for action 31/05/08 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 Refer to Standard OP1 OP7 YA20 OP9 Good Practice Recommendations To comply with the regulations the service user guide should include information about the fee levels and what are and are not included in the fees. The care plans should be drawn up with the involvement of the person and or representative, agreed and signed A person’s consent to medication should be obtained and recorded in the individual plan of care. Medication should be administered at the correct time as per instructions from the general practitioner. DS0000067681.V356367.R01.S.doc Version 5.2 Page 28 The Coach House 5 6 OP15 OP28 7 8 OP31 OP33 9 OP38 Consideration should be given to improving the current practice of serving meals to enhance the social occasion of dining. A ratio of 50 of trained care staff (National Vocational Qualification in care level 2) should be achieved to ensure that suitably qualified, competent and experienced staff are working at the care home at all times. The formal application for the registration of the manager should be submitted without delay. The policy for the safe keeping of a persons money at the home should be amended to include the maximum amount held on behalf of any one person with any surplus money over and above the stated amount being placed in an individual interest bearing savings account or returned to the local authorities. It is recommended that routine checks be carried out on the bedrails, with records kept, to ensure that they are fitted correctly and safe. The Coach House DS0000067681.V356367.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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