Inspection on 04/07/06 for The Coach House

This inspection was carried out on 4th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 03/06/08

The Coach House 25/05/07

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 09/07/2008.

CARE HOME ADULTS 18-65 The Coach House Mythe Road Tewkesbury Gloucestershire GL20 6ED Lead Inspector Mr Simon Massey Key Unannounced Inspection 4th& 12th July 2006 10:00 The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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.V291596.R02.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 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.V291596.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Coach House Address Mythe Road Tewkesbury Gloucestershire GL20 6ED 01684 299507 01684 299507 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 Mr Mark Anthony James Dooley Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Date of last inspection 6th March 2006 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 acting manager, who was previously the deputy manager. 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 was not available at the time of the inspection. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 4th and 12th July 2006 and lasted for a total of 12 hours. The home was previously visited on 6th March 2006. This inspection looked at the key national minimum standards and was unannounced, though the second visit was arranged in conjunction with the Deputy Manager. This inspection was supported by members of the care staff and also by the Deputy Manager. The Registered Manager was on leave at the time of both visits. The Inspector had contact with all of the service users who live in the home. Other staff were also observed supporting the service users. The inspector also spoke with the Provider’s Quality Assurance manager. Records relating to care planning, medication, health and safety and staffing were examined. An inspection of the premises was also undertaken. What the service does well: What has improved since the last inspection? No areas identified. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Pre-admission assessments and the home’s admission policy help ensure the appropriate people are admitted to the home whose needs can be met. EVIDENCE: There have been no admissions to the home since the previous inspection, but the home has an admission policy in place that complies with the regulations. Information and assessments are prepared and collected or completed, and people have an opportunity for visits and overnight stays before a decision is made on admission. All admissions are subject to a trial period. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Service user’s needs would be better met if the care planning process ensured a clear link between documentation and practice and if there was a regular reviewing process. Updating and reviewing of risk assessments would better support service users to live a more independent lifestyle. EVIDENCE: A sample of care plans and personal files were examined and staff were also spoken to about their key-working responsibilities. The care plans contained regular recording about behaviours and incidents, trips out, visits to relatives, college attendance and activities undertaken. The following shortfalls in the files were identified. Some of the plans were not dated or signed and it was unclear when reviews were planned and who had the lead responsibility for this. There appears to be limited setting of goals and objectives, and who the designated people would be for taking the appropriate action. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 10 Some files had had bruise chats completed but there were no corresponding entries in the daily notes for the relevant individual. The files contained weight charts but some of these had few entries over the previous 6 months. One person has a monthly summary that states they are undertaking more independence skills but there is no detailed reference to this in their care plan or guidance as to how this should be progressed by the staff. Some of the notes are poorly written and difficult to follow, something that is compounded by the fact that several of the files appeared not to be well organised with information difficult to locate. Some of the recording around behavioural incidents that required physical intervention from staff contained insufficient detail about the antecedent behaviour. There also appeared to be lack of recording to attempt to explain or evaluate incidents. Some of the monthly summaries contain “goals” but it is unclear how these have been arrived at and how they are to be followed up. Some of these did not seem to relate to the information contained in the original care plans. Again a lot of recording in these summaries has not been signed and dated. Some of the daily notes contain mainly comments such as “appeared happy”, with no recording against specific goals or objectives. The list of activities for one person for the previous three months consisted of references to two things, going for a “drive” and “gym visit”. Some risk assessments seen were not dated or signed. In summary the concerns identified are as follows. • • • • • • When are plans reviewed and by whom What is the involvement of the service users in this process Goals and objectives not clearly identified People responsible for taking goals forward not identified nor the timescale that is being considered Lack of dates and signatures on key documents Inconsistent and illegible recording of daily notes Service users were observed being supported to make decisions about their daily routines and activities and there was recording about some limitations, which for safety reasons, are in place. References to the difficulties placed upon staff due to the limitations of office space are referred to under the environment and staffing standards. Through observation and interviews it is evident that it is often difficult for staff to find the right space and opportunity to record what can be complicated observations and details. The lack of sufficient private office space will also make it difficult for staff to confer, and discuss situations and issues with one another. Often this can only be done whilst sharing space with service users, or taking over the home’s kitchen, which is a secure area for reasons of safety. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 11 Staff were observed completing recording at the dining room table, in the kitchen and also in the garden. A requirement has been made that the home provide details to the Commission of how these issue around care planning, recording and reviewing are to be addressed. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users have some daily and weekly activities but greater variety would provide more opportunities for people to be actively engaged. Service users have access to the local community but this is sometimes limited by choice, lack of appropriate staff or vehicle, or the identifying of a suitable activity. Service users are supported to maintain appropriate family contacts. EVIDENCE: Efforts are made by the staff team to identify activities or interests that will meet the needs of the service users, but this is proving more difficult for some people than others. At the previous inspection in March 2006 it was observed that increased activities and trips away from the home was contributing to a better environment in the house. This was partly due to less numbers in the The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 13 home and also to people enjoying, and being able to undertake, some limited activities in the wider community. Records show that limited variety is being provided for some people and that at times there can be several service users in the house with little structure to the activities or care that is being supported. There are complex needs to be met that require trained staff to be patient and imaginative. In the view of the inspector there is a combination of lack of space, staff training and ineffective care planning that is inhibiting more progress being made in this area. Activities have also been hindered at times by a vehicle being unavailable, lack of drivers and staff absences. Recording shows that contact is maintained with families and relatives, with regular visits being supported and of staff communicating with parents over issues or concerns. The inspector left some questionnaires for the home to give to relatives that could be returned to the Commission. One limitation to daily routines is the kitchen, which for safety reasons due to the behaviours of some service users is kept locked. Details about this are contained in the personal files. Service users do have the opportunity to prepare food and drinks under staff supervision. Service users are encouraged to have some involvement in daily chores and tasks but participation in this limited due to the needs of individuals. Menus showed that a healthy diet is encouraged and that choice and personal preferences are catered for. The kitchen was well stocked with fresh and frozen produce and all was appropriately stored and labelled. Service users can eat their meals where they choose. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, & 20 Quality in this outcome area is adequate, though some parts are judged as being poor. This judgement has been made using available evidence including a visit to the service. Health needs are monitored and service users are supported to access specialist health professionals as part of their care. Better training of staff and auditing of medication procedures would provide improved protection for the service users. EVIDENCE: The care plans contain information about how personal care and support is to be delivered and the extent to which service users are able to complete tasks independently. The personal files contain records of appointments to, and visits from health professionals. There is evidence that the health needs of the service users are being monitored and people are receiving regular health checks. Service users access specialist services, and correspondence and advice is kept in the personal files. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 15 The medication storage and administration was examined and some concerns were identified. The protocols for the PRN medication could not be located and staff were not entirely clear about the procedure to follow before administering. Two gaps were found on the medication records and it was unclear whether this medication had been administered or not. At present only the senior staff complete accredited medication training and new staff are supposed to undertake training from these staff before being assessed as competent. This is done by shadowing the staff member concerned. However the records show that some staff have begun administering medication before completing their induction period and the inspector is concerned that insufficient training is being provided before people are assessed as competent. It was also unclear what ongoing monitoring of staff competence was being undertaken. Protocols for the administration of PRN medications should be easily accessible and staff fully aware of the steps to take before administering. The home must review its training protocols to ensure that staff are fully competent before they are allowed to administer medication. The home must ensure there is an auditing system in place that checks and identifies any errors in recording or administration. A requirement has been made that the home provide details of how all the above points are to be addressed. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users able to express their views, are listened to by staff. Regular contact between the home and families helps to ensure that service user’s concerns are identified. Staff training, protocols for managing behaviours and the recording and notifying of incidents help ensure that service users are protected. Improved supervision and more detailed recording would further improve the protection afforded people. EVIDENCE: The home has received no complaints during the previous 12 months and there was evidence of regular contact with parents or relatives over any concerns or issues that had arisen. The inspector left questionnaires for relatives of the service users for the home to distribute, which can be completed and returned to the Commission if they choose. The home has correctly notified the Commission of incidents when physical restraint has had to be employed. Records show that this is used as a last resort and then only by staff who have received the training. There has been a gradual overall decrease in incidents since the previous inspection and staff and records show that the majority of aggressive behaviours are directed toward staff or property. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 17 Whilst there were some good examples of detailed recording there were also some records that contained insufficient detail, particularly about antecedent behaviour. Staff were observed supporting service users and interacting in a calm and appropriate manner. However, one incident was noted when a service user was told to stop doing something, and then shouted at to go to their room. This seemed inappropriate and was not an approach recommended in the relevant care plan. All staff receive training in descalation and low arousal approaches to working with challenging behaviours. This is accredited training, that is monitored with updates being organised by the management when they are due. It is essential that staff have the skills to put this training into practice and are supervised to ensure that a calm and consistent approach is maintained throughout the team. It is also evident that increased activities away from the home can make the environment and service users easier to manage and support. Further comment around this is made under the Lifestyle standards. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements to the access to the property, and better provision for staff to complete administration tasks, would make a more homely environment. The home provides a well maintained and reasonably decorated environment with bedrooms being personalised according to needs and personal taste. EVIDENCE: The home was well maintained and decoration and repairs are completed on an ongoing basis. The carpet in the living room/dining was badly stained and odorous, and it was stated that this was due to be replaced with a vinyl flooring which will better meet the needs of the service users. All the individual rooms were furnished and decorated according to personal tastes and needs. Some service users will tolerate very little décor in their rooms. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 19 The home was clean and hygienic throughout. Requirements have been previously made about the gates that act as the entrance to the home. Visitors are required to phone a number and then a member of staff should come and unlock the gates. There is an obvious assessed need for the garden to be a secure area but steps are yet to be taken to improve the current arrangements. The requirement made in the last report, regarding the access arrangements to the property to ensure ease of access to visitors and to promote a positive image of the service has therefore been repeated. Concern over the lack of office space is recorded in the staffing standards but this issue also impacts upon the extent to which a homely and comfortable environment can be maintained and promoted. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Sufficient space to complete recording and have confidential meetings would improve the efficiency of the staff team and promote better practice. Service users are protected by the homes recruitment procedures but any flexibility if not agreed with the Commission, could compromise their safety. EVIDENCE: Examination of the rotas showed that the correct staffing levels are being maintained and were necessary this is being achieved with the use of agency staff. Efforts are made to ensure that agency staff are known to the home and the service users. There have been a number of staff changes over the past several months. The training records were in need of updating but some staff are overdue their statutory training. Staff were up to date with the Calm training that is provided in managing challenging behaviours. Some staff are undertaking NVQ training and a requirement has been made that the home supply the Commission with the details of how many staff have currently completed their NVQ’s and when the minimum standard of 50 of staff being qualified will be met. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 21 The staff files were examined and correct recruitment procedures were generally being followed. One file contained a risk assessment for a staff member who had been started before a CRB had been completed. The Commission had not been consulted regarding this. Care staff should not commence employment until all the necessary checks have been completed. Any deviation from this must be agreed with the Commission. New staff were undertaking induction training and completing their induction training packs. The home has taken disciplinary action against certain staff but the full details of this were not recorded in the files. The inspector was also informed that probation periods had been extended in some cases, but this was not recorded in the personal files. Supervision notes should reflect discussion of disciplinary issues when these are related to work practice and attitudes. Staff were observed supporting service users and responding to questions and needs in an appropriate manner, though the inspector was concerned about some responses to service users and situations where the staff member displayed irritation or frustration. Staff were observed smoking whilst working with the service users. Though this was in an outside area, this is still poor practice. Staff understanding of the smoking policy was that they should smoke outside. A requirement has been made that the home review its policy and provide a copy to the Commission. There is a lack of office space within the home with staff having to use a small cupboard/office upstairs and also the cupboard under the stairs for storing items. The adjoining registered home has offices in the basement which are utilised to some extent by the management. The lack of space presents practical difficulties for the staff team. It is difficult to have confidential conversations, recording and accessing of information is hampered and there is no suitable space for meetings. Staff were observed completing recording and reading paperwork in the kitchen, dining room and the garden. The kitchen, which for safety reasons is kept locked, can occasionally be used by staff for confidential conversations. The difficulties of space are having an impact upon the ability of the team to deliver the care and support that is required. The service users have complex needs and challenging behaviours, which require reflective and detailed recording. To supervise and advise staff whilst on shift is also important, but this is difficult to do confidentially, without leaving the home and using the offices next door. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 22 The Provider, and the management team, are aware of the difficulties and the Inspector is aware that potential solutions have been considered. In the view of the inspector an improvement in the arrangements for office space is essential if the staff and management team are to effectively deliver a high quality of care and support. A requirement has been made that this situation is reviewed and improvements planned. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Overall quality in this outcome area is adequate though some parts were seen as good and some rated as poor. This judgement has been made using available evidence including a visit to the service. The leadership and direction provided to the staff is professional and informed about the care of people with autism and challenging behaviours but can be undermined by staff changes and the practical arrangements for office and staff areas. Quality Assurance processes help ensure that issues are identified and appropriate action plans developed. Service users are protected by the health and safety procedures, though lapses in recording could compromise people’s safety. EVIDENCE: The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 24 The manager was on leave at the time of this visit and part of the inspection was supported by the recently appointed deputy manager. At the time of the inspection the Quality Assurance manager for the Provider was completing an audit of the home. The results of this were shared with the inspector, as well as the subsequent action plan that was drawn up for the manager to follow. The audit identified a number of areas that required attention and action, and included issue around medication and recording that have also been highlighted in this inspection report. Regulation 26 visits have also been completed every month and reports supplied to the home and to the Commission. All electrical checks and servicing had been completed and all fire safety equipment was being correctly maintained. There was no recording of any alarms being tested since 8/05/06 and a requirement has been made in relation to this. The inspection identified that there are a number of management tasks that have not been competed regularly. However the home continues to attempt to support service users who have complex and challenging needs and direction and leadership have been shown in these areas. Staff changes have also not helped the consistency of the service and the current staff team has a number of relatively inexperienced staff. Managing the service without a proper office base within the home also presents difficulties for the monitoring and informal supervision of staff. Improvements in these arrangements are required for the home to be more effectively managed. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 25 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 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 26 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 YA24 Regulation 12(4)(a)& 23(2)(a) Requirement The manager must review and revise the access arrangements to the property to ensure ease of access to visitors and to promote a positive image of the service. (Timescale of 31/01/06 and 30/04/06 not met)) The home must provide details to the Commission of how the concerns around care planning identified under Standard 6 are to be addressed The home must address the issues identified in the text and ensure that a safe system for administration of medicines is in place The home must review the current arrangements for office space/storage, staff recording and staff meetings and provide additional or improved facilities The home must supply the Timescale for action 30/09/06 2. YA6 12(1)(a) & 15 30/09/06 3. YA20 13(2) 30/09/06 4 YA33 23(1)(a)&23(3) 30/09/06 5. YA32 18(1)(c)(i) 30/09/06 Page 27 The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 6. YA34 7. YA32 8 9. YA42 YA42 Commission with the details regarding NVQ training identified in the text of the report 19(1)(b) The home must not commence employment of staff until all the required checks have been completed 18(1)(c) The home must ensure that all staff have completed the required statutory training n fire safety, first aid and food handling 12(1)(a)&13(4)(a) The home must review its smoking policy and provide a copy to the Commission 23(4) The home must ensure that fire safety tests are completed and recorded 30/07/06 30/09/06 30/09/06 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Guidance and training about person centred principles should be provided for staff responsible for implementing this approach. The Coach House DS0000062579.V291596.R02.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000062579.V291596.R02.S.doc Version 5.1 Page 29 - 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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