Inspection on 06/03/06 for The Coach House

This inspection was carried out on 6th March 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 no outstanding requirements from the previous inspection report, but made 4 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 04/07/06

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 Unannounced Inspection 6th March 2006 10:00 The Coach House DS0000062579.V285727.R01.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.V285727.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 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.V285727.R01.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.V285727.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Home to initially open with four rather than six service users and two service users will be using the two spare rooms as living rooms. The connecting doors installed for this purpose must be removed before the final two places are filled. Confirmation of this has been received from the provider. 13th October 2005 Date of last inspection 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 Coach House DS0000062579.V285727.R01.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 6th March 2006 and lasted for three hours. The home was previously visited on 12th October 2005 and one focus of this inspection was to follow up requirements made from this previous visit. For a fuller report against the national minimum standards this report should be read in conjunction with the report from October 2005. This inspection was supported by a member of the care staff and also by the registered manager. The inspector had contact with four of the service users who live in the home. Other staff were also observed supporting the service users. 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? The home now has the required staffing files in place. Medication protocols and procedures have been improved. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 6 There has been a slight decrease in the frequency of behaviours requiring staff intervention. There has been an improvement in the relations between some of the service users. 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.V285727.R01.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.V285727.R01.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 Pre-admission assessments help ensure the appropriate people are admitted to the home whose needs can be met EVIDENCE: The information relating to the assessment of a new service user has been supplied to the Commission. This was a requirement from the last visit. One other service user has been admitted since the last inspection. This was an emergency placement due to a domestic situation but the service user was previously known to the home. Due to certain anxiety based behaviours this person did not have a pre-admission visit and this is recorded in their file. The inspector met the service user, who appeared settled and relaxed in their new home. The Coach House DS0000062579.V285727.R01.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 Detailed care plans and assessments ensure that staff have the information available to understand and meet the needs of the service users. EVIDENCE: A sample of the care plans and personal files were examined. All plans were being regularly reviewed, though the plan for the newest service user was neither dated nor signed. The plans contained information and detailed guidance on how behaviours should be managed. Guidance is provided on areas such as living skills, access to the community, communication skills and travelling in vehicles. In order to monitor behaviour the home use a “traffic light,” system where staff can record the level of anxiety or challenging behaviour that is being exhibited. These were all completed on a regular basis. Files also contain any records of any bruises or injuries that have been identified by staff. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 10 The home has reorganised some of its storage arrangements for files but space remains very limited. All information was appropriately and securely stored, which was a requirement following the previous inspection. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 11 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 & 17 Increased activities and involvement in the community has improved the ability of the home to meet individual needs. Regular trips out supported by staff have contributed to a decrease in some of the behaviours that challenge the service. The home have a pro-active approach to supporting and maintaining family contacts and relations for the service users. Good recorded information on dietary needs and associated issues help ensure that service user’s needs are met. EVIDENCE: A number of different activities were being undertaken on the day of the inspection. The home tries to provide a varied and structured programme for service users, which involves regular trips to activities in the community. This meets the needs of service users and also helps to maintain a calmer atmosphere within the home. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 12 Service users were also observed asking staff to arrange trips out and these requests were responded to positively. Recording and notifications to the Commission have shown that there has been a decrease in some of the challenging behaviours that the staff have been managing. Staff commented that there had been some improvement in the relations between certain service users and also the increased receptiveness to participate in activities from some people had contributed to this progress. All service users who have family and relatives are supported to maintain contact and records of this are found in the personal files. One person returned from a weekend with their parents during this inspection. One service user with no family involvement is supported to maintain contact with a friend they have had for many years, and who they consider as family. The mains meals are provided from a central kitchen that is located in the adjoining home. The menus were not examined during this visit but the home’s kitchen contained provisions to provide snacks and drinks. All the individual files contain information about dietary needs, likes and dislikes and also information about any behaviours that are associated around food or mealtimes. People can choose where they eat their food, and one person was observed taking their lunch to their room. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 13 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): 20 Service users are better protected by the new procedures and protocols in place for the administration of medication. EVIDENCE: New guidelines and protocols relating to PRN medication and covert administering have been put in place. This was a requirement form the last inspection. Medication records were correctly filled in and there was evidence that medication is reviewed at appropriate intervals. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 14 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): 23 Steps taken to improve the recording of physical intervention further protect the service users. EVIDENCE: A requirement has been made that the home provides more detail about the specific restraint techniques that are used in each situation. The manager undertook to provide details from the training firm CALM who provide the training. This will allow the Commission to know specifically what procedure is being followed. The Commission has liaised with the home over a concern about the frequency of restraint that was required for one service user. The home has been having monthly review meetings involving outside professionals and has kept the Commission informed of the outcomes of these meetings. The recording and evidence form staff confirmed that progress has been made, with far less restraint being required and additional activities being undertaken. There has also been an improvement in relations with other service users. The manager stated that this level of monitoring will continue, as there was still progress to made in the meeting of the person’s needs. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 15 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 Service users have individual rooms that reflect their needs and preferences. The home maintains a clean and hygienic environment. EVIDENCE: A brief tour of the premises was completed and the home appeared to be clean, hygienic and well maintained. Service users were observed making use of their bedrooms and the communal areas of the home. Some of the bedrooms are sparsely furnished and relatively un-personalised but this is due to the preferences or behaviours of the individual service user. This information is recorded on their files. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 16 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): 34 & 36 Improved storing and recording of staff recruitment information ensures the protection of the service users and compliance with the regulations. Staff development and understanding of their roles is supported and encouraged by the provision of regular supervision. EVIDENCE: The home has taken action to address the issues relating to staff recruitment and personal files that were raised following the previous inspection. Not all files has photos attached and this is requirement has been made. Samples of files were examined and these all contained the required information, with one exception. One file did not contain a reference from the previous employment the staff member had had within a care setting. A requirement is made in relation to this. The manager explained that new storage space was being provided in the home which would enable more staff information to be stored there. The present arrangement means that the home uses offices in the basement of the adjoining property, which is run by the same organisation. Records showed that staff are receiving regular supervision, with all having has at least four recorded sessions during the past six months. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 17 The manager stated that the organisation had appointed a training officer who was developing a training matrix, which will be used to monitor when updates on statutory training are required. The manager retains responsibility for monitoring the CALM training relating to challenging behaviour, that all staff undertake and then have yearly updates. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 18 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): 37,38 & 42 Service users benefit from an effectively and professionally run home. Service users benefit from the management and staff adopting a problem solving approach to the issues within the home. Service users are protected by the provision of safe and secure environment. EVIDENCE: The manager is receiving regular supervision and support from their line manager and also from the organisation’s recently appointed quality assurance manager. The manager has taken steps to address all the requirements from the previous inspection and also outlined some further changes that are planned around storage and space which will further help the staff team to perform their duties. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 19 The records for fire safety testing were seen and these were up to date with all testing being completed and evacuations recorded. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 20 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 x 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 X 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x X 3 X 3 3 X X X 3 x The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 21 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 YA23 Regulation 13(7)(8) Requirement Ensure recording of restraint records provides details of which techniques were used.(previous timescale not met 31/12/05) 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 not met) The home must ensure that staff provide a reference from their last employment in care The home must ensure all staff files contain individual photos Timescale for action 30/04/06 2. YA24 12(4)(a)& 23(2)(a) 30/04/06 3 4 YA34 YA34 7,7,10 schedule 2 7,9,19 schedule 2 30/04/06 30/04/06 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 DS0000062579.V285727.R01.S.doc Version 5.1 Page 22 The Coach House should be provided for staff responsible for implementing this approach. The Coach House DS0000062579.V285727.R01.S.doc Version 5.1 Page 23 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.V285727.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!