Inspection on 07/06/07 for The Coach House

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Coach House 09/11/09

The Coach House 19/01/06

The Coach House 21/06/05

The Coach House 16/12/04

The Coach House 09/06/04

The Coach House 02/03/04

The Coach House 13/12/02

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Coach House 58 Lidgett Lane Garforth Leeds West Yorkshire LS25 1LL Lead Inspector Sean Cassidy Key Unannounced Inspection 7th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Coach House DS0000033650.V299035.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. 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 DS0000033650.V299035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 58 Lidgett Lane Garforth Leeds West Yorkshire LS25 1LL 0113 2320884 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Claire Louise Buckle Mrs Alison Jayne Green Mrs Victoria Thompson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: The Coach House is a care home providing accommodation and services to older people; it is situated in a residential area of Garforth and is close to the amenities of the town and public transport. It has been recently purchased by the current providers who have started a programme of improvements in respect of the general facilities and internal appearance and to operational and organisational matters. It provides accommodation for up to nineteen men and women in both single (the majority) and shared rooms, although plans are being considered to reduce the ratio even further. There is a range of communal sitting and dining areas, bathrooms and toilets on both floors and passenger and stair lifts to different parts of the upper floor. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An unannounced visit to the home was conducted by one inspector and lasted one day. The majority of this time was spent speaking to residents, management and staff. Residents’ relatives were contacted by post and were also spoken to on the day of the site visit. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety information. What the service does well: The Coach House provides a welcoming homely environment that is clean and tidy. The people who use the service said the staff are very caring and helpful. ‘They go out of their way to do things for you. They also said that they respect their privacy and dignity at all times.’ Good care plans are developed with the involvement of the people for whom the care is provided. Relatives are also involved. Annual reviews of the care provided also take place. People said they were very happy with the activities that are provided. A good standard of training is provided to the staff group working at the home. All those spoken to over the course of the inspection said the home was very well managed. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People using this service receive a good standard of information that keeps them well informed. EVIDENCE: The Service User Guide and Statement of Purpose are made available to all at the entrance of the home. Both documents are kept under review regularly to reflect any changes in the service provided. They are also provided in large print. The people that use the service and the relatives contacted during the inspection all said they received enough information prior to moving in. Residents and their relatives said that they were offered the opportunity to visit the premises before making a decision to move in. Three people said they had the opportunity to come and stay for a day, which they thought was very helpful. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 9 The care files inspected showed evidence that all prospective residents are assessed prior to moving into the home. The document used to carry out this assessment is thorough and assists the assessor with making a decision as to whether the home will be able to meet their needs. It was noted that one person’s assessment documentation was from a previous admission. This must be reviewed to update any changes in a persons care needs. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The people that use this service said the home ensures their health needs are always met. They also feel that their privacy and dignity is always respected. EVIDENCE: The care plans for three people were inspected. Each one showed that each person had a clear plan of care set out to meet his or her care needs. These were written in plain English and were very person centred. The care plans were reviewed monthly and evidence was seen to show that when a care need changed this was incorporated into their care plan. The care files also contain risk assessments for areas such as falls, moving and handling and medication. Although the content is good, they should be reviewed more regularly than they are. Falls risk assessments are not reviewed when a fall occurs. By not doing so, the resident could be placed at further risk. The daily records seen do not provide enough detail as to how each individual resident spends their day. Statements such as “Had a good day” and “No The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 11 problems to report” were common. These should be more detailed to provide evidence as to how the person spent their day. Care staff spoken to said they used the care plan documents to help ensure they were providing the right care. The people who used the service said that they were aware of the documents and gave their consent to the planned care. Evidence was seen to show this did happen. The care files show clear evidence that the health needs of the individual are well met by the home. Health professionals such as chiropodists, dentists, opticians and general practitioners make regular visits to provide care. They are also asked to visit at the request of the resident. One file showed that when a resident’s tooth broke the home made a call to the local dentist who called and provided the appropriate care. Many positive comments were made about the home and how they ensure health needs are met. “When I need to see anyone about my health the home sorts it out.” “I’m very happy with the way that they help me when I need it. They arranged for the dentist to see me recently.” “We are really confident in the home. They are excellent at ensuring mum’s health needs are seen to very quickly.” The people that use the service were very complimentary about the staff group and the way they care for them. “The staff are brilliant. They are very caring and helpful. They cannot do enough for you.” “The staff have made my move into the home very easy. If it wasn’t for their kindness I don’t think I would have managed the move as well as I did.” “The staff are very kind, courteous and helpful.” During the inspection, the staff were observed carrying out their roles. They did this in a courteous and helpful manner and it was clear that there was a very good relationship between the people who live in the home and the staff. Visiting health professionals were provided good positive feedback about the standard of care provided by the home and the excellent standard of interaction between staff and residents. The majority of staff have received good training in the area of medication. The manager ensures two staff are involved with the administration of medication. A random check of the medication scripts showed that all medications were properly signed for. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Service users are supported and encouraged to enjoy a flexible lifestyle. EVIDENCE: The people that use the service said that the activities provided by the home meet their expectations. Staff regularly involve themselves in activities such as baking, reminiscence therapy, dominoes and bingo. Arrangements are made for regular entertainers to visit the home and pictures are on display to remind people of these events. A garden fair is planned for the weekend after the inspection and everyone was looking forward to it. Some people talked about what job they would be doing at the fair. People praised the home for providing them with a good standard of entertainment and activities. Records are kept of what entertainments and outings are provided. The home has an identified activities coordinator who keeps a record of residents’ likes and dislikes and attempts to provide for them wherever possible. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 13 People spoke positively about how they past their days. Close friendships have developed amongst the people that live there and these are promoted by the home. There are no time restrictions placed upon visiting in the home. The manager attempts to promote visiting at every opportunity as she recognises the benefits to the individual residents with maintaining contact with their family and friends. The home attempts to involve the residents with making choices regarding decisions about their own lives within the home. Regular resident meetings are held and residents do regularly express their views regarding issues that are important to them, food and activities being the popular talking point. People said that they felt involved with making decisions about what they did from an activity point of view. People said they were encouraged to vote at the recent local elections. Evidence was seen in the care files to show people had been enabled to send their votes by post. The feedback regarding the food was all positive. Generally, people found the food to their liking. Some felt there could be more choice as to what they could have at teatime. Regular discussions are held with the manager regarding meals and people acknowledged these. People also said that they were well catered for with hot and cold drinks and snacks. Fresh fruit was also available. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are confident that the home protects them from harm. EVIDENCE: The home has a safeguarding adults policy and procedure, which is accessible to all. Staff spoken to showed a good awareness and understanding of safeguarding adult issues. The people that use the service spoke very highly of the staff group and praised them for the support and kindness they provided. Comments made were, “ The staff are extremely caring and nice. I couldn’t manage without them.” “The staff have really helped me to cope with moving into the care home.” Regular safeguarding adults training is provided to the staff group to help them protect the people who live in the home. A record of all complaints is kept in the home. Those people spoken to were fully aware of how to make a complaint. They showed complete confidence in the management team with regards to dealing with the complaints. The registered manager was identified as being very thorough with ensuring any complaints were dealt with satisfactorily. One lady said that when she complained about an item of clothing going missing the manager reimbursed her when they failed to find the item. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 15 The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience excellent quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are very satisfied with the standard of the environment and the facilities provided within the home. EVIDENCE: The environment of the home has undergone some improvements since the last inspection. A new conservatory has been built; the gardens have been improved and made more user friendly; a new heating system has been installed and a new walk in shower room has been provided. The feedback provided from all sources spoke very highly about the quality of the environment. Some comments were, “It’s just like living in my own home. I have everything I need.” “ The layout and furnishings of the home helped me make my choice to move in.” “ The cleanliness of the home is tip top. It’s very The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 17 clean and tidy all the time.” “ Its cleaner than my own home and that’s saying something!” The home employs suitable numbers of domestic staff to ensure the standard of cleanliness is maintained. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The care is provided by people who are well trained in the areas of care need relevant to the people living in the home. EVIDENCE: The home has an identified staff rota that ensures the correct numbers of staff are on duty at all time. The number of staff on duty on the day of the inspection appeared to be appropriate. Staff were observed having the time to provide the appropriate care. They did not appear to be rushed or harassed. The staff spoken to said that they felt the correct numbers of staff were always on duty. Agency staff are used whenever the need arises. The people who live in the home were very happy with the numbers of staff on duty “ There is always enough staff on to help you.” “ The staff are very quick to answer the buzzers at night when you need them.” The manager has developed a training rota that clearly shows the training each member of staff has received. Staff spoken to said they were happy with the training provided and that it helped them ensure they provide the best possible care. Each new member of staff is provided with an induction that is based on the Skills for Care Induction Standards. Staff receive an appraisal on a yearly basis, this helps identify areas of training that may be required. People spoken The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 19 to praised the staff team and were very confident that they are able to meet their care needs. The recruitment files of two of the most recent employees were inspected. The majority of the required information needed to ensure people are protected was contained within these files. It was noted that there were unexplained gaps in the employee recruitment records and also they did not contain any picture identification to show they are who they say they are. The absence of this information could place people at risk of harm. The home has a programme in place for ensuring staff are trained to NVQ Level 2 or above. The staff spoken to said that they are encouraged to attend training whenever possible. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People benefit from living in a home that is managed to a good standard. EVIDENCE: The home is managed and run to a good standard. The people who use the service and their relatives all spoke very highly of the manager. Some comments made were, “She is an excellent manager. Always has time to listen to what you have to say.” “ You know that if something needs doing she will get it done.” “She communicates with us very well. If mum needs any medical attention or she is not feeling very well we are always informed.” The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 21 A number of different quality assurance tools are used by the manager to improve the quality of care in the home. The people that use the service and their relatives are provided with questionnaires on a regular basis to obtain their views of the home. However, there is no clear system in place to show how the manager assures the overall quality of care within the home. Discussions were held with the manager and different examples of how this could be done were talked about. Assurances were given that this area would be reviewed as a matter of priority. The manager keeps some monies locked away in the home safe. This is money that has been provided by relatives to obtain necessary items. The records and receipts were in good order for these monies. The people living in the home said that they always felt safe and well cared for within the home. Relatives made many positive comments as well. However, there were a few areas identified that posed possible risks to the health and safety of the people living in the home and also the staff that work there. Not all staff have received the correct fire training. The physical layout of the home has not been appropriately risk assessed to ensure all potential hazards have been identified. The walk in shower room has a raised floor level that poses a trip hazard, but no signs alerted the person entering the room. The manager gave assurances that these risks would be assessed correctly. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 19(1)(b) Requirement Timescale for action 30/06/07 2 OP33 24(1) 3 OP38 14(2) All the required information needed before a person can be employed must be obtained. This will help to ensure individuals are appropriately protected. The manager must implement 31/10/07 appropriate quality assurance system to help maintain and improve the quality of care provided within the home. The registered person must 31/10/07 ensure residents’ health and safety is protected at all times. Risk assessments must be reviewed regularly. When a fall occurs the risk assessment must be reviewed. This will help to minimise any further risk to the person The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 24 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 OP7 Good Practice Recommendations The daily records should be more detailed. This will provide evidence to show how each person spent their day. The Coach House DS0000033650.V299035.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000033650.V299035.R01.S.doc Version 5.2 Page 26 - 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!