Inspection on 07/11/06 for The Coach House

This inspection was carried out on 7th November 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 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 12/08/08

The Coach House 04/12/07

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE The Coach House 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU Lead Inspector Joy Hoelzel Key Unannounced Inspection 7th November 2006 09:40 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 DS0000067681.V308505.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 DS0000067681.V308505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 48-60 Goldthorn Hill Wolverhampton West Midlands WV2 3HU 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) 01902 343 000 Select Healthcare 2006 limited Care Home 70 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number disorder, excluding learning disability or of places dementia (70), Mental Disorder, excluding learning disability or dementia - over 65 years of age (70) The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate 12 people with a mental disorder who may have a learning disability in a specific unit within. The home can accommodate 12 people with a mental disorder who may also have a physical disability in a specific unit within the home. People accommodated at the home who are over 65 may also have a physical disability. New service first inspection Date of last inspection Brief Description of the Service: The Coach House is a purpose built care home and has recently benefited from a new extension to the existing building. In June 2006 the home was registered with Select Healthcare Ltd as new providers for the service and can now provide accommodation nursing and personal care for up to seventy people of all age groups. All bedrooms are single occupancy and have en suite facilities. The home is located at Goldthorn Hill, Wolverhampton and is within easy walking distance of the local shops and amenities. Current weekly fees range from £428.00 - £850.00. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection is the first of the statutory inspections for 2006/07 and took place over five hours on Tuesday 7th November 2006. It was conducted by one regulation inspector. Twenty three of the thirty eight National Minimum Standards for older people and seventeen standards for younger adults were inspected on this occasion. Thirty three people are currently living at the home, staffing numbers were observed to be at satisfactory levels. Three case files were selected for case tracking, relevant documents and procedures were inspected, together with a selection of staff personnel files. A full tour of the premises was conducted. Service users, staff and visitors asking their opinions of what the home does well, what has improved over the past six months and what could be done better completed nine on site surveys. What the service does well: What has improved since the last inspection? Staffing levels have been significantly increased in line with the dependency needs of the people living at the home. A suitable person has been recruited for the position of manager. Staff from various cultural and ethnic backgrounds have been recruited to ensure effective communication, dietary needs and individual care needs can be fully met. Areas of the home have been redecorated, with further plans for more alterations, refurbishment and redecoration. Comments on the on site survey included ‘ better standards of care’, friendly management, more training’, ‘better and easy documentation’, The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Coach House DS0000067681.V308505.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 DS0000067681.V308505.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,3,6 YA 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their care needs assessed before moving into the home and whenever possible have the opportunity to visit the home to assess its quality, facilities and ability to meet an individual’s needs prior to admission EVIDENCE: The home has a statement of purpose and service user guide detailing all aspects of the care provision. Both documents are readily available to current and prospective residents and other interested parties. The acting manager stated that both documents are to be revised to ensure that the details and information included are up to date. The case file of the person most recently admitted to the home was inspected and included an assessment carried out by a senior staff member prior to the person moving into the home. Other pre admission information was available from the local primary care trust. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 9 The acting manager discussed the admission procedure and the prospective service users on the waiting list and the difficulties with securing funding for the placements. The home does not offer an intermediate care service. The Coach House DS0000067681.V308505.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10. YA 6,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan and whenever possible the individual is fully involved with the process. The plan in most cases includes the information necessary to plan the individuals care, however, some omissions of recording information has the potential for not fully meeting a persons needs. EVIDENCE: A plan of care is generated at the point of admission to the home based on the information gained from the assessments of a persons care needs. Since June 2006 the acting manager has revised all service users care plans and has introduced some new documentation for monitoring healthcare needs. Three case files were selected for inspection each contained a comprehensive plan based on the identified needs and dependency requirements of each individual. Two care plans had been discussed and agreed with the person’s next of kin on behalf of the service users. Risk assessments are carried out for maintaining skin integrity, nutrition, moving and handling, falls and the use of equipment, however not all records had been signed, dated or a review date identified. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 11 One nutritional risk assessment had been completed identifying a high-risk level; a specific plan of care had not been implemented to set out in detail the action to be taken by staff to ensure that good nutritional status is maintained. Policies for continence and oral hygiene pathways have been introduced and provide staff with clear information of the interventions needed for each individual. One care plan contained very clear instructions for end of life arrangements, however the arrangements for a person of a different ethnicity and culture had not. A record is made of visits to and from specialist healthcare professionals and includes the tissue viability specialist, community mental health nurses, McMillan nurses, GP’s etc. All three care plans had not been reviewed on a regular basis, the registered nurse commented that ‘all staff have been working hard with getting the plans up to date but things have slipped a bit’. The home operates a twenty eight day regimen for the administration of medication using a monitored dose system with the additional use of bottles and boxes. A registered nurse is carrying out monthly audits. The Medication Administration Record appears to be correctly completed no gaps in the record were observed. The amount of controlled drugs recorded in the controlled drugs register and the actual amount of drugs kept in the controlled drugs cabinet accurately corresponded. A fridge is available for the safe storage of medications; it was advised that supplies of insulin that are in use are not stored in the fridge but kept at room temperature (not above 26 degrees centigrade), this being for the safe administration of the injections. The fridge was registering a temperature of 0 degrees centigrade, it was recommended that a safe temperature of between 2 – 8 degrees centigrade is maintained. The nurse was advised to contact the supplying pharmacist and ask advice on the integrity of the insulin stored at this low temperature. The care staff were observed to be assisting service users with personal care discreetly and in a manner which promotes service users’ dignity. Staff, service users and visitors were observed to be interacting well with lots of chatter and conversation occurring. The Coach House DS0000067681.V308505.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, 13,14,15 YA 16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant improvements have been made to the daily living routines; staff have made a considerable effort to provide a flexible service, enabling people living at the home to enjoy a better quality of life. EVIDENCE: At the time of the inspection lots of activity was happening at the home, the hairdresser was busy attending to washing, blow-drying and colouring hair. One lady had the colour of her hair changed and was very pleased with the end result. Other ladies even the most frail were being attended to. A clothes party had been arranged for the afternoon offering service users the opportunity to purchase new clothing. Many people appeared to be enjoying this and were pleased with their new clothes. The acting manager was observed to be reassuring one lady that she did have sufficient funds for the items she wished to purchase. Some service users spoke of the previous evenings entertainment when a vocalist and musician visited ‘ a very enjoyable evening …. I enjoyed joining in with the songs’. Daily activities are arranged throughout the week with details of the sessions displayed on the notice board. Social coordinators employed by the care homes The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 13 group visit each week with this weeks activities being craftwork and making calendars. One staff member was reading to a lady in Punjabi and both were having discussions regarding the book. Other service users were receiving one to one care with staff. Two ladies from the local church visited during the morning. People visiting the home during the inspection confirmed that they are able to visit at times suitable to their relative and friend and that they always felt welcome to visit. They made additional comments on the change of management and the improvements that have recently been made. During the tour of the premises many of the bedrooms were individualised with personal possessions. Staff were observed to be offering service users choices and preferences as to the activities of the day in an appropriate way, very much dependent on the capabilities and capacity of each individual. Morning coffee and biscuits were being offered and served to service users; additionally portions of fresh fruit were available. The inspector was invited to have lunch with service users in the main dining room and joined service users at the dining table. Staff confirmed that some people prefer to have their meals in the alternative dining room and felt it was ‘ a bit quieter’. One service user stated that he liked the meals offered and felt there was sufficient choice. The cook served the meals in the main dining room ensuring that each person had sufficient to eat and offered alternatives if the main course was not to a persons liking. Staff were observed to be assisting frail service users with the meal when required. Kitchen personnel from various ethnicities have been recruited to ensure that cultural and religious dietary needs are catered for. The Coach House DS0000067681.V308505.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18. YA 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a clear complaints procedure that highlights the importance of complaining or making suggestions for improvement and is very clear when an incident needs external input, and is open in discussing incidents with external bodies (CSCI, local adult protection). EVIDENCE: The statement of purpose and service user guide contains information of the home procedures for dealing with concerns and complaints. A copy of the procedure is displayed at the entrance of the home. A complaint log is maintained for the auditing of complaints, the acting manager stating that no formal complaints have been received since June 2006. Policies and procedures in the protection of vulnerable adults are readily available for staff reference if required. The acting manager demonstrated a good awareness of the multi agency adult protection procedures. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,26. YA 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for those in residence. The planned alterations will further enhance the living and working conditions for service users and staff. EVIDENCE: The acting manager discussed the preparation for the alterations being made to the front entrance of the premises and confirmed that the authorities had been supplied with a copy of the plans and contractors have been approached. The main ground floor lounge is being closed next week for redecoration and refurbishment together with alterations being made to the smoking room. The home will be operational in four separate units when further occupancy is accomplished, each unit with then have a dining room, fully fitted kitchenette and lounge area. Some areas of the home have benefited from new flooring and redecoration. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 16 During the tour of the premises some doors were being kept open by pieces of furniture. All areas of the home were clean and hygienic. Good systems of control appear to be in place for the prevention of cross infections. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30. YA 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice, recognition of the importance of effective recruitment procedures in the delivery of good quality services and for the protection of service users. EVIDENCE: At the time of the inspection the acting manager was supernumery and was supported by four registered nurses, seven care staff with additional catering and domestic personnel. A rota is maintained to show which staff are on duty at any given time of the day or night. Recruitment for staff has been ongoing since June 2006; the acting manager stated there had been a high turnover of staff necessitating the recruitment drive. One staff member completed the on site survey with the comment ‘ we have more qualified staff, which means more professional care for the residents’. Three surveys indicated on the ‘what could be done better’ part of the survey that staffing levels should be further increased. Service users appear to have benefited from the increase of the staffing compliment most looked well groomed and nourished. All care staff are encouraged to gain accreditation for National Vocational Qualification Level 2 and 3 in care. A kitchen assistant informed the inspector The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 18 of her recent inclusion on National Vocational Qualification Training and stated that she was enjoying the course. Two staff personnel files were selected for inspection and contain all documents relating to a robust recruitment procedure. Certificates and records of achievement are retained to evidence the training undertaken by each individual. Each staff member has regular supervision with his or her line manager and an annual appraisal of his or her work performance will be taking place in January 2007. A very active training programme is operational with core and specialist topics being arranged throughout the year. A comprehensive induction programme covering ten areas using the modular structure has been arranged and available for new staff. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,38. YA 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the service users benefit. EVIDENCE: The acting manager is a first level nurse with the knowledge and experience to successfully manage the home on a day-to-day basis. Throughout the duration of the inspection the acting manager demonstrated a sound knowledge of the current service users and the difficulties and dilemmas encountered with the ageing process and mental health difficulties. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 20 The central registration team of the commission is currently processing the formal application for the registered managers position, an interview date has been identified in October 2006. There are very clear lines of accountability both within the home and with the external management structure. The home has regular visits from the area manager of the company. Quality assurance and monitoring systems continue with weekly and monthly audits conducted. Staff meetings are arranged on a regular basis with minutes kept of the content of the meeting. Procedures are in place for the safekeeping of residents’ monies should they so wish. The money is kept in individually named wallets with records maintained of each transaction. Documentary evidence is available for promoting and protecting the health, safety and welfare of service users, staff and visitors. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X N/a X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 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 X 3 X X 3 X X 3 The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15(1) Requirement Timescale for action 30/11/06 2 OP7 15(2) 3 OP9 13(2) 4 OP19 23(4) The registered person must ensure that all risk assessments and care plans are fully completed and set out in detail the action to be taken by staff to ensure all care needs are fully met. The registered person must 30/11/06 ensure that all care plans are reviewed at regular intervals or when a change of need has been identified. The registered person must 14/11/06 ensure that the medication fridge is maintained at a correct temperature. The registered person must 31/03/07 ensure that if there is a need or personal preference for doors to be kept open then a suitable door closure should be fitted so as to close efficiently when the fire alarm is activated The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations It is strongly recommended that the registered person contact the supplying pharmacist for advice on the safe storage of insulin. The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Coach House DS0000067681.V308505.R01.S.doc Version 5.2 Page 25 - 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. 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