Inspection on 08/01/07 for The Coach House

This inspection was carried out on 8th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Coach House 06/01/09

The Coach House 05/10/05

The Coach House 23/05/05

The Coach House 25/11/04

The Coach House 17/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Coach House 1 Hernbrook Drive Horsham West Sussex RH13 6EW Lead Inspector Mrs M McCourt Unannounced Inspection 8th January 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 DS0000014462.V321851.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 DS0000014462.V321851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Address 1 Hernbrook Drive Horsham West Sussex RH13 6EW 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) 01403 255197 Ms Sharon Anne Waters Ms Sharon Anne Waters Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: The Coach House is a family run care home providing personal care for older people, and is registered to accommodate up to three residents. The registered provider is Ms Sharon Waters, who is also responsible for the dayto-day management of the home. The home is a detached property located in a residential area, just outside Horsham town centre, West Sussex. Accommodation for residents is provided in three single rooms all with en-suite facilities. The Coach House is arranged on two floors. Accommodation for residents is provided on the ground floor, with the first floor reserved for the private dwelling of the proprietor and her family. There is a medium sized garden at the rear and front of the property, which is mainly laid to patio, well maintained and easily accessible. The home provides for the needs of elderly people with a degree of mobility and independence. The home does not provide specialist equipment. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Monday 8th January 2007, lasting a total of two and a half hours. Pre-inspection planning took approximately two days. Preparation for the inspection included review of information, the request and examination of a Pre-Inspection Questionnaire, the reading of various policies and procedures, including; admissions/referral procedures, complaints policy and any complaints received by the Commission for Social Care Inspection. A tour of the building took place and included the observation of health and safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Ms Waters, the provider, was available throughout the inspection. The Inspector spoke briefly with a visiting social worker and two of the Service Users accommodated at the home. Case tracking was carried out by examination of relevant records and information held on residents. Policies and procedures were examined during the site visit. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well: What has improved since the last inspection? The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 6 Thermostatic valves have now been fitted to all taps in bedrooms, following a requirement made at a previous inspection visit. 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 DS0000014462.V321851.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 DS0000014462.V321851.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): 2, 3, 5 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users’ needs are assessed prior to admission. The home does not offer intermediate care. Although Service Users do have a written contract in place, these have not been signed by either the individual or the provider. EVIDENCE: There is a brief statement of purpose and Service Users Guide available. The Service Users Guide is in need of updating to include the correct contact details of the Commission for Social Care Inspection. Contracts are on each Service Users’ personal file, but none have been signed by either the provider or individual residents. One document states that the The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 9 Service User refused to sign, but regardless of this the provider/manager has not signed it either. Ms Waters does carry out an assessment of need prior to Service Users’ admission to the home, covering all aspects of standard 3.3. However, these are not transferred into plans of care. Instead the assessment is revisited on a monthly basis. One Service User spoken with confirmed that she did visit the home prior to admission. The home does not offer intermediate care. The Coach House DS0000014462.V321851.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users health, personal and social care needs are supported by relatives and the provider. However, care plans must be implemented for individual services users, and a requirement has been made in respect of this. Medication administration and storage was sufficient for the environment. EVIDENCE: As previously highlighted, there are no care plans in place. The provider carries out an assessment prior to admission and this is revisited on a monthly basis in order to monitor any changes. However, reviewing of notes has lapsed since October 2006 as the owner said her NVQ studies are taking up much of her time. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 11 Service Users access various health care services as and when required. They are either escorted to health appointments by family members or the provider. Alternatively, if too frail or ill, health professionals will visit the house. One of the Service Users has been visited regularly by the Community Nurse, and the Inspector saw written notes to support this. On the day of inspection a social worker arrived to re-assess one of the residents living at the home. Her needs have changed following recent ill health and the home is unable to support her. Medication is stored in a lockable metal briefcase. There are no controlled drugs kept. Only Ms Waters administers medication. MAR sheets looked at were accurate and up-to-date. The Inspector observed the interaction between the provider and the residents. This was found to be caring, sensitive and appropriate. The Coach House DS0000014462.V321851.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): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users do maintain close contact with family & friends, and are supported to access the local community and attend personal interests. Service Users are provided with balanced, nutritious, home cooked meals. EVIDENCE: The Inspector spoke with two residents. Both said that they are able to go out and about, either with family members or occasionally with Ms Waters. As far as possible Service Users are able to make choices about their daily lives. Family members were seen visiting and are able to be received in private. One Service Users told the Inspector how she often visits relatives, church, hairdressers and so on. In addition she attends a handi-craft class fortnightly where she crotchets. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 13 Fresh, homely meals are cooked each day. Although there is no initial choice, one Service User did tell the Inspector that if she did not like what was being offered, she could ask for an alternative, which she is sure would be provided. The Coach House DS0000014462.V321851.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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although a complaints procedure is in place, there have been no logged complaints and the Registered Manager would be advised to ensure all complaints are logged, regardless of how minor. Service Users are protected from abuse, however the provider should obtain a copy of the West Sussex County Council Adult Protection procedures, in order to familiarise herself with the correct procedures where abuse is suspected. EVIDENCE: The provider has written up a complaints procedure, however there are no logged complaints. The Inspector was told that “little niggles are settled at the time.” The Inspector advised that any concern or complaint, regardless of how minor should be recorded. There was no copy of the West Sussex County Council Adult Protection procedures at the home. The provider was advised to obtain a copy as soon as possible. Ms Waters said that she has been on Protection of Vulnerable Adults training recently. The Coach House DS0000014462.V321851.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): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users live in a safe and well maintained environment. EVIDENCE: The property is a 1870’s Victorian House, set in a residential area on the outskirts of Horsham town centre. Service Users have access to all rooms on the ground floor and their own, en suite bedrooms. All rooms looked at were found to be pleasantly decorated and well maintained throughout. Communal areas consist of the main dining room/lounge, with fixtures and fittings that include wooden beams, a fireplace with wood burner and a piano. There is an additional quiet room/lounge that is not used by the current group. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 16 In addition, Service Users have direct access via patio doors to the garden area surrounding the house. Baths have handrails fixed to them and where necessary, an assisted bath chair. A nurse call bell system is used, with points found in all bedrooms and bathrooms. The Coach House DS0000014462.V321851.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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The nature of the care home is such that it does not currently employ any care staff. The provider is assisted twice a week with household chores, but carries out all care needs herself. EVIDENCE: Ms Waters provides the majority of care herself. She lives on the premises with her three daughters who help out from time-to-time. Twice a week she receives assistance from one employed staff member who works five hours each of the two days. This enables Ms Waters to run errands, pick up prescriptions and so on. A Service User spoken with said that the member of staff is “a capable person in every respect.” “She cooks well too.” According to the registered provider, the staff member employed does not wish to attend any training and is not formally supervised by Ms Waters. The Inspector was told that the member of staff does have previous care experience, although is really employed to help with household chores and allow the Ms Waters to run errands. She does not carry out personal care. The provider was able to demonstrate that appropriate records were obtained during the recruitment process. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 18 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): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users live in healthy and safe environment, which is managed by a suitably qualified person, although the home could benefit from some form of quality assurance, to ensure the best interests of Service Users. EVIDENCE: Ms Waters is the owner/manager of the Coach House. She has recently started to study for her NVQ level 4. Ms Waters has attended training in Protection of Vulnerable Adults Register, 1st Aid and Health & Hygiene. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 19 There are no quality assurance systems in place. Ms Waters said that she is constantly checking out with the residents how they are. She feels that the relationships between herself and family members are positive and all parties are able to communicate any concerns, requests and so on. The home does not have responsibility for any Service Users’ finances. These are controlled by family members only. As previously highlighted, there is no staffing structure. Health & Safety issues are assessed continually as part of daily living. Elite carried out safety checks on the Nurse call and fire alarm systems. Thermostatic valves have now been fitted to all taps in bedrooms, following a requirement made at the previous inspection visit. Locks have been fitted to bedroom doors, also following the previous inspection. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 20 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 x 2 2 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 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 2 17 x 18 2 3 4 3 x 3 3 4 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 3 3 3 x 3 2 x 3 The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes 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 Timescale for action The registered person shall, after 28/02/07 consultation with the Service User, or a representative of theirs, prepare a written plan as to how the Service User’s needs in respect of their health and welfare are to be met. (b) keep the Service User’s plan under review. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP18 Good Practice Recommendations 16.3 – A record is kept of all complaints made and includes details of investigations and any action taken. 18.2 – Robust procedures for responding to suspicion or evidence of abuse or neglect (including whistle blowing) ensure the safety and protection of Service Users, including passing on concerns to the CSCI in accordance DS0000014462.V321851.R01.S.doc Version 5.2 Page 22 The Coach House with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets. The home must obtain a copy of West Sussex County Council’s Adult Protection procedures. The Coach House DS0000014462.V321851.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000014462.V321851.R01.S.doc Version 5.2 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. 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