Care Home: Olde Coach House The

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What the care home does well People are well assessed on entry to the home, are given a contract of residence that protects them and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service`s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff with good training and development opportunities work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? The service has fitted all radiators with safety covers, unless they are of the low surface temperature type, to ensure people are protected form the risk of harm. The service has made sure weekly fire tests are carried out and recorded. The service now makes sure an emergency care plan is compiled for anyone being admitted to the home in an emergency. It tries to offer people that are cared for in bed single occupancy, but this is not always possible. The service now makes sure all MAR sheets are signed as people take their medication not just as they are handed it. Also that water temperatures are tested at wash hand basins as well as at shower and bath outlets. The service also makes sure all staff are given the mandatory training on starting the job, regardless of their age, to ensure they are competent in safety aspects of the job. What the care home could do better: The service could make sure all care plans and any other record or document held in the home is dated and signed on compilation, so people are confident their needs are accurately recorded and reviewed. It could make sure all staff designated to administer medication receives annual competence training and that it is recorded, so people are confident their medicines are being administered safely. The service could make sure people`s money held in safe keeping is subjected to regular auditing and an annual external audit is carried out so people are confident their finances are being handled accurately and competently. It could make sure all staff have their safeguarding adults training updated annually and that it is recorded for evidencing, so people are confident they are being cared for by staff that will protect them from harm. The service could make sure wedges to prop fire doors open does not take place, so people are confident they are protected from the risk from fire. It could make sure at least 50% of care staff achieves NVQ level 2 in Care or equivalent, so people are confident they are being cared for by qualified staff. The service could make sure a legionella water test is carried out on the hot water storage tank/s, or if already completed supply evidence to the Commission, so people are confident they are being protected from the risk of disease. It could make sure there is a current PAT certificate available on all portable electrical appliances, or if already carried out supply evidence to the Commission, so people are confident they are being protected from the risk of harm from an electrical fire. CARE HOMES FOR OLDER PEOPLE Olde Coach House The 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW Lead Inspector Janet Lamb Unannounced Key Inspection 09:00 13th February 2009 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 Olde Coach House The DS0000019753.V373943.R02.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. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Olde Coach House The Address 2 & 2a Eastgate Hessle East Yorkshire HU13 9LW 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) 01482 645094 01482 643363 bisey@chouse.karoo.co.uk Dema Residential Homes Limited Mrs Elaine Bismor Care Home 33 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (33) of places Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service user of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE maximum number of places 33 Old Age not falling within any other category - Code OP, maximum number of places, 33 The maximum number of users who can be accommodated is 33 2. Date of last inspection 1st February 2007 Brief Description of the Service: The Olde Coach House is a privately owned care home that is registered to provide care and accommodation for 33 older people, including those with dementia. The accommodation is now provided in 19 single rooms and 7 shared rooms; 7 of the single rooms have en-suite facilities. Information about the home is provided to people and others in the home’s statement of purpose and service user guide. Fees paid at the time of this inspection range from £395.00 to £525.00 per week and there is an additional charge for hairdressing, chiropody/foot care, newspapers, a service user’s own telephone and alcohol. The building is a conversion/extension of two adjacent houses with a new 5 single room extension last October 2008, and with parking space for staff and visitors. There is an inner courtyard and small garden area where people can sit out in fine weather. All areas of the home are accessible to them via the provision of stair lifts and ramps. The home is situated within easy reach of local amenities in the town centre of Hessle where shops, churches, public houses and a range of community facilities are available. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2-star. This means the people who use this service experience good quality outcomes. The Key Inspection of The Olde Coach House took place over a period of time and involved sending a request for information, the annual quality assurance assessment (AQAA) to the home in November 2008 concerning people that use the service and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in mid December 2008 and survey questionnaires were then issued to a selection of people in the home and some staff. Surveys were also sent to the home to hand to health care professionals with an interest in people’s care. The information obtained from surveys and that already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. Janet Lamb made a site visit to the home on 13/02/09 to test these suggestions, and to interview people living there, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with a selection of bedrooms. Two people, the manager, and two staff were interviewed and several other people were briefly spoken to, to seek information, and documents and files were inspected along with some records and other information held. Some of the routine of the day was observed and several visitors were seen going about their business. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People are well assessed on entry to the home, are given a contract of residence that protects them and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 6 They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff with good training and development opportunities work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? The service has fitted all radiators with safety covers, unless they are of the low surface temperature type, to ensure people are protected form the risk of harm. The service has made sure weekly fire tests are carried out and recorded. The service now makes sure an emergency care plan is compiled for anyone being admitted to the home in an emergency. It tries to offer people that are cared for in bed single occupancy, but this is not always possible. The service now makes sure all MAR sheets are signed as people take their medication not just as they are handed it. Also that water temperatures are tested at wash hand basins as well as at shower and bath outlets. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 7 The service also makes sure all staff are given the mandatory training on starting the job, regardless of their age, to ensure they are competent in safety aspects of the job. 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. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 8 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 Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 9 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 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People’s individual and diverse needs are well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. They also receive satisfactory contracts of residence so they know their placement will be protected. EVIDENCE: Discussion with people in the home, the manager and staff and viewing of documents with people’s permission reveals people have information on the home and have their individual needs assessed before they move in, and are protected by a contract of residence. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 10 The contract in place between the person and the home is called a ’service agreement’ and includes details of the room to be occupied, fees, who is responsible to pay etc. as required in standard 2 and regulation 5. There are also contracts in place between the home and the placing local authorities, although none of these were viewed on this occasion. The home has copies of the placing local authorities community care assessment documents and these were viewed, for two people though. The home also has copies of its own assessment of need document held in files and these include 25 areas of need, ranging from 1-11 personal details, religion, height, weight, build etc. to 12-25 health, medication, communication, response, mobility, dexterity, personal hygiene, routines, dress, food intake, physical abilities, equipment needed to feed self, special meal requisites, behaviour, leisure, personal hygiene. Assessments also state needs for chiropody, optician, dentist, hearing tests and show a medical history. Documents are signed and dated and show inclusion of people or their relative in the compilation of them. The homes ‘statement of purpose’ and ‘service user guide’ were not viewed but it is reported they have been updated since the last key inspection of the service. People spoken to say they remember being involved with assessments and care plans etc. and that they understand the protection they have from contracts of residency being in place, but overall they are not very interested in the paper work that involves them and say they are happy for it to be viewed. Intermediate care is not provided in the home so standard 6 is not applicable. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 11 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. People who use the service receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so they are confident their overall quality of life is good. EVIDENCE: Discussion with people in the home, the manager and staff and viewing of some files and records with permission reveals health and personal care is monitored and recorded, medication is handled according to the requirements of The Medicines Act 1968 etc., and people are treated respectfully. There are care plans in place for everyone living in the home and evidence is available that shows they are reviewed monthly and every six months in the form of a review meeting. These contain information under three headings – Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 12 the issue of need, the goal to meet it and the changes as a result. There are ten sections within each care plan, covered under all of these three headings, that include ‘personal care,’ ‘eating and drinking,’ ‘mobility,’ ‘communication,’ ‘elimination,’ ‘sleeping,’ ‘special needs,’ ‘activities and leisure and social,’ ‘physiology’ and ‘intellect’. Documents to assist in the monitoring and recording of care and health care needs are such as diary notes, doctors’ notes, monthly summaries, records of chiropody and optical tests etc., fluid and food intake and output charts, weight records, etc. There are also areas of health care needs within care plans as specific to individuals. Copies of such as hospital discharge notes, letters of medical interventions etc. are kept in files showing the history of a person’s health as well as treatment they have had. There are also accompanying risk assessments that cover the necessary areas identified as being risky for people – for one person listed as walking, transferring, in/out bed, activities and manual handling. People say about their care plans and the assistance they receive, “I can manage to dress myself but need help in the shower. I am treated very well, though I don’t get out much because I cannot walk very well. I am quite happy here it is very good,” and “I look after myself most of the time though I need some help in the shower that’s all. The night staff check me three or four times a night, though they do not disturb me. I am treated fine, though the job must be a frustrating one to do. The weeks just fly by as I always keep busy.” The home keeps copies of placing authority ‘community care’ care plans where possible but none were viewed, as these do not automatically get filed in people’s working files, but are kept in the admin office. Where possible care plan documents need to always be signed and dated, if not by the person they concern then by a relative or advocate. A recommendation is made in this report. A previous recommendation for care plans to be in place immediately after a person is admitted is now met, whenever possible. And a previous recommendation for offering people cared for in bed a single room remains very difficult to achieve, as even though single rooms have increased by four, doubles remain the same at seven. When the home is full there is no scope for room moves for anyone. There is a medication policy and procedure in place, which covers selfmedication where wished, but no one does so at the moment. Medication is stored appropriately within the home. The deputy was observed giving out medicines at lunchtime and uses good practices. There are seven people including the manager and deputy that are trained to administer medication, and evidence of this is available. The manager must make sure staff are Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 13 competence checked each year though and records of this are maintained as evidence. This is a recommendation of this report. A previous recommendation that medication administration record (MAR) sheets must be used as an accurate record of medicines actually taken not just handed to people is now being met. People say of the medication situation, “The home gives my medication to me and that is fine by me. I usually take my own antacid medicine and keep it with me for when needed.” And, “The home looks after my medicines and so they are no worry to me. I take 10 tablets each morning so its’ a lot to think about.” Privacy and dignity observed within the home is being well upheld, people are spoken to how they wish to be addressed, and personal care is only given in private. People say they are treated very well, the staff are polite and helpful and usually everyone is dealt with when they need assistance, unless there is an emergency or staff are dealing with a problem. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with people in the home, the manager and staff and viewing of some records and documents reveal people have clear opportunities to lead lives of their choosing and daily routine is kept to a minimum where possible. There is a detailed activity plan on display and it is usually followed. Choice is exercised about joining in with activities, daily life or routine. Meal times are set but people can deviate from them if they really wish. Personal and social relationships are encouraged and couples may be accommodated in rooms set out according to their choice. Information on activities and outings is supplied verbally and on the activity plan. People with cognitive impairment also have opportunities to take part in pastimes such as the daily quiz devised and presented by one of the people in the home. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 15 Community contact comes in the form of walks to the shops, visits to parks, pubs, concerts etc. and worshipping at the local church. People also receive visitors when they choose and enjoy such as local schools calling in to sing or entertain. Records of activities and outings are held in people’s individual files in their daily diary notes and monthly summaries. Observed on the day of the site visit was the daily quiz, watching of a reminiscence DVD of the streets of Hull, Scrabble with two visitors, listening to music, and general conversation between people. Other activities on offer are monthly music sessions, reminiscence sessions, exercises, floor dominoes, skittles and hoop-la. There is also wireless Internet available in the office and for relatives to use, while people can now choose from satellite television and free view channels. People with cognitive impairment are also provided with lava lamps in rooms at night to help settle them. People spoken to say they enjoy the entertainments and will join in with whatever is available. One says they enjoy the quiz very much, but people are not forced to join in. One says they like to be involved in most things, to keep the mind and body going, and helps to set tables as well as devises the quiz and delivers it. People say in surveys they are able to take or leave pastimes according to individual choice, and usually there is a good balance of things to do. Where possible people are encouraged to handle their own finances, and most have family members that do so for them. However, most also have small amounts of money held in safe keeping and these arrangements are backed up by simple accounting methods and records that generally protect people well. The only thing the home needs to do in this area is to have some kind of regular internal auditing and then an annual or so external finance audit carried out by someone more independent. A recommendation is made in this report. Checks on three people’s accounts were accurate. People spoken to were quite satisfied with the arrangements in place for handling their finances. Some people have their own bits of furniture and personal possessions in their rooms and they have access to their personal information under the Data Protection Act 1998, but no one ever expresses any interest according to staff. There are set menus for food provision with three meals a day provided as well as supper. Menus are displayed in the home for people to see. People were unsure about menu compilation but did say they discuss food in their meetings, so they presumed information was passed to the chef/cook. A staff member was observed in the morning asking people what they wanted from the choice of menu for lunch and tea that day and decisions were recorded. On the day of the site visit people had a choice of fish fingers and chips with peas or baked fish with parsley sauce and chips and peas. The dining room was full of chatter before the meal and everyone seemed very interested in Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 16 life. One person was chattering without waiting for any answers and another person told him to shut up, as she did not want to know. Generally people got on well though. The kitchen is well organised, clean and efficient and staff do a good job as people spoken to say they enjoy the food, “it is very good” and “it is marvellous.” Surveys also say people like the food very much and always eat everything up. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so they are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: There is a complaint policy, procedure and guidelines in place and staff say they are aware of their responsibilities. The complaints policy and a form to record any complaints are given to people or their representative at the time of admission, along with the statement of purpose and contract. People generally say in interview or in surveys they know how to complain but rarely have cause to. One person spoken to says she did complain to the manager when she first arrived, which was quickly resolved and has not been a problem since. Another person says they are all told how to make a complaint if they wish, but personally had never had to make one so far. A complaints and compliments file is held and was viewed with the latter outbalancing the former over the many years the home has been operating. People say they Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 18 usually speak up if they have any concerns or grumbles and staff mostly listen to them and deal with issues quickly. There is also a safeguarding adults policy, procedure and guidelines as supplied by Hull and East Riding of Yorkshire Council Safeguarding Adults Board. Records are kept of any safeguarding referrals though none have been made for some time and not since the last inspection. Senior staff at the home have attended ‘Manager’s Safeguarding Adults’ training and most care staff have done appropriate training, though evidence shows it to be outdated, 2006 for two staff files seen. A recommendation to make sure staff undertake annual updates of safeguarding training and a record of it is maintained, is being made in this report. Staff also complete NVQ level 2, which includes abuse awareness etc. Staff demonstrate an understanding of adult protection issues in interview, including whistle blowing. Some staff have undertaken challenging behaviour and dementia awareness training as well. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 19 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, 25 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Discussion with people in the home, the manager and staff and viewing of some of the communal areas and some private areas with permission form some people reveals the home is suitable for its stated purpose of providing care and accommodation to older people and some with memory impairment. All areas of the building are clean, bright, well furnished and pleasantly decorated, and furnishings and fittings are domestic in nature and of good quality. Some bedrooms have French windows that open out on to the enclosed courtyard garden. The large dining room/conservatory allows ample Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 20 sunlight into the home and enables people to view the front of the property and the courtyard garden, which is well kept and furnished for the summer months. There is a suitable car park facility for approximately 5 or 6 cars. A new extension since the last inspection has increased the registered places from 29 to 33. The new rooms are pleasant and well furnished. The building complies with the requirements of the local fire service and environmental health department, with visits from these having last been made in 1999 for fire safety and September 2006 and June 2008 for environmental health and food hygiene. The manager informs us the fire safety officer is due to visit to check the fire safety systems in the new extension soon. The home has been subject to annual fire safety system checks however with Image 2000, and an ex fire officer carries out yearly fire safety and awareness training, which is last recorded as being held in April 2008. Observation shows there was one wedge being used in a bedroom door in the home and this must cease to ensure safety of people living and staff working there, in the event of a fire. Even though the person in that room has a reason for using the wedge a recommendation is made in this report for it to cease. The laundry meets the Water Supply (Water Fittings) Regulations 1999 as its surfaces and floor covering are readily cleanable and machines have sluicing facilities. Staff have adequate hand cleaning facilities throughout the home and maintain good infection control. Training in infection control is evidenced in staff files and copy certificates on the wall in the office. One requirement at the last key inspection to make sure all radiators are covered for safety, and one recommendation to check the water temperatures at basin outlets as well as showers and baths have both been met. Radiators in the new extension are low surface temperature radiators, some basins now have thermostatic valves and the handyman now makes sure all hot water outlets are tested for safety. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 21 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People are cared for by well-recruited, welltrained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy a good service of care. EVIDENCE: Discussion with the manager and staff and viewing of some staff files, records and copy certificates etc. reveal staffing standards are appropriately met. The staffing complement is satisfactory, rosters seen and observation on the day of the site visit shows there are adequate staffing numbers with a mixture of skills on duty each shift. The rosters in place also record the role of each member of staff. They evidence that four care staff plus a senior carer are on duty each morning and three care staff plus a senior carer are on duty each afternoon. The provider/manager or the deputy may also be present. There are three care staff on duty from 20:00 when night staff commence work. Some staff are employed as room care assistants, as they are under the age of 18 and are not able to undertake personal care tasks. The provider/manager has ensured that these members of staff sign a ‘restricted activity agreement’ that records this. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 22 There are sufficient domestic staff employed with 3 housekeepers on for five days a week and 4 on for two days a week. Observation on the day of the site visit showed 3 cleaners working in the home. Of the care staff in the home there are still insufficient with NVQ level 2 to meet 50 with the award. The provider/manager now tries to hire people with this where possible. There are 3 new staff soon to register to undertake the award and efforts are still being made to achieve the 50 . This remains a recommendation of this report. Recruitment and selection records for three staff were viewed with permission and they evidence that safe practices are followed; application forms are completed, interviews are held and recorded, an initial security check and two written references are in place before staff commence work at the home. The information gathered to verify a staff member’s identification is also held on file. The manager is reminded that an initial security (POVA first) check should only be used in isolation, in exceptional circumstances. In normal recruitment situations a full security (Criminal Records Bureau CRB) check should be obtained prior to someone commencing work at the home. Staff files include details of induction training, and there are individual training records in place as well as a training and development plan that records training achievements for the full staff group. Staff undertake basic and mandatory training in food hygiene, first aid, fire safety, infection control, medication administration, moving and handling and health and safety, as well as more specific training such as bereavement awareness, Parkinson’s disease, challenging behaviour, dementia awareness and diabetes. The home also accesses the Hull City Council Training Diary whenever possible, and is entitled to have nine staff on free training at any one time with a company called ‘Manor Tech.’ ‘Aset’ are also a regularly used training company. Staff training certificate copies are held in files and some are displayed on walls around the home. Staff also confirm all of this in interview. A recommendation made at the last key inspection for all staff to undertake basic mandatory training to enable them to carry out their roles safely, is now met as all staff complete fire safety, health and safety, food hygiene and infection control training. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 23 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, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service. Their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager and staff and viewing of the quality assurance systems, people’s financial records with permission and some of the home’s maintenance certificates and records of safety checks carried out etc. reveals the home is run in the best interests of people and to promote and protect their safety. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 24 The registered provider/registered manager has held these roles for some years. She is suitably qualified with NVQ level 4 Registered Manager’s Award and A1 Assessors Award, is experienced and has an open and inclusive management style. There is a deputy manager that takes charge of the running of the home in the manager’s absence and several senior care staff also assist in taking charge. There is a detailed quality assurance system in operation that uses quality audits, spot check visits from the manager, team brief meetings, resident’s meetings, checklists, and surveys. Samples of these were viewed in the year file for 2008 to 2009 and are available as evidence of the whole system of quality assuring the service. Monitoring has taken place for several years. Every year there is a full quality audit carried out and a report is published. The file also contains letters of complaint (none for well over a year though) and compliments, of which there are very many. Policies and procedures are reviewed annually as part of the monitoring system. People in the home generally have their main finances handled by a relative and keep a small amount of personal allowance in the home in a safekeeping facility in the office. There are accounting records for this and systems use two staff signatures for money in/out and maintain receipts of expenditure where possible. As mentioned in an earlier section the system is not subjected to any financial auditing and should be. See recommendation made in standard 14 on ‘autonomy and choice.’ The home is generally good at maintaining people and staff health, safety and welfare by ensuring maintenance work is carried out, certificates of safety are obtained and safety records are held. One requirement made at the last key inspection was for fire tests to be carried out on a regular basis. These are now being done regularly. Some health and safety sample areas were looked at as part of this inspection and included: - legionella testing and portable appliance testing. These are not fully compliant with the requirements of the standard and therefore have recommendations made against them. However other sampled areas show compliance is very good, on such as fire safety and certification, passenger lift and hoist maintenance, hot water storage and outlet safety checks and records, safe use of bed rails, clinical waste collection, public and employer’s liability insurance, electrical and gas safety certificates etc. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 3 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 3 X 3 X 3 X X 3 Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 registered provider should make sure all care plans and any other record or document held in the home is dated and signed on compilation, so people are confident their needs are accurately recorded and reviewed. The registered provider should make sure all staff designated to administer medication receives annual competence training and that it is recorded, so people are confident their medicines are being administered safely. The registered provider should make sure people’s money held in safe keeping is subjected to regular auditing and an annual external audit is carried out so people are confident their finances are being handled accurately and competently. The registered provider should make sure all staff have their safeguarding adults training updated annually and that it is recorded for evidencing, so people are confident they are being cared for by staff that will protect them DS0000019753.V373943.R02.S.doc Version 5.2 Page 27 2 OP9 3 OP14 4 OP18 Olde Coach House The 5 6 OP19 OP28 7 OP38 8 OP38 from harm. The registered provider should make sure wedges to prop fire doors open does not take place, so people are confident they are protected from the risk from fire. The registered provider should make sure at least 50 of care staff achieves NVQ level 2 in Care or equivalent, so people are confident they are being cared for by qualified staff. The registered provider should make sure a legionella water test is carried out on the hot water storage tank/s, or if already completed supply evidence to the Commission, so people are confident they are being protected from the risk of disease. The registered provider should make sure there is a current PAT certificate available on all portable electrical appliances, or if already carried out supply evidence to the Commission, so people are confident they are being protected from the risk of harm from an electrical fire. Olde Coach House The DS0000019753.V373943.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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