Care Home: The Coach House Residential Home

What the care home does well People wishing to move into The Coach House are given enough information about the home before they move in. This helps them decide if home is the right place for them to live. These are some of the things people said about The Coach House: "All staff are very kind and caring" The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 "All staff willing and spend time with my Mum". "I am always made to feel welcome when I visit here" There is a good choice of food and drinks available throughout the day. This makes sure people receive a varied and nutritious diet. The home organises and provides a variety of activities that people are able to join if they wish. The home is very clean, smells fresh and is a comfortable place for people to live and visit. What has improved since the last inspection? The service has continued to grow over the last year with an increase in people living at the home and new staff recruited. The owner has been changing areas within the home. The dining room has been converted into an office and is now the entrance to the home. The lounge has been altered to also accommodate the dining tables and chairs. This is in readiness for a conservatory to be built at the front of the home which will have an access ramp to the garden. The indoor/outdoor courtyard area has had a wall built across to provide shelter and a safer area for people to sit. What the care home could do better: Everyone at the home must be properly assessed before they move into the home and have agreed terms and conditions or a contract. This is to make sure that the home is able to fully meet their needs and that they are aware of their rights. All staff must be recruited safely with all the required checks being completed on them. This is to make sure that everyone is safe to work at the home. New staff must have commenced induction training within 6 weeks of them working at the home; this is to make sure that people are cared for by a safe and competent staff team. Medication training must be provided in accordance with the Royal Pharmaceutical Guidance for the administration of medicines and staff must adhere to these procedures in administering and completing medication records. Staff must have regular supervision to support them in their work and to ensure the quality of care people experience is consistent.The Coach House Residential HomeDS0000070709.V376891.R01.S.doc Version 5.2 A full staff training audit should be kept to make sure that all staff training is up to date and not overlooked. Additional measures should be taken to ensure all areas of the home are suitable including the windows on the first floor, to make sure that people living at the home are safe from harm. People`s personal records should be stored safely to make sure that information is held confidentially and always protects their privacy. Key inspection report CARE HOMES FOR OLDER PEOPLE The Coach House Residential Home Carla Beck Lane Carleton Skipton North Yorkshire BD23 3BU Lead Inspector Linda Trenouth Key Unannounced Inspection 09:45 31st July 2009 DS0000070709.V376891.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coach House Residential Home Address Carla Beck Lane Carleton Skipton North Yorkshire BD23 3BU 01274 491533 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) coachhouseres@btconnect.com Mrs Jean Ward Manager post vacant Care Home 14 Category(ies) of Dementia (14) registration, with number of places The Coach House Residential Home DS0000070709.V376891.R01.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 users of the following gender: Either Whose primary care needs on admission to the Home are within the following category:: 2. 3. Dementia - Code DE, maximum number of places 14 The maximum number of service users who can be accommodated is: 14 Aged 55 years and above on admission Date of last inspection 7th August 2008 Brief Description of the Service: The new owners took over The Coach House in February 2008. The Coach House can accommodate up to 14 older people who may be have memory impairment or have a learning disability. The house is a large detached property, set in its own grounds. The new owners are in the process of altering the interior of the property to make full use of the space. The changes are detailed in the Environment section of this report. The home has both single and shared rooms. A stair lift is available to take people from the ground floor up to the first floor. There is a well-tended garden and enclosed patio area with seating with a car park in the grounds. The home is located close to the local services and amenities of Carleton and Skipton. There is an information pack and service user guide, which informs people about the home. The fees on the 31st July 2009 ranged from £400 to £480 per week. Services such as hairdressing and private chiropody are available, but an additional charge is made. The Coach House Residential Home DS0000070709.V376891.R01.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 care home is a one star - adequate service. This was an unannounced key inspection of The Coach House. The site visit was completed on 31st July and was completed by one inspector. This unannounced visit was done in one day over 7 hours. We looked at a selection of records, observed care practice and meal times, looked around the building and talked to people who live at the home, the staff and Mrs Ward the owner of the home. Before our inspection visit we reviewed all of the information we had received about the service since the last inspection and we asked the home to complete a self assessment. This was completed and returned to us on time. It provided the information we had asked for and told us what the home did well and what could be improved. We also sent a selection of surveys to the home, for the manager to hand out and ask people to complete and return to us. Six surveys were returned. Information from the surveys and the self-assessment form are included in this report. 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 commendations, 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. Feedback was given to the owner Mrs Ward at the end of the visit. The requirements made during this visit can be found at the end of the report. What the service does well: People wishing to move into The Coach House are given enough information about the home before they move in. This helps them decide if home is the right place for them to live. These are some of the things people said about The Coach House: “All staff are very kind and caring” The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 6 “All staff willing and spend time with my Mum”. “I am always made to feel welcome when I visit here” There is a good choice of food and drinks available throughout the day. This makes sure people receive a varied and nutritious diet. The home organises and provides a variety of activities that people are able to join if they wish. The home is very clean, smells fresh and is a comfortable place for people to live and visit. What has improved since the last inspection? What they could do better: Everyone at the home must be properly assessed before they move into the home and have agreed terms and conditions or a contract. This is to make sure that the home is able to fully meet their needs and that they are aware of their rights. All staff must be recruited safely with all the required checks being completed on them. This is to make sure that everyone is safe to work at the home. New staff must have commenced induction training within 6 weeks of them working at the home; this is to make sure that people are cared for by a safe and competent staff team. Medication training must be provided in accordance with the Royal Pharmaceutical Guidance for the administration of medicines and staff must adhere to these procedures in administering and completing medication records. Staff must have regular supervision to support them in their work and to ensure the quality of care people experience is consistent. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 7 A full staff training audit should be kept to make sure that all staff training is up to date and not overlooked. Additional measures should be taken to ensure all areas of the home are suitable including the windows on the first floor, to make sure that people living at the home are safe from harm. People’s personal records should be stored safely to make sure that information is held confidentially and always protects their privacy. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Coach House Residential Home DS0000070709.V376891.R01.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 The Coach House Residential Home DS0000070709.V376891.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, and 5. People using the service experience adequate quality outcomes in this area. People are not always properly assessed prior to moving into the home and their rights could be better protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information about the range of services is available in the service user guide and brochure. Historically the home was for men only; the home has expanded in the last 16 months and now has 14 people living at the home. The owners have opened their admissions policy up to men and women. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 10 The owner did not have contracts or terms and conditions available for individuals living at the home. These documents are being developed with an external agency before they are put into place. It is important that the contracts or terms and conditions are agreed before a person moves in to the home to make sure that their rights are properly protected. The records showed that people’s needs were not always assessed before they moved into the home. In the records reviewed the owner could not find the social services assessments or the care home’s own assessment. It is important that people are assessed before they come into the home to make sure the home can fully meet their needs and that care needs are not overlooked. People living at the home confirmed that they had the opportunity to visit the home with their relatives before they decided to move in. Staff confirmed that individuals are encouraged to visit and also stay for tea. This is important so that everyone gets a good opportunity to see if the home is right for them. The Coach House Residential Home DS0000070709.V376891.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,and 10. People using the service experience adequate quality outcomes in this area. People’s needs are generally met at the home but medication procedures must be followed and staff trained properly. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A selection of care plans were looked at. Generally the care plans were completed to a good standard and set out how individual needs should be met. There were some examples where changes had been made in the care needed and this had been recorded. On the whole the care plans seen were person centred, this means that they look at the individual and identify their abilities or the areas where they need support to carry out daily activities. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 12 Risk assessments are in place for falls, nutrition, and the risk of developing pressure sores. One person was in their bedroom through choice and was spending the day in bed. Visits by GPs, and Health and Social Care Professionals are recorded and it was evident that people have Chiropody and Eye tests The care plans were however held in a public thoroughfare and needed to be stored safely to ensure people’s confidentiality. People are well cared for at the home and the staff support people with dignity and sensitivity. Relatives visiting the home say, “My dad is very well cared for here; they help keep him looking smart and deal with his personal care showing respect” “All staff are very caring and kind” “My relative always looks nice” and “Mum’s always very nice turned out” Staff had a good rapport and were gentle and sensitive when supporting individuals. The medicines in the home were reviewed. There were some problems with the administration and recording of medicines. We observed the medicines being administered by a member of staff other than the trained member of staff signing for the medication. The owner was aware this practice was not safe and said they would stop this practice with immediate effect. Also the controlled drugs were not being counter signed for. There must be two signatures for controlled drugs as in accordance with the Royal Pharmaceutical Society’s Guidance for the administration of medicines in Care Homes. The owner, who is a qualified nurse said that the staff have been trained by her and other experienced staff to give medication. It was advised however that staff must have certified medication training to make sure that they are administering medication safely. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. People have a good choice of activities and a varied diet at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Daily routines were flexible, people can get up and go to bed when they wish and stay in their rooms. During the inspection two people spent time in their rooms as was their choice. The home arranges many activities for people to participate in. The activity organiser has increased her hours to provide more flexibility. People spoken to said they enjoyed the activities they joined in and they said they chose whether to take part or not. People living in the home seem satisfied that there are activities for them to take part in if they wanted to. One person commented, “I enjoy playing bingo and winning cups” The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 14 People attend the local church and luncheon clubs, one relative said, “That keep my relative busy and they can wander around wherever they want. They sit out when the weather is good” Relatives also tell us that they are welcome at any time. One relative said, “Me or my sister can pop in any time and we do, the home is always welcoming and staff easy to talk to if we have a problem” People said they liked and enjoyed the food. The menus were varied and nutritious and the owner said they are changed periodically. The staff have a good idea of what people’s likes and dislikes are and organise the menus around them. The inspector joined the people for lunch in the lounge/dining area. People were offered a cold drink with their meal and a hot drink afterwards. Food is served plated from the kitchen. The meal was nicely presented; it was fish, potatoes and peas with a white sauce and trifle to follow. People said the meal was good and that they had sufficient to eat at breakfast and tea times. At supper times people are offered a sandwich or biscuits with a warm drink. Staff were available to help people with dining. One member of staff was observed crouching down to help support an individual with their meal. People should always be supported in a dignified and unhurried manner and staff should always sit with the individual, preferably at a table when they are supporting people with their meals. Other people observed had their meal in a relaxed and unhurried manner, giving people time to eat at their own pace. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. People feel that their complaints are listened to and will be acted upon. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information about the complaints procedure is available in the home. People, who completed the survey or talked to the inspector, said they know who to speak to if they are not happy. A relative said, “I haven’t had to make any complaint I just talk to the staff or the owner and things get sorted. If I was unhappy I would move my Dad elsewhere as simple as that”. Another relative commented, “No complaints or comments, we are always listened to” There has been one complaint since the last inspection received by the (Care Quality Commission) CQC. The owner has investigated the concerns and responded promptly. The areas of concern were staff recruitment and staff having the right training. The staff were not always recruited properly and there were examples of staff not having the right training to do their work safely. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 16 The home has a policy on the protection of vulnerable adults, (safeguarding). Staff spoken to had a good understanding of their responsibilities to protect people and had an understanding of what they would do if they had any concerns about someone’s welfare. However, it is important that they receive up to date training to make sure they are working to the current practice guidelines. The owner must make sure this training is in place for all staff. This was raised at the last inspection. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. People live in a clean and comfortable home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and tidy on the day of the visit. Relatives visiting the home said that the home was always clean, well kept and free from odour. There is an ongoing programme of refurbishment and redecoration and there is a range of improvements being planned. There are plans to provide a new front entrance, with ramped access and a new conservatory area with dining space. The lounge and dining area are presently merged into one, which may mean the home is presently not providing enough communal space. This will however be rectified on completion of the conservatory. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 18 The use of (Close Circuit Television) CCTV to monitor the outside of the home should not impinge on the daily life of people living at the home. The lounge and dining areas had a bank of surveillance monitors adjacent to the fire place and television. This equipment must be moved to a more appropriate setting. The home is set in its own grounds and there is small car park. The owners are planning to make the car parking area bigger. The enclosed patio area, with glass canopy, is an area people use in all weathers to sit out. This is a safe area for people who may want to have a walk outside. People had lots of their own belongings and personal items in their bedrooms and rooms were individually decorated. The home is equipped to meet the needs of people with physical disabilities. There were some ensuite and communal bathrooms and toilets. One of the two bathrooms has a device to help people get in and out of the bath. The other was domestic in style and people step in and out. There was a stair lift in the home and the owner is considering installing a passenger lift in the future. Concerns were expressed about the windows on the first floor of the home needing urgent review as some did not have suitable restrictors fitted. This may mean that people are not safe. The owner of the home said that these would be fixed and made safe. The home employs a handyman who takes care of all routine maintenance, the gardening and carries out Health and Safety checks. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. Staff did not have the right training to do their jobs in a safe and competent way. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The records of four staff were reviewed; three had satisfactory CRB checks to work at the home although the application form was limited, only asking for the last employer. This does not allow the employer to look back over a person’s employment history and decide where gaps have occurred and where their previous experience has been gained. One individual working at the home was related to the owner and there was no evidence of proper recruitment or satisfactory checks being undertaken. Also in two other staff records the recruitment information only had one reference. It is important that all staff are checked properly to ensure that only those people suitable to work with vulnerable adults are employed at the home. Concerns were also expressed that one worker had only a POVA (Protection of Vulnerable Adults) check and had not had induction training. Other new staff employed in the last year have not undertaken induction training. This training is important to make sure that they have the right skills to do their job safely. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 20 Staff did not have contracts or job descriptions. The owner explained that they were presently developing these with an external company. The owner said that two staff have achieved National Vocational Qualifications level 2. The home needs to work towards a minimum of 50 of the staff team being trained to this level. Other staff have had training in areas such as food hygiene, first aid and infection control. It was difficult to see other training that had been completed by staff as there wasn’t a full training audit and the staff certificates were not always available. The owner must make sure that the training needs are better coordinated to ensure that training needs are not over looked and updates are not missed. When the owners took over it was agreed that particular training was to be provided specifically around Adult Protection, Dementia care needs and Equality and Diversity. This is still outstanding for new staff at the home. The rota showed that there are enough staff on each shift. There are always a minimum of two on shift throughout the day with a senior member of staff on duty. There is a cook and a maintenance man based at the home. The owner said that the Staff have not had supervision and hopes to put this into place soon. All staff must have regular supervision to support them in their work and to ensure the quality of care people experience is consistent. Staff say however that they feel well supported to do their job and feel they have enough knowledge to meet the needs of people who live at the home. Staff were seen to carry out their jobs in a polite, friendly and competent way. Staff showed respect to people in their work and people appeared relaxed and comfortable at the home. People visiting the home said staff were always available and helpful. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience adequate quality outcomes in this area. The service could be managed better and important areas need improvement to ensure that people have a good quality of life at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The owner Mrs Ward and her husband have until recently owned and run a nursing home for over 20 years in Bradford. The Registered Manager left some time ago and Mrs Ward is managing the home. Mrs Ward is a qualified nurse and has completed the registered Managers Award. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 22 The home has sent out annual questionnaires to people living at the home and their relatives. The home has begun to hold house meetings giving people the chance to have their say and two staff meetings were held in the last year. The owner runs an open door policy welcoming people to talk to her and express their views about the home. One relative said they thought the new owners were good and were making improvements to the property, “They have plans to put in a lift and build a conservatory”. The home has provided written evidence that shows all equipment is maintained and serviced at the required intervals. During the inspection the Electrical and Gas Safety Certificates were checked and found to be up to date. Our view however is that the home is not managed sufficiently to ensure that peoples interests and care needs are continually met. People are not being assessed and contracts are omitted which may mean their rights are not protected. Staff are not always recruited safely, and new staff not sufficiently trained and supported to do their job well. These areas need addressing to ensure the home is run in the best interest of the people living and working at the home. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 23 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 n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 2 The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5 Requirement People living at the home must have a contract or terms and conditions so that their rights are properly protected. Everyone moving into the home must have a full assessment before they are admitted to the home. Staff must follow the medication policies and procedures correctly and ensure medicines are administered in a safe way and recorded properly. Staff must also have appropriate medication training to make sure they administer medication safely. All parts of the home must be safe. The windows on the first floor were not adequately retained and could mean people are at risk. Thorough recruitment procedures must be followed at all times. This is to protect people using the service and to ensure only suitable staff are employed at the home. Staff must complete a full DS0000070709.V376891.R01.S.doc Timescale for action 30/09/09 2 OP3 14 30/09/09 3 OP9 13 30/09/09 4 OP19 24 30/09/09 5 OP29 19 30/09/09 The Coach House Residential Home Version 5.2 Page 25 6 OP19 24 7 OP30 18 8 OP30 12 9 10 OP30 12 18 OP36 application form and give details of previous employment. Any gaps in employment must be explored and details given. The use of CCTV should not impinge on the daily life of people living at the home. The monitors in the lounge used for surveillance must be removed to a more appropriate place. All new staff must be provided with up to date training so that they can do their jobs competently. New Staff must have induction training within 6 weeks of being employed at the home to make sure they are competent to care for people safely. A training audit must be in place to make sure that staff training needs are not overlooked. Staff must have regular supervision to make sure they are safe to do their work competently. 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 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 3 Refer to Standard OP10 OP28 OP37 Good Practice Recommendations Staff should sit with people at meals times to assist them with their food, to provide a relaxed and unhurried meal time. A minimum ratio of 50 of care staff should hold National Vocational Qualification (NVQ) Level 2. Personal information must be stored confidentially in line with Data protection. The care files must be removed from the entrance area of the home and secured safely. The Coach House Residential Home DS0000070709.V376891.R01.S.doc Version 5.2 Page 26 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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