CQC report explained · a nursing home
What the CQC found at The Coach House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2023
The Coach House is rated Requires Improvement; inspectors found unsafe fire arrangements, gaps in risk records and weak oversight, although staff knew people well and medicines were managed safely.
This was an unannounced inspection over three visits in January 2023. One inspector reviewed records, observed care, spoke with people, relatives, managers and staff, and checked medicines, recruitment and management systems.
The overall rating was Requires Improvement. Safe and well-led were both rated Requires Improvement, with breaches of Regulations 12 and 17. Fire safety arrangements were not safe, some people's risks were missing from their records, safeguarding procedures had not always been followed, and quality checks did not reliably find or address problems.
There were also positive findings. People said they felt safe, staff had a good understanding of people's specialist communication needs, recruitment checks were thorough, and medicines records showed people received medicines at the right times. The rating had fallen from Good at the previous inspection, published in December 2018.
Staff understood people
Staff knew people's individual needs, communication styles and preferences. Inspectors saw relaxed, comfortable interactions.
“Staff were observed to have a very good rapport with the people they supported, including having a good understanding of their specialist communication needs and how they liked to be supported.” from the report
Medicines records
The records checked showed medicines were given at the correct times and stored securely.
“These showed people received their medication at the times they needed them, and records were maintained and kept in good order.” from the report
Recruitment checks
The recruitment files checked showed thorough checks before staff started work, including references and criminal record checks.
“Recruitment records showed in-depth recruitment procedures were in place to keep people safe.” from the report
People felt safe
People and relatives told inspectors they felt safe, and visiting was allowed without restrictions.
“People told us they felt safe and comments included, "Definitely, I feel safe" and, "Yes, I am safe.” from the report
Fire safety
seriousThe provider was not meeting fire safety requirements after a fire service visit in December 2022. Inspectors were also not assured that enough staff were available to evacuate people safely, particularly at night.
“The service's fire arrangements were not safe. The provider was non-compliant with the requirements of the Regulatory Reform [Fire Safety] Order 2005” from the report
Missing risk records
seriousSome important risks were not recorded in care plans, including risks linked to tracheostomy tubes, PEG feeding tubes and catheters. Staff knew these risks, but the records did not give enough assurance that they could be managed safely.
“Not all risks for people were identified and recorded in relation to their care and support needs to ensure their safety and wellbeing.” from the report
Weak oversight
seriousAudits and governance checks did not reliably identify problems or show that actions had been completed. This included fire safety, staffing, furniture and clinical information.
“Systems were not robust enough to evidence effective oversight of the service or ensure suitable arrangements were in place to assess and monitor the quality of the service.” from the report
Safeguarding process
seriousA serious incident had not been referred to the local authority or CQC, and no internal investigation had been started to identify lessons.
“The management team failed to raise a safeguarding concern with the Local Authority or to notify the Care Quality Commission.” from the report
Staffing concerns
needs fixingThree relatives said staffing was not always sufficient, including for mobility support and during busier afternoons. The provider later said an extra night worker had been introduced.
“Three relatives spoken with felt there were not always enough staff available to meet their family care and support needs.” from the report
Medicines competency checks
needs fixingStaff had medicines training, but there was no evidence that their practical competency had been assessed. Monthly medicines audits were also not completed as expected.
“However, no evidence was available to demonstrate staff had had their competency assessed to ensure they remained competent to undertake this task safely.” from the report
- 01What action has been completed to address the fire service's concerns, and when was the work checked?
- 02How many staff are now on duty at night, and how would they evacuate each person safely using their Personal Emergency Evacuation Plan?
- 03Have all risks linked to tracheostomy tubes, PEG feeding tubes and catheters been added to people's care plans?
- 04Have medicines staff had their competency assessed, and are monthly medicines audits now being completed?
- 05What changes have been made to quality audits, safeguarding investigations and the review of relatives' satisfaction feedback?
This was an unannounced inspection focused on Safe and Well-led; the report gives ratings only for those two areas, while the previous overall rating was Good in December 2018. This explanation was written from the published report of 24 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2018
Rated Good; inspectors found safe, kind and responsive care, with some fire-safety works still outstanding.
This was the first inspection since the home was newly registered. It was an unannounced, comprehensive inspection on 25 October 2018. Inspectors spoke with people living there, staff, relatives, the provider and the manager. They also reviewed care plans, medicines records, staff records and the home's quality checks.
The home provided accommodation, personal care and nursing care for up to 13 people with neurological conditions acquired through a life-changing event or diagnosis. There were 13 people living there at the inspection. Inspectors found suitable arrangements to keep people safe, enough staff, safe medicines support and thorough staff recruitment.
Inspectors found staff had suitable training and supervision. People's health, nutrition and hydration needs were met. Care was kind, respectful and adapted to people's communication needs, routines and preferences. Activities were available both in the home and in the local community.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspection found the home was meeting the relevant requirements in these areas at that time. The report also noted two outstanding actions from an earlier fire inspection and some medicines-record gaps being monitored.
Kind and respectful care
Staff knew people well and adapted their communication and personal care to individual needs, preferences and dignity.
“Our observations showed people received good person-centred care.” from the report
Detailed care planning
Care plans covered people's specific needs and preferred routines. They were updated when people's needs changed.
“People's care plans were detailed to enable staff to deliver care and therapies that met people's individual needs.” from the report
Strong oversight
The management team used audits, surveys, meetings and action plans to monitor the service and address improvements.
“Quality assurance arrangements were robust and identified what was working well and areas for improvement.” from the report
Fire-safety actions outstanding
needs fixingAn earlier fire inspection had found two areas of non-compliance. These actions were still outstanding at this inspection, although the provider had contacted a contractor about the work.
“The service had received an inspection by Essex Fire and Rescue in December 2017, where it had been found to be non-compliant in two areas and at the time of this inspection these actions remained outstanding.” from the report
Medicines records needed monitoring
needs fixingAudits had found gaps on medicines administration records. The manager was considering a new electronic system to reduce these gaps and improve auditing.
“For example, where gaps on MAR forms had been identified, the registered manager was proactive in identifying this as an issue” from the report
- 01Have the two outstanding fire-safety actions identified in December 2017 now been completed, and what evidence can you show?
- 02Have the gaps found on medicines administration records been resolved?
- 03Was the proposed electronic medicines system introduced, and how do you check that medicines are given and recorded correctly?
- 04What specialist training do staff receive for neurological conditions, swallowing difficulties, epilepsy and pressure-ulcer prevention?
- 05How are care plans reviewed when a person's needs or preferred routines change?
This was an unannounced first comprehensive inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 14 December 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of The Coach House
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018GoodSafe: GoodWell-led: Good
- December 2017
Registered with the Care Quality Commission on 14 December 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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