CQC report explained · a residential care home
What the CQC found at The Coach House SBDP1 Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2019
The Coach House SBDP1 Limited was rated Requires Improvement; inspectors found kind care, but important safety, consent, staffing and management improvements were needed.
This was an unannounced inspection on 21 May 2019. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They observed care, checked medicines, reviewed seven care records and examined staff and management records.
People were usually treated kindly, and staff knew them well. Staff were seen giving skilled support to people with complex needs and helping people who became distressed. Healthcare professionals said referrals were made promptly and staff followed advice.
However, care plans and risk assessments were often incomplete or inaccurate. Staff training and recruitment checks were not always up to date or robust. The home did not always follow the Mental Capacity Act, and its quality checks had not found several of these problems.
All five areas were rated Requires Improvement. The previous rating was Good, published on 13 December 2016. The provider was asked for an action plan, and CQC said it would continue to monitor the home.
Kind and reassuring staff
Inspectors saw kind interactions and staff using effective ways to calm people who were distressed. People and relatives also gave mostly positive feedback about the care.
“We saw kind, caring, and meaningful interactions from staff.” from the report
Good knowledge of people
Staff knew people well and were able to support complex physical and emotional needs. This helped people receive appropriate care even when written records were weak.
“Staff knew people well and used effective techniques to reassure people when they became distressed.” from the report
Healthcare links
Healthcare professionals were contacted when needed. Inspectors found records of healthcare visits and said referrals were made promptly.
“Health and social care professionals were arranged when needed to support people.” from the report
Food and dietary support
People received food that took account of their preferences and special dietary needs. Staff supported people patiently when they needed help eating.
“Our observations showed people received a healthy balanced diet which met their needs and took into consideration their preferences and any special dietary needs.” from the report
Incomplete risk information
seriousRisk assessments and care plans did not always explain how staff should reduce risks such as falls, choking, moving and handling or distress. One person was moved using an unsafe underarm technique.
“Risks in relation to people's care were not always sufficiently detailed or accurate.” from the report
Mental Capacity Act not followed
seriousBest-interests decisions were not always recorded where people lacked capacity. Conditions linked to Deprivation of Liberty Safeguards were not always checked or explained to staff.
“This constitutes a breach of Regulation 11 of the Health and Social Care Act (Regulated Activities) Regulations 2014.” from the report
Staff checks and training
seriousSome recruitment files lacked employment histories, suitable references or clear identity checks. Several staff had not completed important training, including safeguarding, fire safety, first aid, dementia awareness or end-of-life care.
“Recruitment procedures were not sufficiently robust to ensure staff were suitable for the role.” from the report
Care records and end-of-life wishes
needs fixingRecords were not consistently person-centred or detailed enough. End-of-life plans sometimes contained no information or only very limited information about people's wishes.
“People's care plans contained a section in relation to their end of life care needs.” from the report
Quality checks
needs fixingAudits had not identified several problems with care records, consent and training. The management team needed stronger systems to track actions and check that improvements were made.
“The quality and auditing system needed to be developed further so findings could be collated and actions taken to drive improvement.” from the report
Staffing and dining experience
minorInspectors saw staff available and attentive, but people and staff gave mixed views about staffing levels. Lunch service in one unit was slow and poorly organised.
“However, given some of the feedback, we would recommend the service monitors staffing levels to ensure they remain adequate.” from the report
- 01What has been done to make risk assessments and care plans accurate and detailed, especially for falls, choking, moving and handling and distress?
- 02How do you now record and review best-interests decisions, CCTV consent and conditions attached to Deprivation of Liberty Safeguards?
- 03Which staff training was overdue at the inspection, and has all required safeguarding, medicines, moving and handling, dementia and end-of-life training now been completed?
- 04How have recruitment checks been strengthened, including employment histories, identity documents and references?
- 05How do you monitor staffing levels on each unit, including at night, and what changes have been made to the dining service?
This was an unannounced inspection covering the premises, care and all five CQC questions; it followed the previous Good rating published on 13 December 2016. This explanation was written from the published report of 29 June 2019 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 2016
The Coach House SBDP1 Limited was rated Good; inspectors found kind, safe care and said earlier problems had been corrected, but some records were incomplete.
This was an unannounced inspection on 9 and 10 November 2016. Inspectors observed care, spoke with people, relatives, staff and a healthcare professional, and checked care, medicines, recruitment, training, quality and maintenance records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, suitable medicines systems, personalised care plans, kind staff and good support with food, activities and healthcare.
At the previous inspection in January 2015, the home had breached rules about person-centred care and medicines. Inspectors found enough progress had been made for those breaches to be resolved. They still noted some missing or incomplete records, including mental capacity assessments and some building risks.
Safe medicines practice
Inspectors found that medicines were stored safely, changes were recorded and people received medicines as prescribed.
“Medicines management and administration followed good practice and people received their medicines as the prescriber intended.” from the report
Personalised care
Care plans described people’s needs, preferences, health information and interests. Inspectors found that the care observed matched the plans.
“Care plans were individual to each person, accurate and had been regularly reviewed.” from the report
Kind and respectful staff
Staff were patient, courteous and reassuring. They promoted dignity, privacy, choice and independence.
“Care and support was delivered in a respectful and courteous manner and staff understood the importance of empowering the people they cared for.” from the report
Good staffing and training
People, relatives and healthcare professionals said staff were available when needed. Staff had inductions, relevant training and regular support.
“Everyone we spoke with said there were enough staff to meet people's individual needs.” from the report
Visible management
People and staff described the management team as approachable and supportive. The provider used audits and feedback to identify improvements.
“The system the provider had in place to monitor the quality of the service was effective.” from the report
Mental capacity records
needs fixingThe service was following mental capacity principles in practice, but assessments made before some deprivation of liberty applications had not been recorded.
“However, the mental capacity assessments the registered manager had undertaken prior to making these applications had not been recorded.” from the report
Incomplete building risk records
needs fixingSome risks linked to the building had not been recorded. Inspectors saw regular maintenance checks, which helped reduce the risks.
“Although some risks associated with the building had not been recorded, we saw that regular maintenance checks were in place and had been completed, to mitigate these risks.” from the report
Undated covert medicines reviews
needs fixingRecords for medicines given crushed in food or drink did not show dates or review dates. Inspectors said the procedures followed were appropriate, but the records needed updating.
“The records showed staff had followed appropriate procedures, however, the assessments were not dated and gave no indication of review dates to ensure they remained appropriate to give people their medicines in this way.” from the report
- 01How are mental capacity assessments now recorded before deprivation of liberty applications are made?
- 02How often are decisions about giving medicines covertly reviewed and where are the review dates recorded?
- 03Which building risks were not recorded at the inspection, and how are they now monitored?
- 04How do you check that pressure-relieving care and repositioning records remain complete?
- 05How do you use feedback from people and relatives to make improvements?
This was an unannounced inspection covering all five key questions and the overall quality of the home, with follow-up checks on breaches identified at the January 2015 inspection. This explanation was written from the published report of 13 December 2016 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 SBDP1 Limited
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- June 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Coach House SBDP1 Limited →
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at The Coach House SBDP1 Limited →
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 January 2011.
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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