Archived: The Coach House Care Home

Updated 27 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by 1 inspector and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

The Coach House Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Coach House Care Home] is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We sought feedback from the local authority and professionals who work with the service. We reviewed information we had received about the service since the last inspection. We contacted Healthwatch for information they held about the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We observed staff interaction with people during the site visit. We spoke with 5 people who used the service and 7 relatives about their experience of the care provided. We spoke with 9 members of staff including the registered manager/nominated individual, deputy manager senior care staff, care staff and ancillary staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 6 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 27 May 2023

About the service

The Coach House Care Home is a residential care home providing accommodation and personal care for up to 21 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 16 people using the service. The service is in a residential area of Leeds city, in one building set out over 2 floors. The ground floor has a communal dining area and lounges.

People’s experience of using this service and what we found

There were inconsistences in people’s care records and quality assurance systems had not identified these. The provider had systems to review accidents, incidents and feedback about the service. However, there was little evidence how this was being used to improve the quality of the service.

Staff were clear about their roles and responsibilities and knew people well. We saw evidence of how the provider was working with other healthcare professionals to meet people’s needs. People and relatives felt communicated and consulted with.

There were inconsistencies in safe recruitment systems, we have recommended the provider consider current guidance on safe recruitment. Staffing levels were appropriate to meet people’s needs and people and their relatives consistently told us they felt safe. Medicines were managed safely and infection protection controls measures were good.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Rating at last inspection and update

The last rating for this service was requires improvement (published 29 July 2019) and there was 1 breach of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. This is the sixth consecutive inspection the provider has been rated requires improvement.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 29 July 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Coach House Care Home on our website at www.cqc.org.uk

Enforcement and recommendations

We have identified breaches in relation to governance systems at this inspection and made a recommendation about safe recruitment.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.