What life is like for people using this service:

Since our last inspection the provider had failed to effectively act on the recommendations and breaches identified to make sufficient and sustained improvements. The provider displayed a commitment to providing high quality person centred care but lacked the knowledge in some areas to implement safe systems to achieve this. The provider demonstrated their motivation to improve by working alongside the local authority and ourselves during and after the inspection.

The provider told us they would be seeking up to date policies which they could follow to demonstrate they worked within the law and used best practice to achieve positive outcomes for people in the future. The quality assurance system in place was not robust enough to ensure quality and safety. Formal ways of involving staff, people and their relatives were not in place. Systems to learn from accident and incidents to demonstrate continuous improvement were not in place. Risk assessments based on recognised evidence were not used to prevent people being at risk of avoidable harm. These systems need to work together to improve the safety and quality of the service.

People did not always receive effective care and support based on best practice. Where people’s needs had changed the provider did not always consider their environmental and moving and handling needs.

People told us they felt safe and well cared for. Staff afforded people respect and dignity and delivered care and support with compassion. People enjoyed the opportunities available to participate in activities. They told us overall, they would like to see more activities and time to access the community.

More information is in detailed findings below. We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around governance and the environment. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: Requires Improvement (report published 21 March 2017)

About the service: The Coach House Residential Home is a residential care home for up to 15 older people, some of whom may be living with dementia. At the time of the inspection 11 people lived in the service.

Why we inspected: This was a planned inspection based on the rating at the last inspection. Sufficient improvements had not been made since our last inspection which means the rating remains at requires improvement. This is the second consecutive time this service has been rated requires improvement.

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 undertook this inspection of The Coach House Residential Home on 18 January 2017. The inspection visit was unannounced.

The Coach House Residential Home is registered to provide personal care and accommodation for up to 15 people. The home focuses on providing care to older people and people who may be living with a dementia. At the time of this inspection the home was providing care to 14 people.

At the time of our inspection The Coach House Residential Home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our previous inspection of The Coach House Residential Home took place in December 2014, when the service was given an overall rating of good.

People told us they were happy with their care and would recommend the home. Staff knew people well and told us that they enjoyed working at the service. People felt safe at The Coach House and relatives told us they thought their relations were safe and well cared for.

The registered provider’s recruitment process reduced the risk of unsuitable staff being employed. Staff knew what to do if they had concerns or suspicions of abuse and felt able to raise any concerns they might have with the registered manager or provider.

Overall we found that staffing arrangements met people’s needs, but that this needed to be kept under constant formal review to ensure that people were safe. We have recommended that the registered provider implements a formal system for calculating and monitoring dependency based staffing levels at the home, based on current best practice guidance.

There was a lack of clarity about some medicines that were being given ‘as required’ or ‘as directed’ and medicine administration records did not always evidence that medicines had been given as prescribed. The policies and procedures relating to medicines would benefit from updating to reflect current best practice guidelines.

Most maintenance and inspection checks had been completed as required. We found that inspection of manual handling equipment and fire equipment was overdue, but was arranged and completed when prompted by our inspection.

On one occasion during 2016, staff had not identified a serious injury after someone fell and as a result had not sought prompt medical attention. Training for staff on what to do after someone had a fall had been provided in response to this incident, but we found that a competent first aider was not always on duty in the home. The registered provider may wish to refer to good practice documents for example, The Health and Safety (First-Aid) Regulations 1981. Guidance on Regulations and decide that if a first-aider is not required in the care home, a person should be appointed to take charge of the first-aid arrangements. The role of this appointed person includes looking after the first-aid equipment and facilities and calling the emergency services when required. To fulfil their role, the appointed person does not need first-aid training, though emergency first-aid training may be beneficial.

We had concerns about fire safety and night time staffing arrangements, which have been shared with the local fire safety officer.

We saw that people were involved in day to day decisions regarding their lives and the support they received. However, staff had limited understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), which had not been fully implemented at the home.

Staff told us they received appropriate training and support. Records showed that staff had received supervision and appraisal, but there were gaps in some staff members training and some training was old or out of date.

People received enough to eat and drink

This was an unannounced inspection carried out on 8 December 2014.

The Coach House Residential Home is registered to provide care for up to fifteen adults. The Coach House is not a nursing home. The house is a large detached property, set in its own grounds in Carleton near Skipton in North Yorkshire. There are both single and shared rooms. The three double rooms are also used for single occupancy, depending on individual choice and availability. A stair lift is provided to take people from the ground floor up to the first floor.

There was a registered manager in post, who is also the registered provider, along with her husband. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People who used the service told us they were very happy living at the service. They said they felt safe and knew how to report concerns if they had any. We saw care practices were good. Staff respected people’s choices and treated them with dignity and respect. People were encouraged to maintain good health and received the support they needed to do this. Medication was managed safely and people received their medication when they needed it and as prescribed for them.

People told us they enjoyed the food in the home and that staff knew what they liked and provided food they could enjoy. Meal times were organised in a way which made them a social occasion for people.

People told us they thought they had enough to do to occupy them through the day and they told us their visitors were made to feel welcome. Our observations on the day of our visit, showed people were engaged in meaningful activity and socialisation.

Staff said they felt well supported in their role and knew what was expected of them. Staff told us they received supervision every two or three months and one member of staff confirmed they had had an appraisal recently. Staff told us they could discuss their role and learning needs during their supervisions. The registered manager was not available during our inspection so the joint registered provider assisted with the inspection. It was evident that the registered manager and registered provider were aware of their responsibilities regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. However, staff had not been trained in this area and therefore we could not be confident that they were aware of the implications of this legislation for people who used the service. The registered provider told us there were plans to provide a training event for staff in the New Year.

We found people were cared for by a sufficient number of suitably qualified, skilled and experienced staff. However, we asked the registered provider to make sure they were providing enough staff during the night time and that staff on duty could meet the needs of those needing assistance during the night and continually assess the needs of people during this time. There was a training programme being developed for staff to ensure they were kept up to date and aware of current good practice. Robust recruitment procedures were in place and appropriate checks had been undertaken before staff began work.

Staff and people who used the service spoke in positive terms about the management team; saying they were approachable and that it mattered to them to provide a good service. We found that systems were in place to monitor the quality of the service and that the registered provider was continually looking at ways to make improvements in the home.

People told us they were confident to make a complaint if they needed to. Staff were aware of how to support people to raise concerns and complaints and we saw the registered provider learnt from complaints and suggestions and made improvements to the service when necessary.

We spoke with ten visitors, seven people who used the service and some of the staff on duty, including one of the owners. People were supported to make their own decisions where possible, with best interest meetings being used where people lacked capacity to decide for themselves. Where appropriate, relatives were kept informed and involved in people’s care. People told us they were treated well by the staff. One person told us, “The care is here is very good.” We observed staff being friendly and respectful towards people.

We saw from people's care records that they were supported to retain their independence as much as possible. The records we reviewed were person centred and included essential risk assessments. The information used was kept under review, to enable appropriate treatment, care and support to be given.

People were protected against the risks associated with unsafe practices relating to medicines because there were appropriate arrangements in place to manage the administration of medicines safely.

There were robust recruitment and selection processes in place. People were supported by suitably qualified, skilled and experienced staff. Staff were described to us as ‘very kind and thoughtful.’ People told us they thought they were well looked after. People told us their experiences at the service were positive and they received a good standard of care.

There was an effective complaints system available. At the time of our inspection there were no outstanding complaints.

Our inspection in September 2012 found there were problems with cleanliness and infection control in the buidling and managing the quality of the service.

On this visit we found the home was clean and that there were no odour problems. We also found the provider had organised a cleaning schedule which was regularly conducted and audited to ensure the home was clean. We also found that the provider was now auditing cleaniness in the home.

We also looked at staffing levels during this visit as we had received some information that these were not always safe. We found that two members of staff were on shift during the day but at night there was one member of staff caring for up to 14 people at the home. There were however on call arrangements in place as the provider lived next door to the home. We asked the provider to provide evidence of how they met people’s care needs and risk assessed individuals to make sure they were safe. The provider showed us that they had risk assessed the current staffing arrangements available during the night. They confirmed that they met people’s needs and could keep them safe. They also confirmed that they would change the staffing levels should there be a change in the dependency of people in the home. We did however ask them to further consult with the fire authority to seek advice in managing an emergency, for example,in the event of a fire.

People expressed their views and were involved in making decisions about their care and treatment.

We were not able to communicate with some people living at the home due to their complex communication needs, but through observations they appeared relaxed and comfortable. We did however speak with four people who told us that they were happy living there and that they were supported to make choices in their daily routines, according to their wishes.

People told us that they felt there were enough staff on duty, and that the staff were very attentive to their needs.

Those people who were able to told us they were offered choices about the care they received and how this was done. One person said “I am asked what I want to do during the day, what I want to eat and if I am comfortable.”

We were also able to talk to three staff about their work, training and experiences at the home.

People told us they were involved in making decisions about their care and consulted over their preferences. They told us that they were able to get up and go to bed when it suited them, and freely choose what they wanted to do from day-to-day.

People also told us that the care in the home was good and that the staff were helpful and caring. They told us they felt safe and that they would be happy to raise any concerns.

Staff told us that they felt well supported by the Registered Provider and that they were well trained to care for people safely.