• Care Home
  • Care home

Prestwood Coach House

Overall: Requires improvement read more about inspection ratings

Wolverhampton Road, Prestwood, Stourbridge, West Midlands, DY7 5AL (01384) 877111

Provided and run by:
Completelink Limited

Latest inspection summary

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Background to this inspection

Updated 30 July 2020

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 Care Act 2014.

Inspection team

The inspection team consisted of two inspectors.

Service and service type

Prestwood Coach House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with seven people who used the service and three relatives about their experience of the care provided. We spoke with five members of staff including the registered manager, nurses and care workers. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at a variety of records relating to the management of the service, including quality assurance tools.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two healthcare professionals who regularly visit the service.

Overall inspection

Requires improvement

Updated 30 July 2020

About the service

Prestwood Coach House is a nursing home providing personal and nursing care to 32 people aged 60 and over at the time of the inspection, some of who were living with dementia. The service can support up to 40 people.

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

People were not always supported to have their needs met in a timely way by staff. People gave mixed feedback about whether there were sufficient staff to meet people's needs and engage with them in a meaningful and flexible way.

People were not consistently supported to receive their medicines as prescribed and in a safe way. Medicines were not consistently stored and disposed of in a safe way. Medicines records did not always contain clear guidance for staff to follow in relation to ‘as required’ medicines. The provider did not always take timely action where people had not received support with their medicines.

People’s care files did not consistently contain clear guidance to enable to staff to meet their needs. People's daily care notes did not always reflect they were supported with their care needs. People had access to health professionals, however professional feedback was mixed in relation to whether their guidance was always followed to support people's recovery.

People were supported to access regular meaningful activities however did not always have time to engage with staff outside of care tasks. Quality assurance tools were not effective at identifying where improvements were required at the service. The management team had not ensured systems were effective at sustaining quality and improvement.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. However, the policies and systems in the service did not always support this practice due to staffing constraints.

People were supported by staff who knew them well. Staff understood safeguarding and made referrals the safeguarding team where required. People were supported by safely recruited staff. People were supported to maintain their independence. People knew how to complain and the registered manager acted on people’s concerns.

People were supported to maintain a diet of their choice. People were supported to access a variety of activities both inside and outside of the home.

People found the registered manager approachable. The registered manager sought and shared people’s feedback about the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 12 December 2018).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to people’s safe care and treatment, staffing and the governance of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 also request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.