The Coach House SBDP1 Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the service was no longer in breach of this regulation.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had policies and procedures for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. Staff told us they were confident about how to respond and report correctly.

A member of staff told us, “I want to tell you that we have all been working really hard and sincerely since last year's CQC inspection. All the staff have improved with the records and the notes, understanding the resident's needs and updating injuries. I have witnessed the learning and work progression of staff.”

The provider conducted investigations when incidents occurred and took appropriate action to prevent recurrences. We saw that ‘lessons learned’ were discussed and shared with staff. Staff attended regular meetings, which helped ensure any learning from events was shared and actioned.

A member of staff explained, “We have regular team/staff meetings. This is very hard within the care industry, so we complete these meetings in stages as we need staff to be on the floor with the residents. We complete a lot of one-to-one prompted supervisions with staff if things have gone wrong, within this meeting senior staff will explain why the meeting is taking place and then there will be a discussion on how things went and how we can improve.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Suitably trained staff completed and regularly reviewed assessments of people’s health and well-being, risks and wishes, to make sure they accurately reflected their needs.

Care plans were developed and shared with health and social care professionals when required, such as GPs, dietitians, speech and language therapists, physiotherapists and community mental health teams, to ensure people’s well-being was supported and maintained. Staff worked effectively with health and social care professionals to make sure people received appropriate support that met their needs.

We received positive feedback from health professionals to confirm this, including, “They have accepted some of our challenging patients and been very active with helping them adapt and adjust to new surroundings and try to engage with them to get to know their likes and dislikes.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their representatives told us they felt safe and well cared for. A person using the service told us, “They [staff] are all wonderful. I am quite settled here now thank you and I feel very safe and secure.” A person’s representative said, “I feel that my [relative] is quite safe at The Coach House.”

The provider had safeguarding policies and procedures in place. Staff were knowledgeable about recognising potential abuse and harm. Staff told us they had completed training for safeguarding adults and said they were confident that any concerns raised would be managed appropriately. Staff confirmed they always reported any concerns and told us they would also follow the whistleblowing policy if needed.

A member of staff told us, “My understanding of safeguarding is that it is about protecting vulnerable people from harm, abuse or neglect. I understand that safeguarding is everyone's responsibility. If I have a concern that something may constitute a safeguarding issue, I understand that I must report it appropriately rather than ignore it.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments with people and care plans were developed to mitigate identified risks. For example, nutrition and hydration, falls risks and skin integrity. People’s risk assessments and care plans were regularly reviewed to ensure they continued to reflect people’s needs and remained effective in helping people to keep safe.

People’s representatives told us they were happy with the way their loved ones were supported to manage identified risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We saw the premises were clean, safe, well maintained and meeting people's needs. A maintenance person was employed at the service and this person demonstrated their commitment to making sure the home and facilities were kept safe and pleasant for people living in the home. The maintenance person completed regular health and safety checks, as well as making sure any required remedial works were carried out, to ensure the environment remained safe and well maintained.

We saw servicing records in respect of health and safety in and around the premises, such as the fire alarm system, electrical safety and legionella testing. Servicing, checks and audits were also carried out on slings, hoisting equipment, baths and the call bell system. Regular fire drills were also conducted.

Personal emergency evacuation plans (PEEPs) were in place for people. These contained information around how to support people to evacuate the home.

People’s representatives told us they felt the environment was well maintained and suitable for people’s needs. They made comments such as, “The home is safe and always very clean.” And, “I would describe the environment as family like.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The majority of people told us they received prompt support. We noted that the management team regularly assessed people’s dependency levels and used this information to determine staffing levels. At the time of our assessment, the rotas and our observations showed the home to be sufficiently staffed and able to meet people’s assessed needs. Healthcare professionals and people’s representatives also gave positive feedback about the staffing levels.

A member of staff told us, “Most of the time, there are enough staff available to cover the shifts. I have never felt rushed when providing personal care.”

The registered manager explained how they continually monitored staffing levels to ensure these were determined and maintained, based on the needs of individuals, as well as the needs of the home as a whole. We saw that 1-1 support was provided, where necessary, to help keep people safe. We also saw that appropriate referrals and applications were made to Continuing Healthcare (CHC) to help secure additional funding for individuals when their needs increased.

The provider had safe recruitment practices to help ensure suitable staff were employed. All necessary pre-employment checks were completed before staff began working in the home.

Staff completed regular training, to make sure they had the knowledge and skills to carry out their duties. The management team monitored the training matrix to make sure staff remained up to date. Staff also confirmed they received support, supervision and appraisals. We queried the frequency of formal supervisions with the management team and were reassured that all staff were continually supported by way of 1-1 meetings, as well as team meetings, group supervisions, competency checks and spot checks.

A member of staff told us, “I have felt supported in my role. I receive regular support, supervision and appraisal, and observations are carried out regularly. There are also monthly staff meetings, which provide an opportunity for staff to receive information, raise issues and remain up to date.”

Some staff commented that it would be helpful if the rotas could be prepared a bit further in advance. We spoke to the management team about this, and they showed us how they were already taking steps to improve this area and make things better for staff. A member of the management team also explained, “Organising the rotas can be a very challenging role and to ensure everyone is happy, we also support staff in that they can swap and exchange shifts if they swap – like for like so that we can have the right skill set on shift. We try to be as supportive and flexible as possible.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and free from unpleasant odours. The provider employed dedicated domestic staff and everyone we spoke with complimented the home on its cleanliness.

Staff had sufficient supplies of personal protective equipment (PPE), which they wore and used appropriately. Staff completed training for infection control and regular audits were effective in identifying any areas for improvement, which were actioned promptly.

A member of staff told us, “My understanding of infection control is that good personal hygiene must be maintained at all times. Appropriate PPE should be used when required, and PPE should be disposed of correctly. One of the areas I consider to be particularly good at The Coach House is its approach to infection control.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were available, safely stored, and temperatures were within range for the storage of medicines, except for one injection that was found in the fridge when it should be stored at room temperature. We asked the provider to confirm that this was safe to give before it was administered. Although trolleys where medicines were stored were clean, cupboards and worktops within the treatment room were dirty, had unclean surfaces and splashes on the cupboard doors, this was immediately addressed by the provider.

Medicines administration was being recorded on an electronic record system. People’s allergies were clearly documented. Medicines that were time specific were being given when they were needed, such a Parkinson’s medicines.

We saw people treated with care and dignity when administering medicines. We looked at the records for people who were administered their medicines covertly (hidden within food or drink) and found that the relevant health care professionals and important family members or advocates had been involved in the decision-making process. However, the administration details were not always correct, and the best interest decision did not specify which medicines the decision related to.

Controlled drugs were stored, recorded and checked appropriately.

Previously we had found that when medicines were administered by patch, the site of application was not rotated properly. This was now being clearly documented although analgesic drug patches that were changed once a week were not being checked daily to ensure they remained in situ. Topical medicines (creams and ointments) were being consistently applied and documented.

There were protocols in place to give staff guidance as when it would be appropriate to administer ‘when required’ (PRN) medicines. These occasionally lacked detail, for example one person became very agitated when receiving personal care and this had been discussed with GP and a sedative had been agreed to be administered if necessary. This was not documented in the PRN protocol. The review of PRN protocols was already on the improvement plan supplied by the provider with a completion date of December 2026.

Care plans were in place for medicines such as antipsychotics and contained important information with regards to actions taken if doses were missed and how to monitor for constipation, a significant side effect of some antipsychotics. However, other care plans were missing information such as actions to take if people taking anticoagulants had a fall, or information about when to administer a sedative that had been prescribed the previous month, or up to date information about the monitoring of blood glucose in a person with diabetes.

Homely remedies to treat minor ailments were available if people needed them such as paracetamol or a laxative. An error within the electronic system had allowed a prescription only drug to be added to someone’s record as a homely remedy without being prescribed by the GP. When they received a dose of paracetamol as a homely remedy this was not recorded accurately. The provider reported this immediately as an incident and the electronic system was updated.

When people were moved into or out of the providers’ care, processes ensured the information about people’s medicines was correctly transferred with them.

Staff had completed medication training and had competency assessments in place.

We saw that medicine incidents were being reported and reviewed monthly, regular audits were taking place both by the provider and from the external supplying pharmacy and actions were followed up and lessons learnt.