Inspection on 14/02/06 for Coxbench Hall Residential Home

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Coxbench Hall Residential Home 22/11/07

Coxbench Hall Residential Home 29/01/07

Coxbench Hall Residential Home 26/09/05

Coxbench Hall Residential Home 28/02/05

Coxbench Hall Residential Home 20/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Coxbench Hall Residential Home Coxbench Hall Alfreton Road Coxbench Derby Derbyshire DE21 5BB Lead Inspector Andrew Bailey Unannounced Inspection 14th February 2006 10:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Coxbench Hall Residential Home Address Coxbench Hall Alfreton Road Coxbench Derby Derbyshire DE21 5BB (01332) 880200 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Coxbench Hall Limited Vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 Brief Description of the Service: Coxbench Hall is a converted Georgian building in its own grounds, situated in the village of Coxbench. The building is on 3 floors with communal areas comprising of lounges and a dining room on the ground floor, with bedrooms on all three floors. The care home is registered for up to 39 people aged over 65, and provides personal care. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately five and a half hours. Discussions were held with the manager, staff, four residents and two visitors. All of the residents spoken with were able to give detailed feedback about life at the home. A number of records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents). Many of the previous requirements had been addressed following the last inspection. The inspection focused on key National Minimum Standards. What the service does well: What has improved since the last inspection? There had been progress in addressing many of the previous requirements. Care plans show signs of some improvement, although there is still some way to go to ensure that these are sufficiently detailed. There were a number of environmental issues identified at the last inspection and most of these have received attention. For example, a window and frame has been replaced in one of the lounges. The manager has applied to CSCI for registered status and the ‘fit person’ process is currently being undertaken. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessments are undertaken prior to admission to ensure that the home can provide appropriate provision for residents. EVIDENCE: The care plans of three residents were inspected as part of the case tracking process and to examine the pre-admission assessment procedures. The manager and deputy assess residents prior to admission and an assessment document is completed for these assessments. There were assessment documents on file within the case-tracked samples examined at this inspection. The minority of residents were receiving funded care and the manager stated that in these instances social services assessments were received prior to admission of the residents. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents report that the home meets their personal care needs. There is written care plan documentation for each resident, but this tends to be insufficiently detailed to provide adequate guidance to staff to meet the needs of residents. Residents are protected by systems that promote the safe administration and handling of medicines. Residents feel that their privacy and dignity is respected. EVIDENCE: The care plans of three residents were inspected as part of the case tracking process and to evaluate progress in improving care planning since the last inspection. There have been some improvements to the care planning, for example in the monthly review procedures. However, there is need to develop the systems further. Overall, care plans contain little prescriptive detail about how care needs are to be met by staff. The care plans should also primarily focus on identified areas Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 10 of need, rather than involve writing about issues that have not been identified as deficits. Whilst there is a risk assessment in use in respect of falls, this is not of the scoring type that includes subject areas such as the number of medications that the resident is taking (written information was left with the manager at this inspection about scoring systems for the prevention of falls). There was no evidence of nutritional scoring for residents (National Minimum Standard 8), as part of the assessment process. Completed risk assessments should be placed on file within each resident’s care plan, rather than being filed separately, since these form part of the care records. Periodic reviews for privately funded residents should be organised, as good practice. This would provide the opportunity to formally review the care of each resident in a similar way that the Care Management reviews operate for residents who are funded/part funded by social services. Reviews could include the resident, a family representative (or advocate) and the keyworker. A brief examination of the medication systems was undertaken, with no shortfalls apparent that would provide significant risk to residents. The Inspector provided the Royal Pharmaceutical Society guidance on medications in care homes. This was photocopied at the time of the inspection and the manager agreed to make this available as a resource document for staff. Three staff were undertaking medication training on the day of the inspection, arranged with an external retail pharmacy. Residents spoken with confirmed that staff respect their privacy and dignity, for example by knocking on bedroom doors before entering. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 There is a programme of activities and trips that provides a range of opportunities for the residents. Residents are encouraged to make their own choices and maintain as much control over their lives as possible. Residents feel that the catering service provides a good standard of food, with choices available. EVIDENCE: A senior carer organises the social and leisure programme. Examples of activities within the home include bowls, games, crafts and videos. On the afternoon of the inspection there was a visiting entertainer. A ‘Mrs Motivator’ attends once per week to undertake keep-fit sessions. There is a monthly ‘residents’ dinner’ to which residents may invite guests. A mini-bus is utilised to take residents out to places of interest. A programme of activities/events is displayed within the home and there are photos of some of the past events on display. The level of participation in the programme varies from resident to resident, with personal choice exercised. There is an open visiting system at the home and visitors stated that they were made to feel welcome. Residents commented that there are few fixed routines and that they choose when to get up and go to bed, for example. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 12 There was positive feedback overall about the catering service, with most of the residents spoken with considering that the quality of the service was good. One resident felt that the menus were somewhat repetitive. Snacks/refreshments are available between the main meals. The daily menus are displayed and are arranged on a five-week rotational basis. Alternatives are available and the cook ascertains residents’ choices on a daily basis. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a complaints procedure and this is made known to residents and their representatives. Staff had received training in adult protection to safeguard the residents. EVIDENCE: There had been no recent complaints recorded. The complaints procedure is included within the Service User Guide: A copy of the guide is placed in each bedroom. Residents and visitors felt able to raise any issues with the management and those spoken with felt that communication was good between staff and the residents/families. There were certificates on display confirming that staff had received recent training in recognising and dealing with abuse. A recommendation has been made for the manager to attend a local authority adult protection training session, since there had been no recent attendance by senior staff at this training. Specific information about Derbyshire Adult Protection procedures can then be cascaded to staff, as appropriate. Although the local authority guidance was available on-site, it was noted that the reporting cards for alleged abuse were not available and the manager agreed to obtain these. The home’s adult protection policy and procedure was rather brief and did not refer to Derbyshire Adult Protection guidance. The policy and procedure should be updated and should align with local authority guidance. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 & 26 There have been improvements to the environmental standards since the last inspection. The home provides a comfortable setting for the residents. EVIDENCE: There is an on-going programme of redecoration and two bedrooms had been refurbished or redecorated since the last inspection. A lounge window and frame had also been replaced. The window restrictors had been adjusted to comply with Health & Safety Executive guidance i.e. maximum 100mm opening (applies to rooms on floors above ground level). There were no outstanding matters from recent Environmental Health and Fire Service inspections. It is noted that there is no provision of a sluice. There have been previous requirements in respect of this. The situation will be monitored by CSCI on an on-going basis, since the registered provider considers that the arrangements in place are proportionate to the needs and dependency of the residents Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 15 currently accommodated. There was no evidence to contradict this at this inspection, but the needs of residents could change over time, necessitating review of the situation. The laundry and domestic services received positive feedback from the residents and visitors spoken with at this inspection. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 On-going staff training is promoted to meet the needs of residents, but the induction programme does not comply with recognised training standards. EVIDENCE: There is satisfactory progress with National Vocational Qualification (NVQ) training, with ten out of twenty-one staff qualified to NVQ Level 2, or above. A further six staff are undertaking NVQ training and numbers will then exceed the 50 requirement of trained members of staff with NVQ Level 2, or equivalent. The staff induction programme was examined and did not meet with Skills for Care criteria (recognised workforce training standards). The Inspector provided relevant written information for the manager about Skills for Care induction standards. A sample of recruitment documentation was examined. Management stated that there was the possibility that some of the evidence of required checks was secured in an area not accessible at the time of the inspection. Further checks will be made at future inspections. However, one current file that was available was inspected and it was confirmed that the required preemployment checks had been made in respect of this member of staff. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Management is accessible and responsive to residents, and the views of residents are sought and responded to. In general, the safe working practices systems promote the health and safety of the residents, but there is an outstanding requirement to address to further protect the residents. EVIDENCE: The manager has applied to CSCI to be registered. She is currently undergoing the ‘fit person’ process, with some final stages of the process not yet complete. She has also commenced NVQ Level 4 training in care and management, with an anticipated completion early in 2007. Current CSCI guidance requires completion of the required qualifications by 30/09/07. Residents confirmed that meetings are held and that they have the opportunity to influence aspects of the running of the home. For example, residents’ likes and dislikes are made known at residents’ meetings in respect of food choices, which can in turn influence the development of the menus. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 18 Discussion took place at this inspection about periodic satisfaction surveys and it is suggested that surveys be undertaken with feedback made available to residents (and prospective residents) about their views. This would ordinarily have been made a requirement, but there was sufficient evidence that resident’s views are sought via a range of means, and accordingly this has been made a recommendation at this stage. The manager reported that there is minimal involvement with personal monies of residents, with a billing system employed e.g. for hairdressing. Staff receive on-going training in safe working practices, such as moving & handling and fire safety. Certificates were available to confirm this training. A sample of service/maintenance records was examined and in general there was confirmation that equipment and services had been properly maintained. However, there is an outstanding requirement from previous inspections to obtain a valid certificate for the electrical installation. The manager and maintenance person confirmed that quotations have been obtained for this work. In recognition of this a short extension of the timescale has been granted, but CSCI will consider escalating the level of enforcement if noncompliance continues. Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that all service users have care plans that set out in detail the action that needs to be taken by staff to ensure that all aspects of identified care needs are met. The registered person must ensure that relevant risk assessment and screening (e.g. nutritional screening) is undertaken for all service users and that this information, including any identified intervention, is recorded in care plans. The staff induction programme must meet recognised training criteria (Skills for Care). The manager (currently undergoing the registration process) must attain qualifications at Level 4 NVQ in management and care by the timescale. Timescale for action 31/05/06 2. OP8 15 31/05/06 3. OP30 18 31/05/06 4. OP31 9 30/09/07 Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 21 5. OP38 12 The registered person must ensure that there is an up to date electrical wiring certificate for Coxbench Hall. (Outstanding from previous inspections – short extension of timescale granted to reflect that quotations for this work have now been obtained) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations The falls risk assessment document should be reviewed with a view to utilising a recognised scoring system (information left with the manager at this inspection). Periodic reviews for privately funded residents should be arranged (of similar type to those available to residents placed by social services i.e. Care Management reviews). Reviews could include the resident and family representative or advocate and the keyworker. The manager should attend local authority adult protection training to ensure that there is up to date knowledge of local procedures to cascade to staff. The policy and procedure on abuse should be developed and should make specific reference to local authority adult protection procedures. Feedback to service users/prospective service users should be published and made available on the summary results of satisfaction surveys. 3. 4. 5. OP18 OP18 OP33 Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coxbench Hall Residential Home DS0000019968.V281679.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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