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Inspection on 22/11/07 for Coxbench Hall Residential Home

Also see our care home review for Coxbench Hall Residential Home for more information

This inspection was carried out on 22nd November 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

All of the requirements that were left at the last inspection have been met. Care plans show improvement, a new format is now used which covers all areas of health, social and personal care needs. The registered manager has achieved a National Vocational Qualification in care at Level 4. A new bathroom suite, with under floor heating has been installed, which includes a hoisting facility over the bath and a separate shower area, therefore this bathroom should benefit all residents once in use.

What the care home could do better:

The admission date for residents was not recorded on their care plan or on their application and admission form, although the date the room was required from was included. However as agreed this may not always be the actual date of admission. Care plans seen stated the date they had been prepared and the date they were due for review, however there was no written evidence to demonstrate that reviews were taking place. This has the potential to suggest that any changing needs of residents may not be identified and addressed promptly. The handwritten medication administration records had not been signed or countersigned by staff. Therefore the potential for errors when handwriting prescribed medications was greater, and without staff signatures a clear audit trail is not in place to identify the member of staff responsible for the hand written instructions. Discussions took place with the managing director regarding this and an instruction was left for staff on the front of the medication administration records folder, at the time of this inspection.

CARE HOMES FOR OLDER PEOPLE Coxbench Hall Residential Home Coxbench Hall Alfreton Road Coxbench Derby Derbyshire DE21 5BB Lead Inspector Angela Kennedy Unannounced Inspection 22nd November 2007 09:30 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.V354272.R02.S.doc Version 5.2 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.V354272.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coxbench Hall Residential Home Address Coxbench Hall Alfreton Road Coxbench Derby Derbyshire DE21 5BB (01332) 880200 01332 881199 coxbench.hall@btopenworld.com www.coxbench-hall.co.uk Coxbench Hall Limited 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) Olive Tomlinson 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.V354272.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 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. The fees for residency at Coxbench Hall at the time of this inspection ranged from £416- £551 per week. Further information regarding the home is available in the homes service user guide or by contacting the manager at Coxbench Hall. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately seven hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. On the day of this inspection the registered manager was not on duty, therefore the Managing Director and a senior member of the care staff team assisted the inspector with any records required. Some of the people living at Coxbench Hall were spoken with, regarding the care, support and services provided to them at Coxbench Hall. Two members of staff were spoken with at length to ascertain their views on the care and services provided to residents, and their opinion of the training and support offered to staff. At this inspection two residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. What the service does well: Positive comments from some of the residents and their visitors included “ the staff are lovely, friendly and very kind”. “The staff are nice they look after us very well” and “ The staff seem very caring”. The décor at Coxbench was of a good standard and maintenance was provided on an ongoing basis, this ensured that residents lived in a homely, comfortable and attractive environment. Social and leisure activities were organised on a daily basis with opportunities for residents to become involved in as many of the activities and events as they wished. The meals provided to residents received positive comments such as, “ I enjoy the food, its very good” and “ the meals are excellent”. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 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.V354272.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To ensure the service is able to meet each person’s needs an assessment of need is undertaken before admission is agreed. EVIDENCE: The care plans of two residents were inspected as part of the case tracking process and to examine the pre-admission assessment procedures. Both of the residents’ case tracked had needs assessments in place; these had been undertaken by the manager at Coxbench Hall prior to the residents’ admission. Although neither of the residents case tracked were funded through the local authority there was confirmation that Local Authority assessments were also in place for those residents who received funded care. This ensured Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 9 that each residents needs were identified and could be met by the staff and services provided at Coxbench Hall. Contracts of residency were in place within both residents files seen. One visitor spoken with stated that when looking for residential care for her relative she had called at Coxbench Hall, without an appointment and asked if she could be shown around the home. She confirmed that staff were welcoming and happy to show her around and discuss her relatives needs. This visitor also stated that prior to moving in to Coxbench Hall her relative came for respite on two occasions, and then decided she wanted to stay at Coxbench Hall on a permanent basis. Coxbench Hall does not provide intermediate care and therefore standard 6 is not applicable at this service. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care plans and risk assessments informed staff of how each residents assessed needs were to be met. Residents who self-administer their medication were protected by the homes practices. EVIDENCE: The care plan format had been revised and expanded since the last inspection. The format enabled each area of care to be addressed. Included within the care plan format was information regarding professional health care input, medication on admission and who was to administer the medication, i.e. staff or the resident and the daily routine of the resident. In general the information provided was clear and instructed staff on the support the resident required in order for their needs to be met. However some areas of support plans could have provided more detail, for example one Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 11 of the care plans seen regarding religious and cultural needs stated ‘non to speak of’. This doesn’t clearly reflect if this persons needs are being met regarding their religious beliefs and cultural requirements. It was also noted that nothing had been recorded in the care plan regarding this individual’s social interests and hobbies. However this information was recorded in the pre admission assessment. This information should be transferred to their care plan. The admission date was not recorded on the care plan although both care plans seen stated the date they had been prepared and the date they were due for review, however there was no written evidence to demonstrate that reviews were taking place. This has the potential to suggest that any changing needs of residents may not be identified and addressed promptly. Discussions took place with the managing director regarding the date of admission being recorded on each persons care plan and a review form was created on the day of this inspection and shown to the inspector. Evidence was in place to demonstrate that both residents case tracked were involved in the development of their care plan. Risk assessments seen were detailed, this ensured staff were instructed as to how certain risks were to be minimised and managed. The risk assessments were dated and had been reviewed. Signatures were in place from the resident, their relative/ representative and the member of staff that had undertaken the assessment The residents spoken with were very positive regarding the standard of care and support provided by the staff team, and the comments made included “the staff are very nice, they are kind and respectful” and “the staff are lovely, friendly and very kind”. One relative that was spoken with said, “ mum seems very happy here and the staff seem very caring” Within the three residents files seen regular records of weight were in place, this demonstrates that residents weight is regularly monitored to ensure that any nutritional needs can be identified. Resident’s health care needs were met at Coxbench Hall, and evidence was in place to demonstrate that residents received dental, optical and foot care as required. The registered doctor visited Coxbench Hall weekly to provide surgery to residents, and it was confirmed he was also available upon request. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 12 The medication systems in place were examined and in general were satisfactory. However the handwritten medication administration records had not been signed or countersigned by staff. Therefore the potential for errors when handwriting prescribed medications was greater, and without staff signatures a clear audit trail is not in place to identify the member of staff responsible for the hand written instructions. Discussions took place with the Managing Director regarding this and an instruction was left for staff on the front of the medication administration records folder, at the time of this inspection. Risk assessments were now in place that clearly demonstrated that residents wishing to administer their medication had the capacity to do so. Within this assessment was a disclaimer for the individuals G.P to sign to confirm that they were in agreement with the individual administering their medication. Information regarding self-administration of medication/s was also in place within the homes application and admission information, this included selfcustody of medicines declaration form, which cross-referenced to the risk assessment. This demonstrates that safe working practices are in place that allows residents with capacity to keep and administer their medication, which in turn enables them to retain their independence and autonomy. The residents spoken with confirmed that staff respected their privacy and dignity, for example by knocking on bedroom doors before entering. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To promote the rights of individuals and enhance their well being, residents were supported to maintain their relationships with family and friends and encouraged to maintain their social and religious needs. The meals provided were of a good quality and alternative choices were available to ensure individual tastes were catered for. EVIDENCE: The activities provided at Coxbench Hall were discussed with residents, visitors and the staff and Managing Director of the service. Themed dinners were organised once a month for residents and their visitors and both residents and visitors spoken with confirmed that these were thoroughly enjoyed, one visitor said “ we come to the themed nights which are very good, the food is fantastic, its restaurant standard”. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 14 Monthly events were placed on the notice board and a copy of these events was sent with residents’ monthly accounts, this ensured that families and representatives were aware of the activities on offer. Activities included; pat the dog, carpet bowls, table top games, Mrs Motivator, quizzes, a mystery trip once a week, a mobile library service and a hairdresser once a week. A library was available within Coxbench Hall for residents’ use. A mini bus was also available to take residents out, and each Thursday ‘mystery tours’ were organised for residents who wished to participate. The managing director also confirmed that during the warmer months a variety of trips were undertaken both within the local community, such as local drama groups, fetes and garden parties, and trips to the peak district and seaside resorts. Of the residents spoken with all confirmed that there were sufficient activities for them to participate in if they chose to. Residents that were able accessed the local community independently, for example one resident played golf and tennis at local facilities and two residents attend a luncheon club every week. The religious and cultural needs of residents were met at Coxbench Hall by providing in house non denominational services once a month and communion once a month for those residents who wished to participate. The Managing Director confirmed that at the present time none of the residents chose to attend religious services within the local community. Visiting hours were open at Coxbench Hall and visitors spoken with confirmed that staff were friendly and always made them feel welcome. One resident commented “ my visitors are always made welcome and come to the themed dinners every month, they’re very good”. The daily menus were seen and were displayed and arranged on a six-week rotational basis. Alternative choices were available and the cook ascertained residents’ choices on a daily basis. Cooked breakfasts were available each day and an early morning cup of tea at 7am was available for those residents who wanted one. Comments from residents regarding the meals at Coxbench included, “ the meals are excellent, they’re very good” and “ the meals are lovely, I enjoy them” Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 15 Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents and their representatives were confident that any concerns they had were listened to and taken seriously and acted upon by the staff at Coxbench Hall. The practices and policies in place protect residents from abuse. EVIDENCE: The complaints procedure is included within the Service User Guide: A copy of the guide is placed in each bedroom. The copy of the complaints procedure seen in the reception area referred to the previous local office contact details. However following the inspection confirmation has been provided to demonstrate that the Complaints policy within the entrance hall and within the Service user Guide has now been amended to the new area office address. The Managing Director stated that the home had received no complaints since the last inspection visit. The commission received one complaint since the last inspection visit and this complaint was returned to the Managing Director to investigate. The Managing Director investigated this complaint and reported back to the commission in writing the outcome of their investigation. The commission are satisfied that the complaint was investigated thoroughly and the allegations made were not upheld. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 17 Residents spoken with confirmed that they were aware of the complaints procedure and felt that they would be able to raise any concerns if they needed to. The homes safeguarding policy was looked at and included the local authorities procedure in safeguarding investigations and referrals. This information ensures that staff have clear instruction as to the procedure to follow in any safeguarding referrals or concerns. The majority of the staff team had undertaken training in safeguarding adults; this included domestic, catering and administration staff. Staff spoken with had a good understanding of the safeguarding adults procedure. No safeguarding referrals or investigations have been made regarding any residents at Coxbench Hall since the last inspection visit. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and attractive home that is well maintained with good standards of hygiene in place. EVIDENCE: A guided tour of the building was undertaken. A new bathroom was in place, which provided under floor heating, a bath with adjustable height and over bath hoist, and a shower area with shower chair. This bathroom was not yet in use, as a lock had not yet been fitted to the door. The furnishings seen throughout the home were of good quality and residents and visitors spoken with were complimentary regarding the standards of décor and hygiene maintained. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 19 The laundry area was seen and housed sufficient equipment to ensure residents clothing could be laundered to meet disinfection standards. The laundry was staffed each day, and night staff provided support with any additional laundry requirements. Four vacant bedrooms were seen and all were pleasantly decorated with suitable furniture. One vacant room was without a bed as a new bed was being purchased for this room. Attractive grounds were available for residents’ use and included seating areas, a sensory garden, and a green house, which the Managing Director stated was used by one of the residents to grow plants and vegetables. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported by a trained and competent staff team and the recruitment practices in place, enhanced residents’ protection. EVIDENCE: The staffing rotas were examined and demonstrated that a senior member of staff was on duty throughout the day. During the last two weeks the rotas demonstrated that due to staff sickness and annual leave only three staff were on duty for the majority of late shifts. This was discussed with the staff on duty, who confirmed that during this period they were able to meet residents care needs but confirmed that they had not had the opportunity to spend time socially, ‘chatting’ with residents. The rotas demonstrated that for the majority of night shifts two staff were on duty, there were occasions when three staff were rostered on shift, and this was discussed with the managing director who confirmed this was due to staffs contracted hours and therefore used for additional cleaning duties to be undertaken. Out of twenty-one care staff, twelve have achieved a National Vocational Qualification (NVQ) in care at level 2, and three have achieved an NVQ in care at level 3. At the time of this inspection four staff were undertaking NVQ 2. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 21 The deputy manager and registered manager had achieved an NVQ 4 in care. The registered manager had also achieved the Registered Manager’s Award. The recruitment documentation was examined on three staff files. And the required recruitment documentation was in place, which demonstrates that the recruitment practices at Coxbench Hall enhance residents’ safety. At the last inspection the staff induction programme was examined and did not meet with Skills for Care criteria (recognised workforce training standards). Evidence was in place at this inspection to demonstrate that the induction programme for staff is now undertaken using the skills for care programme. This demonstrates that staff are provided with appropriate training on which to develop their skills and competence. A training matrix was in place that demonstrated staff training that had been undertaken and demonstrated that mandatory training was provided to staff as and when required. Training undertaken since the last inspection included; moving and handling training for all care staff, basic food hygiene for nine staff, fire training for all care staff and safeguarding adults training for twenty four staff, this included domestic staff, kitchen and administration staff. Two members of staff were spoken with regarding the training and support provided to them. One member of staff had recently commenced employment at Coxbench Hall and confirmed the induction training they had received was detailed. This member of staff although new to Coxbench Hall had several years experience in care work and therefore had a good understanding of the training and support required for new staff. They stated that the staff at Coxbench Hall appeared to work well as a team. The other member of staff spoken with had worked at Coxbench Hall for two and a half years. This person said that the training was kept up to date for staff. They confirmed that staff meetings were held every two months and alternated between afternoons and evenings to enable night staff to attend. This member of staff had attended the safeguarding adults training and stated that, although this training was good they would have preferred a smaller group of staff to attend this training. As they felt this would have allowed for better staff interaction. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Coxbench Hall is well managed and is run in the best interests of the residents. Good health and safety practices are in place, that safeguard the welfare of residents, staff and visitors to the home. EVIDENCE: The registered manager has now achieved the Registered Managers Award and an NVQ at level 4. Staff spoken with confirmed that the management structure in place was supportive. Visitors and residents were complimentary regarding the manager’s skills and abilities in running the home. Comments Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 23 included, “ she’s a nice woman, and seems very caring” and “ if I had any concerns I would speak to the manager, she’s very approachable. Surveys were sent out to residents and relatives every three months, the audited results from the last questionnaires were seen and the feedback received was very positive. The Managing Director confirmed that residents who stay at Coxbench Hall for respite are posted satisfaction questionnaires on discharge. Residents meetings are held at Coxbench Hall every two months. Feedback is now made available to residents following satisfaction questionnaires and residents meetings. This feedback is provided through notices displayed on the notice boards around the service and through regular newsletters to residents. Residents spoken with confirmed that meetings were held and stated that these meetings provided them with the opportunity to discuss any ideas or issues they had. The Managing Director reported that there is minimal involvement with personal monies of residents, with a billing system employed e.g. for hairdressing. Staff received on-going training in safe working practices, such as moving & handling and fire safety and all staff had received training in first aid. A sample of service/maintenance records was examined and all were found to be satisfactory, including weekly fire tests, emergency lighting tests, gas safety certificate and lift and hoist service certificates. Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 24 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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 7 (4) Requirement Timescale for action 01/03/08 2 3 OP7 OP9 17 (1) (a) 13.2 Care plans must kept under review to ensure any changing needs can be identified and actioned. The date on which the resident 01/02/08 was admitted to the service must be recorded. 01/02/08 Medications that are hand written onto medication administration records must be signed by the member of staff that is hand writing the medications and countersigned by a second member of staff that has checked the handwritten instructions to confirm the prescribing practitioners instructions have been followed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 26 1 2. OP7 OP7 Care plans must be reviewed at least once a month to ensure any changing needs can be identified and actioned 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 key worker. Further detail should be included in care plans to assist staff in ensuring that resident’s needs are fully met. 3. OP7 Coxbench Hall Residential Home DS0000019968.V354272.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V354272.R02.S.doc Version 5.2 Page 28 - 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. 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