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Inspection on 26/09/05 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 26th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

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

As previously stated this was a limited inspection, and only a few standards were assessed. However the inspector did find that the bedrooms were personalised by the service users and the home although large (39) had a very homely atmosphere. On speaking with the staff, acting manager and registered person, they all expressed a commitment to provide a good standard of care and service provision. The service users who spoke with the inspector were satisfied with the care and service provision.

What has improved since the last inspection?

At the previous inspection there were a considerable amount of requirements. The inspector established that many of the requirements had been or were being addressed, any outstanding requirements have been commented on within the body of this report.

What the care home could do better:

The inspection recognised there were some shortfalls outstanding from the previous inspection and some identified at this inspection. The issues to be addressed are regarding care plans, the environment, and the registration of a manager. The inspector has received verbal assurances from the registered person that all issues raised within this report will be acted upon. Therefore full compliance should have been achieved by the next inspection.

CARE HOMES FOR OLDER PEOPLE Coxbench Hall Residential Home Coxbench Hall Alfreton Road Coxbench Derby Derbyshire DE21 5BB Lead Inspector Ivan Barker Unannounced Inspection 26th September 2005 09:50 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.V251443.R01.S.doc Version 5.0 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.V251443.R01.S.doc Version 5.0 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 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.V251443.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/02/05 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, of lounges and dining room on the ground floor and 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.V251443.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection by this particular inspector, so these judgements were based on the previous report and this inspection rather than his knowledge of the home over several years. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on several of the ‘key standards’), and the previous requirements. The persons present at the inspection were: Mr B Ballin, registered person Mrs L Hodson, acting manager. Within this inspection, which occurred over a five hours and forty minute period, the inspector toured the building, spoke with service users and staff and examined the care plans and other documentation. He spoke with 8 service users, and staff during the inspection. Unfortunately no relatives were visiting at the time of the inspection. What the service does well: What has improved since the last inspection? At the previous inspection there were a considerable amount of requirements. The inspector established that many of the requirements had been or were being addressed, any outstanding requirements have been commented on within the body of this report. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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.V251443.R01.S.doc Version 5.0 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.V251443.R01.S.doc Version 5.0 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): Standard 6 Standard 6 was not applicable. EVIDENCE: The acting manager advised the inspector that no intermediate care was provided. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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): Standards 7, 8. Inaccurate care plans may contribute to the delivery of poor care. All parties should be aware of the intended care and ‘sign up’ to the care provision. EVIDENCE: On examination of 4 care plans (personal care service users), which included both written and computerised documents. The care plans did not have a daily entry, the directive of care was limited and could be more prescriptive, giving clearer instructions, and the documents need to evidence that they had been evaluated at monthly intervals. There was no signature from either the relative or the service user, on the care plans, which identified that they had been consulted regarding the care being provided. On discussing this fact with the acting manager, she informed the inspector that some service users were unable to sign and had no relatives, and some had no relatives, who visited. The inspector informed the acting manager that if no signature could be obtained she should record that fact, but Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 10 also to look to other people who may support the service user for example care managers, advocates etc. Despite the comments detailed above, the acting manager, and her deputy had re-evaluated the care plans as required from the last inspection, and were keen to ‘get it right’. The inspector went through the documents identifying were the documents required attention as detailed above, but also suggested other means of improvement. The acting manager assured the inspector that she would take on board these suggestions. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed at this inspection. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed at this inspection, except for the previous requirement. This had been acted upon and resolved. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 13 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, 24, 25, 26. The environment had not been maintained to the required standard. EVIDENCE: On touring the building, at this inspection, the following was found: Within the ‘top floor’ bathroom the enamel within the bath had been chipped in several areas. The registered person advised the inspector that this bathroom was being upgrade and the bath would receive attention as part of the upgrade. The windows were fitted with pieces of chain to act as restrictors. The guidance from Health and Safety executive is that the opening should be 10cm or 4 inches. The distance of the openings was greater than this measurement. As the windows had restrictors, then the inspector did not issue an immediate requirement notice. However it has been recorded as a requirement. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 14 Room 25 had restricted light, from the window, because of over hanging tree branches. Within room 24, therefore was a shelf that should have been secured to the wall, however the brackets were loose. The carpet between the dining room and conservatory had been released from the carpet gripper. The registered person informed the inspector that the carpet being shampooed, over the weekend had caused this. The loose carpet was a dangerous tripping hazard. As soon as the hazard was brought to the attention of the acting manager the handyman applied some adhesive to the carpet, as an interim measure. The health and safety issue of a tripping hazard had been acted upon, therefore an immediate requirement notice was not issued, however it was stated as a requirement as a more permanent fix needs to occur. The home was using commode pans, which required cleansing. The home did not have any sluicing facilities as detailed in Standard 26.6. The registered person identified that the home had not provided sluicing facilities, because the service users were not requiring that particular level of care. However as some service users were now requiring a higher level of care, he would have to reevaluate how to meet this need. Within the laundry, the washing machine had broken, and had been replaced by a larger model. However the old washer was still plumbed into the water and drainage system. A discussion occurred between the inspector, registered person and acting manager regarding the possible use of the water and draining facility used by the old washer, to provide a sluice facility. The inspector informed the registered person that the requirement would be that the commode pans were adequately cleansed to prevent the risk of infection. The registered person accepted the comment from the inspector. The previous requirements relating to the environment were monitored: The smoke room had been cleaned and upgraded. The rotting window frame, established to be in the large lounge, not the small lounge, had not received attention, despite it having previous timescales of 30/10/04 and 30/6/05. The registered person informed the inspector that the work would be completed by the 5/12/05. The inspector accepted this as a new and final timescale. The previous requirement relating to the heating was not assessed, as the heating was not switched on at the time of the inspection. However the registered person did inform the inspector that he had looked at the two systems of storage heaters and central heating via hot water radiators which Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 15 were provided as part of the heating system within the home and he had done risk assessments. From these assessments, his first action had been to reduce the risks in the greater risk areas. The inspector will assess the heating, on the next inspection. The inspector discussed the need to comply with Standard 24.2, which was the provision of furnishings. The registered person agreed to provide the service user with the items listed in the standard, if it was acceptable to the service user and safe for that amount of furnishings to be in the room. The inspector accepted the registered person comments. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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): Standard 27 Current staffing levels in place would appear to meet the current dependency needs of service users, accommodated within the home. EVIDENCE: On examination of the duty rotas and discussion with the acting manager, the inspector established the following: On the am shifts, there were 1 senior member of care and 5 care assistants On the pm shifts, there were 1 senior member of care and 3 care assistants. On the night shifts, there were 3 care assistants. Providing care to 35 service users, with personal needs. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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): Standard 31. No registered manager was in post. EVIDENCE: The role of the acting manager and the lack of a registered manager were discussed with the registered person. He informed the inspector that he intends to submit an application from the current acting manager, and hoped to get the process completed within the next 3 months. As no registered manager was in post, then this has been raised as a requirement. The previous requirement was assessed: The electrical wiring certificate was not available for inspection. The registered person advised the inspector that the work was yet to be done and the certificate obtained. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 18 This requirement had been outstanding since 30/09/04. The registered person informed the inspector that he had every intention of completing this work, but he had experience difficulty in obtaining estimates from electrical companies. However the registered person informed the inspector that the work would be completed by the 28/2/06. The inspector accepted this as a new and final timescale. Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 2 X X X 2 X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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 Timescale for action 26/12/05 2 OP19OP21 23 3 OP21 23 4 OP19OP25 12 and 23 The registered person must ensure that the care plans are up to date, evaluated monthly and signed by the service user, relative, or a person acting on their behalf. The register person must ensure 26/12/05 that repairs to the shelf, bath and carpet are carried out to ensure that the environment meets the required standard. The register person must ensure 26/12/05 that there is a reduction in the possible risk of infection by adequate cleansing of the commode pans occurs, with the provision of a sliuce. The register person must ensure 05/12/05 that the windows receive attention. The window in the lounge needs to be repaired or replaced. Timescale 5/12/05 (window repair/ replace) The window restrictors need to be reduced in size. Timescale 26/10/05 (restrictors) Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 Page 21 5 OP31 8 The registered person must appoint a manager. This person must undertake the ‘fit person’ process. Timescales since 30/07/04, now 26/12/05 The registered person must ensure that there is an up to date electrical wiring certificate for Coxbench Hall. Timescale since 30/09/04, now 28/02/06. 26/12/05 6 OP38 12 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coxbench Hall Residential Home DS0000019968.V251443.R01.S.doc Version 5.0 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.V251443.R01.S.doc Version 5.0 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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