Inspection on 29/01/07 for Coxbench Hall Residential Home

This inspection was carried out on 29th January 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 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 14/02/06

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 Angela Kennedy Unannounced Inspection 29th January 2007 09:45 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.V300757.R01.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.V300757.R01.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.V300757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 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 £425- £540 per week. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which means that the service was assessed against all of the key national minimum standards. The duration of the inspection was approximately five hours. Discussions were held with the manager, staff, three residents and the relatives of one resident. All of the residents spoken with were able to give detailed feedback about life at Coxbench Hall. 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). Some of the previous requirements left at the last inspection had been met What the service does well: What has improved since the last inspection? Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 6 Progress has been made in addressing some of the previous requirements. Care plans show improvement, although more detail is required to ensure staff receive detailed instruction on how residents assessed needs are to be met. The manager now has registered status with the commission and has achieved the registered managers award. At the time of inspection the registered manager was due to commence a National Vocational Qualification in Care at level 4. Redecoration was being undertaken within some areas of the home, this included some of the bedrooms that were not in use at present and included the purchase of new furniture for these rooms. Corridors were also being redecorated and a new central heating system and boiler were also being installed. 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 home and through regular newsletters to residents. Works on the electrical wiring of Coxbench Hall was in the process of being undertaken on the day of this inspection. It was requested by the inspector that once these works were completed a copy of the electrical wiring certificate issued be sent to the commission, as this is an outstanding requirement from previous inspections. What they could do better: Within the residents files seen, few risk assessments were in place that addressed the risks identified within the residents care plans. Therefore specific instruction was not provided to staff on how these risks were to be minimised and managed. Although the manager has now attended a two day local authority training session in safeguarding adults and a senior carer has attended a five day train the trainer’s local authority training course in safeguarding adults, this training has not been cascaded to all staff. Three members of staff spoken with stated that they had not undertaken safeguarding adults training, and from the discussions held with these three staff it was evident that their knowledge regarding safeguarding adults procedures was limited. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 7 The staff induction programme does not meet with Skills for Care criteria (recognised workforce training standards). Information was provided to the registered manager as to how the skills for care induction criteria could be obtained. 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.V300757.R01.S.doc Version 5.2 Page 8 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.V300757.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To ensure residents’ needs could be met at Coxbench Hall, an assessment of their needs was undertaken prior to admission EVIDENCE: The care plans of three residents were inspected as part of the case tracking process and to examine the pre-admission assessment procedures. All 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. Local Authority assessments were also in place for those residents who received funded care. This ensured that each residents needs were Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 10 identified and could be met by the staff and services provided at Coxbench Hall. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents care plans and risk assessments require further development to better inform staff of how each residents assessed needs are to be met. The systems in place for the safe administration and handling of medicines is generally good, but requires further development to ensure residents safety is maintained. 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. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 12 Care plans had improved since the last inspection, however further detail about how identified care needs are to be met by staff would assist staff in ensuring that residents needs were fully met. Not all care plans had review dates in place and those that did were not reviewed on a monthly basis as set out in standard 7 of the national minimum standards. This has the potential to suggest that any changing needs of residents may not be identified and addressed promptly. Some of the risk assessments in place included nutritional assessments, dependency levels, smoking and falls. Some assessments had not been dated, making it difficult to determining if these assessments were still valid. Not all identified areas of risk had risk assessments in place. Therefore staff were not instructed as to how certain risks were to be minimised and managed. Discussions took place with the registered manager regarding care plans and risk assessment and how these could be further developed. The three residents spoken with felt that the standard of care provided was very good, and the comments made included “the staff are very caring” and “they’re good staff, they will always get you what you want”. 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. A chiropodist visited every six weeks to provide foot care for residents. An optician visited annually to provide eye tests for residents, although the registered manager confirmed that new residents were seen by the optician following admission. The registered doctor visited Coxbench Hall each Thursday morning to provide surgery to residents, although it was confirmed he was also available upon request. The majority of residents accessed their dentist with family support or assistance and transport was arranged by Coxbench Hall. The manager confirmed that formal reviews of care for privately funded residents did not take place. It is recommended that as a good practice measure, reviews take place 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. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 13 The medication systems in place were examined and in general were satisfactory. However it was noted that residents who retained and administered their medication did not have risk assessments in place that demonstrated their capacity to do so. Therefore there is potential for residents to be retaining and administering their medication when it is not safe to do so and could put themselves and/ or other residents at risk. The three 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.V300757.R01.S.doc Version 5.2 Page 14 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. A range of social and leisure activities were available to residents and residents were maintained contact with family and friends as they wished. Residents were encouraged to make their own choices and maintain as much control over their lives as possible. The catering services in place were of a good standard with choices available. EVIDENCE: A senior carer organised the social and leisure programme. Activities included; gentle exercise sessions, bowls, games, crafts, ladies manicures and videos. A mobile library visited Coxbench Hall on a regular basis to provide books for residents and a library was available within Coxbench Hall for residents’ use. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 15 A monthly residents themed dinner took place to which residents were able to invite guests. Two relatives commented on the range of activities provided stating that there was lots of entertainment on offer to residents. These relatives also expressed their enjoyment of the themed dinner evenings, which they felt were very good and enjoyed by everyone. External entertainers also visited the service on a regular basis to provide a variety of entertainment for residents. One resident at Coxbench Hall had his own greenhouse within the grounds and during the warmer months grew tomatoes and a variety of plants. A mini bus was also available to take residents out, and each Thursday ‘mystery tours’ were organised for residents who wished to participate. A hairdressing service was available to residents on a weekly basis. All three residents spoken with confirmed that there were sufficient activities available which they were able to participate in if they chose to. All three residents confirmed that their personal choice in participating was respected. The religious and cultural needs of residents were met at Coxbench Hall by providing in house services once a month and communion once a month for those residents who wished to participate. The manager stated that at the present time none of the residents chose to attend religious services within the local community. Visiting hours at Coxbench were open, although the registered manager did state that she requested visitors called after 9.30 am if possible. Residents and relatives spoken with confirmed that visitors were always made to feel welcome, and one relative stated that “ staff can’t do enough, they always make us a cup of tea”. Residents spoken with confirmed that there were few fixed routines and stated they were able to decide when to retire to bed and when to get up. One resident discussed how she preferred to retire to bed after tea, as she liked to read in bed and enjoyed spending some time alone. This resident said that the staff were respectful of her wishes and supported her in making her own decisions. 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. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 16 Mealtimes were as follows: Breakfast 8.30am Lunch 12.30pm Dinner 4.30pm Supper 8pm Morning coffee was held at 11am and afternoon tea at 3pm. The feedback from the three residents about the catering services was very positive and included comments such as “the food here is beautiful” and “the meals are wonderful, there’s plenty of choice”. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure and this is made known to residents and their representatives. Training in Safeguarding adult’s needs to be cascaded through the staff team to ensure residents protection from abuse is safeguarded and promoted. 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. The copy of the complaints procedure seen in the office referred to the previous regulatory body, the NCSC rather than the Commission for Social Care Inspection (CSCI). However following the inspection confirmation and evidence have been provided to demonstrate that the Complaints policy within the entrance hall and within the Service user Guide refer to the CSCI. All three 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 procedure for Safeguarding Adults was examined and in general was satisfactory, however it did not refer to the Local Authority Procedure. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 18 The importance of this was discussed with the registered manager who made enquiries on the day of inspection and stated that she would obtain a copy of the local authorities multi agency safeguarding adult’s procedure within the near future. From the training matrix seen and through discussions with the registered manager it was ascertained that only a minority of the staff team had undertaken training in safeguarding adults. The registered manager had undertaken a two day training course in safeguarding adults and one of the senior staff had undertaken the five day train the trainer’s course, which enabled her to train the staff team in safeguarding adults. However at the time of this inspection this training had not been given to the staff that required it. Two members of the care team and one member of the domestic team were spoken with and all three stated that they had not received training in safeguarding adults. From discussions with these three staff it was evident that their knowledge regarding the local authority procedure in safeguarding adults was limited. Lack of knowledge in this area has the potential to hinder the safeguarding of residents from abuse. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Improvements to the environmental standards continue on an ongoing basis. The home provides a comfortable setting for the residents that is decorated to a good standard. EVIDENCE: There is an on-going programme of redecoration, this included some of the bedrooms that were not in use at the present time and included the purchase of new furniture for these rooms. Corridors were also being redecorated and a new central heating system and boiler were also being installed. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 20 The registered manager confirmed that an environmental health inspection had been undertaken the week previous to this inspection and stated that no matters had been outstanding following this inspection. The laundry and domestic services received positive feedback from the residents spoken with A brief tour of the laundry was undertaken and sufficient washers and driers were in place to meet the laundering requirements of the resident group. Laundry staff were employed to manage the laundering needs of the residents. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Adequate numbers of staff are available to meet resident’s needs. On-going staff training is promoted to ensure residents needs can be met, but the induction programme requires further development to ensure it complies with recognised training standards. EVIDENCE: Eight care staff have achieved a National Vocational Qualification (NVQ) in care at level 2, and two have achieved an NVQ in care at level 3.There is satisfactory progress with NVQ training, and at the time of this inspection five staff were undertaking NVQ 2, three staff were undertaking NVQ 3 and the registered manager and another senior member of staff were in the process of undertaking NVQ 4. . A sample of recruitment documentation was examined on three staff files. All of the required recruitment documentation and records were in place, which Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 22 demonstrates that the recruitment practices at Coxbench Hall are proficient in promoting residents safety. 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. The staff induction programme was examined and did not meet with Skills for Care criteria (recognised workforce training standards). The Inspector provided relevant information to the manager about Skills for Care induction standards Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 23 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 adequate This judgement has been made using available evidence including a visit to this service. The manager is accessible and responsive to the staff team and residents, this includes ensuring that the opinions of residents are sought and responded to. The safe working practices at Coxbench Hall are in general good and the welfare of residents and staff safety will be further evidenced once an outstanding requirement has been completed. EVIDENCE: Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 24 The manager now has registered status with the commission and has achieved the Registered Managers Award. She confirmed that she was due commence an NVQ at level 4 in care within the near future. Comments from the staff regarding the manager’s ability to run the home were very positive and included, “ she’s lovely, very supportive and caring with a big heart” and “ she treats everybody equally, she’s very fair” and “ she’s lovely, very approachable”. Residents spoken with also were very positive in their comments about the registered manager, and said, “ the manager is a lovely woman, nothing is too much trouble” and “ she’s very caring, lovely”. Surveys had been sent out to residents and relatives prior to Christmas, the registered manager stated that to date few had been returned. 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 felt that their opinions were listened to and acted upon. The minutes of the last two residents meetings were read and demonstrated that discussions took place between the residents and the manager, and clearly showed how any issues were to be resolved and who would be responsible for ensuring this was done. 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 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 hot water temperature checks, potable electrical appliance tests and lift and hoist service certificates. A new gas boiler had been installed at Coxbench Hall and plumbers were on site installing a new central heating system. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 25 An outstanding requirement from previous inspections related to obtaining a valid certificate for the electrical installation. On the day of this inspection it was stated that the work had commenced that day regarding this. The registered manager was therefore asked to provide the commission with a copy of the valid certificate once in place. This requirement will therefore remain in place until confirmation is obtained that this work has been completed, but CSCI will consider escalating the level of enforcement if a copy of the valid certificate is not received within the timescale specified. Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 26 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 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 27 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 OP38 Regulation 12 Requirement The registered person must ensure that there is an up to date electrical wiring certificate for Coxbench Hall. And a copy of this certificate must be sent to the Commission upon completion. (Outstanding from previous inspections – (timescale of 31/03/06 extended for work that has commenced to be completed) All identified areas of risk must have a risk assessment in place to instruct staff as to how the risk will be minimised and managed. Risk assessments must be dated to demonstrate their validity Residents who retain and selfadminister their medication must have a risk assessment in place to demonstrate their capacity to do so. All staff that come into contact with residents must undertake DS0000019968.V300757.R01.S.doc Timescale for action 31/03/07 2. OP7 14 (2) 31/05/07 3. 4. OP7 OP9 14 13 (2) (4,b) 31/05/07 01/04/07 5. OP18 13 (6) 31/08/07 Coxbench Hall Residential Home Version 5.2 Page 28 training in safeguarding adults. 6 OP30 18 The staff induction programme must meet recognised training criteria (Skills for Care). (Previous timescale of 31/05/06 extended) 01/04/07 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. 3. Refer to Standard OP7 OP7 OP7 Good Practice Recommendations Further detail should be included in care plans to assist staff in ensuring that resident’s needs are fully met. Care Plans should be reviewed monthly to ensure any changing needs can be identified and the appropriate action taken to ensure needs are met. 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 policy and procedure on abuse should be developed and should make specific reference to local authority adult protection procedures. 4. OP18 Coxbench Hall Residential Home DS0000019968.V300757.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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