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Inspection on 15/09/05 for Coxhill Manor Nursing And Residential Home

Also see our care home review for Coxhill Manor Nursing And Residential Home for more information

This inspection was carried out on 15th September 2005.

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

The home has a positive attitude towards seeking the views of service users and looking for ways to further improve the care and services offered by the home. The staff work hard to ensure that service users` needs are appropriately assessed and that these needs are met, whilst encouraging and enabling service users to maintain their independence where possible. The home and gardens are well maintained and provide pleasant and homely surroundings in which to live. Meals are varied, well balanced and nicely presented, offering choice and variety.

What has improved since the last inspection?

The ongoing maintenance and redecoration of the home and gardens provide the service users with homely and comfortable surroundings in which to live.

What the care home could do better:

There were no requirements or recommendations for improvement made at this inspection.

CARE HOMES FOR OLDER PEOPLE Coxhill Manor Nursing and Residential Home Station Road Chobham Woking GU24 8AU Lead Inspector Denise Debieux Announced 15 September 2005 @ 10:00am th 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 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. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Coxhill Manor Nursing and Residential Home Address Station Road Chobham Woking Surrey GU24 8AU 01276 858926 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Coxhill Manor Limited Mrs Janet Susan Varndell CRH - Care Home 74 Category(ies) of DE(E) - Dementia over 65 (9) registration, with number OP - Old Age (74) of places PD(E) - Physical Disability over 65 (3) Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Up to 37 beds providing nursing care for older persons from the age of 60 years. 2 - Of the older people accommodated, up to 9 may be in the category DE(E) Dementia over 65. 3 - Of the older people accommodated, up to 3 may be in category PD(E) Physical Disability over 65. Date of last inspection 16th May 2005 Brief Description of the Service: Coxhill Manor Nursing and Residential Home is an extended Elizabethan Manor House, situated on the outskirts of Chobham. The service is privately owned by Coxhill Manor Limited and is run and operated by the Principals, Dr & Mrs Swift-Hook. Both Principals are closely involved with the day-to-day operation of the home. A Matron/Manager is employed to oversee the general running of the home. Care is offered for up to seventy-four older people in single and shared rooms, all with en suite facilities. There are extensive gardens and communal areas, all of which are actively used by the service users. Car parking is available to the front of the building. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4.75 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs J. Varndell, Registered Manager, was present as the representative for the establishment. A tour of the premises took place. Prior to the inspection, survey forms were sent to the home and distributed to service users, with fifteen being returned, to their relatives, with ten being returned and to health and social care professionals, with one being returned. The results of these surveys and comments made are used in this report, as are comments made by service users and their relatives to the inspector during this inspection. Four care plans were inspected in depth and menus, complaints log, accident log, fire log, staff rota, maintenance records, safety check records and policies and procedures were all sampled. Five of the service users were spoken to at length; with a further seven service users and nine on-duty staff being spoken with during the tour. The inspector would like to thank the service users, manager and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: The home has a positive attitude towards seeking the views of service users and looking for ways to further improve the care and services offered by the home. The staff work hard to ensure that service users’ needs are appropriately assessed and that these needs are met, whilst encouraging and enabling service users to maintain their independence where possible. The home and gardens are well maintained and provide pleasant and homely surroundings in which to live. Meals are varied, well balanced and nicely presented, offering choice and variety. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 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. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 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 standard(s) 3 Each service user is only admitted to the home following a needs assessment to ensure that the home can meet the service user’s identified needs. EVIDENCE: The four care plans sampled during this inspection were seen to be based on comprehensive assessments of needs and clearly set out staff actions required to be taken in order to meet those needs. All service users spoken with confirmed that their needs were being met. Fourteen of the service users surveyed answered that they felt well cared for and one answered ‘sometimes’. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, and 9 Personal and healthcare support and assistance was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: Service users spoken with were complimentary regarding the care they receive at the home. One service user commented that ‘the staff are friendly and caring.’ The home has now introduced their new care planning system on all units since the last inspection. The four care plans inspected were comprehensive and clearly set out actions which need to be taken by care staff to ensure that all aspects of the personal, health and social care needs of the service users are met. Daily staff recording showed that the required actions are being carried out and the care plans were seen to be regularly reviewed and promptly updated should any new problems be identified. The staff spoken with during this inspection were positive regarding the new system and stated that they felt it was much easier to have all the information in one place. Service users are all registered with a local GP and the services of other health care professionals are accessed via GP referral. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 10 Medication administration records (MAR) sheets, medication storage and the lunchtime medication round was observed during this inspection. The MAR sheets and controlled drug records were well maintained and the medication administration observed was in line with the home’s policies and procedures. All interactions observed between the staff and service users were seen to be caring and respectful. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 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 standard(s) 12,13 and 15 The activities provided by the home are varied, well planned, and include contact with the local community. Contacts with family and friends are encouraged. Meals are well-balanced and varied with special dietary needs, individual choices and preferences catered for. EVIDENCE: The care plans now include details of individual social care/activity needs. The new activities co-ordinator has met with each service user and established their present and previous interests and hobbies. With this information she is in the process of tailoring the activities offered at the home and has introduced some additional small group activities, e.g. a ‘sketching’ group. Some of the activities provided include quizzes, crosswords, board games, films, poetry and story reading, arts and crafts and discussion groups. There are also physiotherapy classes once a week and a local musician recently came to the home and gave a piano recital. Service users surveyed said that the home provided suitable activities with one service user commenting on how much he had enjoyed the piano recital. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 12 Sample menus were seen and the lunchtime meal was taking place during this inspection. Service users confirmed that they were enjoying their lunch and the atmosphere in the dining room was relaxed with ample staff available to provide assistance where required. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a simple, clear and accessible complaints procedure which includes timescales for the process. EVIDENCE: The home’s complaint log was inspected. From the documentation in the log it was seen that complaints are acknowledged and dealt with in line with the procedure. The actions taken to resolve the complaint and the outcomes are clearly recorded. All service users spoken with were aware of who to talk to if they had a complaint and all are given a copy of the complaints procedure, which is also available in the home’s service users’ guide. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained with a pleasant and homely atmosphere. EVIDENCE: During the tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and grounds. On the day of inspection the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. The gardens are extensive and well kept. One service user commented on how much she enjoyed her walks in the gardens when the weather is fine. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 The home has a comprehensive staff training programme which incorporates all areas needed to ensure, as far as reasonably possible, that service users are in safe hands at all times. EVIDENCE: The manager expressed a firm commitment and belief in National Vocational Qualification (NVQ) training and stated that she has seen clear benefits for the service users and staff alike. At present fourteen of the twenty-five care workers are qualified to NVQ level 2 in care, which exceeds the required minimum of 50 . All service users surveyed stated that the staff treat them well, with one adding ‘very well.’ Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 Service users’ financial interests are safeguarded by the policies and practices of the home. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The inspector was advised that the home do not handle the financial affairs on behalf of service users. All service users are provided with lockable storage in their rooms for their own personal use. During this inspection an environmental health officer’s health and safety visit report from June 05 was seen. The two requirements that had been made have been actioned by the home. A sample of environmental safety certificates were inspected and found to be in order and up to date, as were the accident book and the fire drill and fire equipment test records. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 17 Staff were observed to be following appropriate health and safety practices as they went about their work. All service users surveyed and spoken with said that they felt safe at the home. Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 3 x x 3 Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? N/A 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 Regulation Requirement NONE Timescale for action 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. Refer to Standard Good Practice Recommendations NONE Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Coxhill Manor Nursing and Residential Home H58 H09 S17601 Coxhill Manor V239656 150905 Stage 4.doc Version 1.40 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!