Inspection on 16/11/04 for Coxhill Manor Nursing And Residential Home

Care Home For Older PeopleCoxhill Manor Nursing And Residential HomeStation Road Chobham Woking Surrey GU24 8AUUnannounced Inspection16th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Coxhill Manor Nursing And Residential Home Address Station Road, Chobham, Woking, Surrey, GU24 8AU Email address Name of registered provider(s)/company (if applicable) Coxhill Manor Limited Name of registered manager (if applicable) Mrs Janet Susan Varndell Type of registration Care Home No. of places registered (if applicable) 74 Tel No: 01276 858926 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (9), Old age, not falling within any other category (74), Physical disability over 65 years of age (3) Registration number H090000142 Date first registered Date of latest registration certificate 24th April 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 6th August 2004 YES YES 08/10/04 If Yes refer to Part CCoxhill Manor Nursing And Residential HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector Name of inspector Name of specialist (e.g. Interpreter/Signer) (if applicable) 1 2 3 416th November 2004 09:45 am Denise DebieuxID Code141099Name of establishment representative at the time of inspectionMrs L.M. Swift-Hook (Responsible Individual) Mrs Janet Varndell (Registered Manager)Coxhill Manor Nursing And Residential HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementCoxhill Manor Nursing And Residential HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Coxhill Manor Nursing And Residential Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Coxhill Manor Nursing And Residential HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Coxhill Manor Nursing And Residential HomePage 6 This was the third inspection to be undertaken in the Commission for Social Care Inspection year April 2004 to March 2005. For details of how each standard was met please refer to the main body of the report. It will be necessary to review all three inspection reports for 2004-05 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Older People. The inspector would like to thank the manager, staff and service users for their time, assistance and hospitality during the inspection. 1. Choice of Home (Standards 1-6) All of the 3 standards assessed were met The home now has a comprehensive statement of purpose and service users guide. Together these documents provide the information required for prospective service users to make an informed choice about where to live. The revised terms and conditions document now meets the standard and the new method of documentation evidences that service users needs are being met. 2. Health and Personal Care (Standards 7-11) 2 of the 3 standards assessed was met Since the previous inspection the home have reviewed and revised their care planning and documentation system. The previous requirement regarding improving the care planning and documentation system has been met with the exception of including individual plans for each service users social care needs. This was discussed at this inspection and a new requirement made. Medication administration record (MAR) sheets, medication storage and controlled drug storage and records were checked at this inspection. These were found to be in keeping with the homes policies, procedures and current legislation. 3. Daily Life and Social Activities (Standards 12-15) Both of the 2 standards assessed were met The home employs one full time activities coordinator. Activities provided at the home are varied and include: daily crossword puzzles; gentle exercise sessions; art sessions; current affairs sessions; film shows; plus entertainment and involvement from local musical groups, clergy people and schools. There are also seasonal activities/entertainment provided at Christmas and a summer garden party. There are no restrictions to visiting times at the home. Service users are able to invite their friends and family for a meal if they wish to do so. 4. Complaints and Protection (Standards 16-18) Both of the 2 standards assessed were met All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. The home has a clearly set out complaints procedure that includes stages and timescales as required. Coxhill Manor Nursing And Residential Home Page 7 5. Environment (Standards 19-26) These standards were fully assessed at the inspection carried out in June of this year and not assessed at this inspection. 6. Staffing (Standards 27-30) 1 of the 2 standards assessed was met All interactions observed between the staff and service users were caring, respectful and inclusive. Since the previous inspection the home has reviewed their staffing levels on The Gables unit and increased the staffing to ensure that the health and safety needs of the service users on that unit can be met. The home operates a recruitment procedure that is based on equal opportunities and is designed to ensure the protection of service users. It has been recommended that the home review their recruitment procedures in line with the new Schedule 2 of The Care Homes Regulations 2001. 7. Management and Administration (Standards 31-38) 4 of the 5 standards assessed were met The registered manager at the home is a registered nurse with over twenty years experience. She is an NVQ assessor and has completed an English National Board certificated course on the Care of the Elderly. She has three years experience as a nursing homes manager and has been the manager at Coxhill Manor for the past sixteen months. She has completed her Registered Managers Award and is awaiting her final verification results. All interactions observed between the manager, staff and service users evidenced an open and positive atmosphere. All required policies, procedures and safety checks were seen to be in place in order to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff.Coxhill Manor Nursing And Residential HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Up to 37 beds providing nursing care for older persons from the age of 60 years Of the older people accommodated up to 9 may be in the category DE(E) ­ older people suffering from dementia Of the older people accommodated up to 3 may be in the category PD(E), older people with a physical disabilityMet (Yes / No) YES YES YESCoxhill Manor Nursing And Residential HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The home must consult service users about their social interests and about the 15(1) programme of activities arranged by the 1 16(2)(m) 7.2 home. Individual care plans to include details 16.02.05 16(2)(n) of social care needs and how these will be met. (1 element not met of requirement 4 from inspection of 29/6/04)RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 29.1-3 It is recommended that the home review their recruitment procedures in line with the new Schedule 2 of The Care Homes Regulations 2001.Coxhill Manor Nursing And Residential HomePage 10 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Coxhill Manor Nursing And Residential HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES YES NO YES YES YES YES YES YES NO NO NO YES NO YES 22 0 1 NO NO YES YES 38 10 16/11/04 0945 4Coxhill Manor Nursing And Residential HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Coxhill Manor Nursing And Residential HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 490 To (£) 1120Any charges for extras If yes, please state what the extras are: Key findings/EvidenceNO Standard met? 3The home now has a comprehensive statement of purpose and service users guide. Together these documents provide the information required of this standard, The Care Homes Regulations 2001 and for prospective service users to make an informed choice about where to live. The inspector was advised that copies of the latest CSCI inspection report and a summary of the most recent service user survey is to be included when providing these documents to prospective service users.Coxhill Manor Nursing And Residential HomePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The home has revised their terms and conditions/contracts, which now includes all items required of this standard.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Since the previous inspection in October the home have totally reviewed their system of care planning and documentation. (See standards 7 and 8 for further details). Twelve care plans were sampled at this inspection. The daily report writing and other newly introduced documentation evidences that the care plans are being followed and that the service users identified needs are being met. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not offer intermediate care.Coxhill Manor Nursing And Residential HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Since the previous inspection the home have reviewed and revised their care planning and documentation system. Twelve service user care plans were sampled at this inspection. These care plans were seen to include individual risk assessments, including prevention of falls and risk of pressure sore development. The needs and goals are clearly set out with actions required of staff to meet the goals. Daily report writing now relates more specifically to the staff actions taken to meet goals and there is evidence of monthly review of the care plans. In addition the home has introduced a personal care document that is kept in each service users room, where the staff carrying out the care document their actions on a daily basis. The inspector was advised that the new system is being monitored in this early stage of implementation with staff suggestions and ideas being sought for improvement. The previous requirement regarding improving the care planning and documentation system has been met with the exception of including individual plans for each service users social care needs. This was discussed at this inspection and a new requirement made. The home must consult service users about their social interests and about the programme of activities arranged by the home. Individual care plans to include details of social care needs and how these will be met. (see Requirement Number 1) The home is to be commended for their pro-active action in this area in the five weeks since the previous inspection.Coxhill Manor Nursing And Residential HomePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence 4 1 Standard met? 3The new documentation and care planning system at the home now includes close monitoring of the dietary intake of service users assessed as being at risk. Intake is recorded at each meal with supplements offered and recorded as appropriate. All service users are now weighed on admission and then weekly or monthly as indicated by the service users risk assessment. The inspector was advised that a GP referral is now made where any weight loss of concern is identified. Actions taken to meet service users oral hygiene needs are now recorded by the care workers on the service users personal care document. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Medication administration record (MAR) sheets, medication storage and controlled drug storage and records were checked at this inspection. These were found to be in keeping with the homes policies, procedures and current legislation.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 18 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The home employs one full time activities coordinator. Activities provided at the home are varied and include: daily crossword puzzles; gentle exercise sessions; art sessions; current affairs sessions; film shows; plus entertainment and involvement from local musical groups, clergy people and schools. There are also seasonal activities/entertainment provided at Christmas and a summer garden party. Information regarding activities is circulated to service users and posted on notice boards. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? There are no restrictions to visiting times at the home. Service users are able to invite their friends and family for a meal if they wish to do so. The home encourages links with the local community. These links include local churches, schools and entertainers. The village of Chobham is nearby and provides shops, restaurants and a pub, which the service users are able to visit with friends and family members. At present the home does not use volunteers.Coxhill Manor Nursing And Residential HomePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 5 3 1 0 1 1 100 3Standard met?The home have now amended their complaints procedure to indicate that the CSCI can be contacted at any stage of the process.Coxhill Manor Nursing And Residential HomePage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Policies and procedures are in place to protect the service users legal rights. All service users are registered to vote.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was not assessed at this inspection. Standard met? YES 0 0Coxhill Manor Nursing And Residential HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 24 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed at this inspection. NO YES NO 55 55 3 3 Standard met? 0 55 01 0 3 0Coxhill Manor Nursing And Residential HomePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X10 38 16 Standard met? 3Since the previous inspection the home has reviewed their staffing levels on The Gables unit and increased the staffing to ensure that the health and safety needs of the service users on that unit can be met.Coxhill Manor Nursing And Residential HomePage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed at this inspection. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The home operates a recruitment procedure that is based on equal opportunities and is designed to ensure the protection of service users. A selection of staff files was inspected. In line with the requirement made at the inspection carried out in June 04, the home has reviewed the staff files to ensure they contain the information required of Schedules 2 and 4 of The Care Homes Regulations 2001. However, since that inspection the regulations have been amended with a new replacement Schedule 2 coming into effect on 26th July 2004. Amongst other changes this schedule now requires a full employment history with a satisfactory written explanation of any gaps in employment, this information was not present in the file of the one staff member employed after 26th July. It was stated that this information will be obtained from the staff member. The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 was discussed with the manager. The inspector was advised that the home will review their application form and recruitment procedure in line with the new Schedule 2 requirements. It is recommended that the home review their recruitment procedures in line with the new Schedule 2 of The Care Homes Regulations 2001. (see Recommendation number 1)Coxhill Manor Nursing And Residential HomePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The registered manager at the home is a registered nurse with over twenty years experience. She is an NVQ assessor and has completed an English National Board certificated course on the Care of the Elderly. She has three years experience as a nursing homes manager and has been the manager at Coxhill Manor for the past sixteen months. She has completed her Registered Managers Award and is awaiting her final verification results. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home has a quality assurance and quality monitoring system, based on seeking the views of service users. This includes informal information gathering and formal surveys. There is a residents committee at the home that holds three monthly meetings which are chaired by members of the committee. The inspector was advised that the home is preparing to carry out a survey of visitors and stakeholders in the community. Visits in compliance with regulation 26 of The Care Homes Regulations 2001 are carried out by the Responsible Individual on a monthly basis with copies sent to the CSCI, Eashing Office. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The homes business and financial plan for the current year was available for inspection. Certificates verifying that all required insurance policies are in place were seen at this inspection.Coxhill Manor Nursing And Residential HomePage 32 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? This standard will be met once the requirement regarding care planning has been fully actioned, see also standard 7. (see Requirement Number 1)Coxhill Manor Nursing And Residential HomePage 33 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Since the inspection in June 2004 the home has now carried out and recorded risk assessments for service users in upper floor rooms with windows that do not have opening restrictors. These risk assessments were inspected and found to meet the requirements of this standard. All required policies, procedures and safety checks were seen to be in place in order to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff.Coxhill Manor Nursing And Residential HomePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSYES Condition Compliance Up to 37 beds providing nursing care for older persons from the age of 60 years CommentsYES Condition Compliance Of the older people accommodated up to 9 may be in the category DE(E) ­ older people suffering from dementia CommentsYES Condition Compliance Of the older people accommodated up to 3 may be in the category PD(E), older people with a physical disability CommentsCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateDenise Debieux Raj Gokhool 17th November 2004Signature Signature SignatureCoxhill Manor Nursing And Residential HomePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Coxhill Manor Nursing And Residential HomePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection. We are working on the best way to include Provider responses in the published report. In the meantime responses received are available on request. We would welcome comments on the content of this report relating to the Inspection conducted on 16th November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCoxhill Manor Nursing And Residential HomePage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 24th December 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Coxhill Manor Nursing And Residential HomePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Coxhill Manor Nursing And Residential HomePage 39 Coxhill Manor Nursing And Residential Home / 16th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000017601.V184085.R01© This report may only be used in its entirety. 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