Inspection on 08/10/04 for Coxhill Manor Nursing And Residential Home

Care Home For Older PeopleCoxhill Manor Nursing And Residential HomeStation Road Chobham Woking Surrey GU24 8AUUnannounced Inspection8th October 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 29/06/04 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 1 2 38th October 2004 12:15 pm Denise Debieux Mary WilliamsonID Code141099 032904Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionDr and Mrs Swift-Hook Sister LongCoxhill 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 second 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 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. This inspection concentrated on The Gables unit, which provides accommodation for up to nine persons with dementia and followed concerns raised with the CSCI, Eashing Office. Progress towards meeting the requirements and recommendations made at the previous inspection carried out on the 29th June 2004 was not evaluated at this inspection. For this reason the requirements and recommendations have been brought forward to this report. This does not indicate that they have not been met. 1. Choice of Home (Standards 1-6) The 1 standard assessed was not met From observations made at this inspection the staff on duty had the skills and experience to meet the needs of the service users accommodated on The Gables unit. See main body of this report for details of action required for this standard to be met. 2. Health and Personal Care (Standards 7-11) The 2 standards assessed were not met The care plans for all service users on The Gables unit were inspected. The care plans were seen to be based on assessments of needs and risk assessments. The care plans included individual plans for immediate health needs and problems. The inspector notes that there have been improvements made, following the last inspection, including plans for maintaining, managing and promoting all areas of health and personal care needs. See main body of this report for details of action required for these standards to be met. 3. Daily Life and Social Activities (Standards 12-15) These standards were not assessed at this inspection 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. 5. Environment (Standards 19-26) Both of the 2 standards assessed were met All rooms in The Gables unit were inspected and found to cater well for the service users accommodated. All rooms have alarm call facilities, which were all functional on the day of this inspection. On the day of inspection The Gables unit was found to be tidy, clean and free from offensive odours. Coxhill Manor Nursing And Residential Home Page 7 6. Staffing (Standards 27-30) 1 of the 2 standards assessed was met Interactions observed between the staff member and service users on The Gables unit on the day of this inspection were seen to be caring and respectful. The home must review staffing levels on The Gables unit to ensure that sufficient staff are provided at all times to fully meet the health, care and safety needs of all service users. 7. Management and Administration (Standards 31-38) The 1 standard assessed was met Security of the premises on The Gables unit was inspected. The fire doors require break glass action to be opened. The lift can only be operated with a key and the entrance to the stairs is secured with a magnetic catch that requires the operation of a switch to be opened. The Gables unit was found to be secure for service users with dementia needs.Coxhill Manor Nursing And Residential HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY 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 Requirements made at the previous inspection on 29th June 2004 were not checked at this inspection and will be evaluated at the next inspection. 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 Standard Recommendations made at the previous inspection on 29th June 2004 were not checked at this inspection and will be evaluated at the next inspection.CONDITIONS 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 REQUIREMENTS 1-8 HAVE ALL BEEN BROUGHT FORWARD FROM THE INSPECTION OF 29TH JUNE 2004 AS NOT CHECKED AT THIS INSPECTION. TIMESCALES FOR ACTION HAVE NOT BEEN EXTENDED. The statement of purpose must be reviewed to include all details required of Regulation 4 and Schedule 1 of The Care Homes Regulations 2001. (from inspection of 29/06/04) The service users guide must be reviewed to include all information set out in Regulation 5 of The Care Homes Regulations 2001 and standard 1.2 of the National Minimum Standards for Older People. (from inspection of 29/06/04) The home must review their contract/ statement of terms and conditions between the home and the service user to include all items required of standard 2 of the National Minimum Standards for Older People. (from inspection of 29/06/04)14 (1)(a-c) 6 (a)(b)1.129.09.0425 (1)(a-f)1.229.09.0435 (1) (b)(c)2.1 2.229.09.04Coxhill Manor Nursing And Residential HomePage 10 4.1 7.1 14(2)(a)(b) 4 15 (1) 15(2)(a-d) 7.2 7.3 7.4 8.1 8.3522(7)(b)16.4619 (1) (b) Sched 2 17 (2)(b) Sched 4(6) 17(3)(a)29.1 29.2 29.3 29.6 37.37813(4)(a)(c)38.3918(1)(a)27.1 27.3 27.4The home must ensure that the care plan and documentation system includes the following: · Individual risk assessments, to include prevention of falls and risk of pressure sore development · Details of individual needs identified, including health, personal and social care needs · Goal/objective for each need 29.09.04 · Actions to be taken to ensure the goals are met · Daily report writing to evidence that identified needs and goals are being met · Monthly reviews with newly identified needs or problems promptly added to the care plan (from inspection of 29/06/04) The complaints procedure must be amended to indicate that the CSCI can be contacted at any stage and reviewed to ensure contact 29.09.04 information is up to date. (from inspection of 29/06/04) The home must ensure that staff records contain all the required information as set out in Schedule 2 and Schedule 4(6) of the Care 29.09.04 Homes Regulations 2001. (from inspection of 29/06/04) Brought forward from inspection carried out on 12/02/04 29.09.04 Service users files must be maintained and completed consistently. The home must fit window restrictors to upper floor windows, in line with current legislation and Health and Safety Executive guidelines, or unless otherwise indicated and 29.08.04 documented by assessment of the vulnerability of and risk to individual service users. (from inspection of 29/06/04) The home must ensure that staffing levels are sufficient to meet the assessed needs of the service users accommodated on The Gables unit at any one time. The assessed needs indicated by the care plans of all service 08.10.04 users on the unit, should be used to calculate staffing levels for each shift and peak times (i.e. mealtimes, bedtime etc.) to ensure that service users health, care and safety needs are fully met.Coxhill Manor Nursing And Residential HomePage 11 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 * RECOMMENDATIONS 1-3 HAVE ALL BEEN BROUGHT FORWARD FROM THE INSPECTION OF 29TH JUNE 2004 AS NOT CHECKED AT THIS INSPECTION Brought forward from inspection carried out on 12/02/04 The Manager should also consider how to ensure that all staff 1 7 responsible for providing personal care to service users have an input into the development and implementation of these care plans. It is recommended that the home obtain a system for calculating staff numbers required, in accordance with guidance recommended by the 2 27.3 Department of Health. (from inspection of 29/06/04) It is recommended that the home expand their quality monitoring system 3 33.7 to include stakeholders in the community. (from inspection of 29/06/04) It is recommended that the home review how often nutritional status is 4 8.9 assessed for the service users in order that earlier interventions can be initiated. * 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 12 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 7 0 0 NO NO YES YES X X 08/10/04 1215 9Coxhill Manor Nursing And Residential HomePage 13 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 14 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 (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceNO Standard met? 0This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 15 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). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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. 2 Key findings/Evidence Standard met? Staff training records were inspected for the staff members who usually work on The Gables unit. These records provided evidence of all safe working practice training. The inspectors were advised that basic care of people with dementia is included in the homes induction training for all staff. The inspectors were advised that the training coordinator has ordered training books and a video for dementia training. Two staff members were due to attend a one-day training course on running activities for people with dementia. This course was cancelled by the course providers, the training coordinator is awaiting information regarding a new date for the course. From observations made at this inspection the staff on duty had the skills and experience to meet the needs of the service users accommodated on The Gables unit. However, staffing levels need to be reviewed in order to ensure that all service users needs are met. This is dealt with in more detail under standard number 27 of this report. (see Requirement Number 9)Coxhill Manor Nursing And Residential HomePage 16 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.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 17 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. 1 Key findings/Evidence Standard met?Coxhill Manor Nursing And Residential HomePage 18 The care plans for all service users on The Gables unit were inspected. The care plans were seen to be based on assessments of needs and risk assessments. The care plans included individual plans for immediate health needs and problems. The inspector notes that there have been improvements made, following the last inspection, in including plans for maintaining, managing and promoting all areas of health and personal care needs. The staff now take baseline recordings of weight and blood pressure readings on a service users admission to the unit, which were seen to be included in the care plans. The home uses pre-printed risk assessments for safe bathing and wheelchair use. However, not all of these pre-printed forms had been individualised for each service user and there was no evidence of them being reviewed on a monthly basis or when a service users condition changes. Also not all pages and assessments in the care plans inspected had been signed and dated. As stated above, the home has introduced improvements in their care planning documentation and is now providing support and training to the care workers, working towards their participation in documenting care given. Service user/representative signatures on some of the care plans evidenced service user and/or their representatives involvement in the planning of their care. However, the requirement made at the previous inspection has still not been fully met and must now be addressed as a priority. In order for this standard to be fully met the care plan and documentation system must include the following: · Individual risk assessments, to include prevention of falls and risk of pressure sore development · Details of individual needs identified, including health, personal and social care needs · Goal/objective for each need · Actions to be taken to ensure the goals are met · Daily report writing to evidence that identified needs and goals are being met · Monthly reviews with newly identified needs or problems promptly added to the care plan (see Requirement Number 4) The recommendation made at the inspection of 12/02/04, that all staff responsible for providing personal care to service users have an input into the development and implementation of these care plans, is brought forward to this report. (see Recommendation number 1)Coxhill Manor Nursing And Residential HomePage 19 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 X X Standard met? 2The care plans for all service users on The Gables unit were inspected with regard to health care needs of reducing the risk of falls, nutrition and oral hygiene. Falls risk assessments are included in the care plan system used, with appropriate actions to be taken to reduce the risk of falls being recorded in the care plan. However, in one file inspected there had been no review or amendment of the service users care plan despite a documented increase of falls. The staff take baseline recordings of weight on a service users admission to the unit, followed by monthly checks of a service users weight. Evidence was seen in one care plan inspected, that the care plans are reviewed and appropriate action taken when weight loss is noted, although there was no evidence that specialist nutritional advice had been sought. However, following a substantial weight loss noted in one file over a period of five weeks, it is recommended that the home review how often nutritional status is assessed for the service users in order that earlier interventions can be initiated. (see Recommendation number 4) Care plans were seen to detail oral hygiene under actions to be taken but there was no documentation to evidence that oral hygiene is being carried out. (see Requirement Number 4) The inspector noted in one care plan that, following the occurrence of a mouth ulcer, medication was prescribed by the GP but no additional oral hygiene care had been planned and the care plan did not reflect the change in oral status. (see Requirement Number 4)Coxhill Manor Nursing And Residential HomePage 20 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. 0 Key findings/Evidence Standard Met? This standard was not assessed at this inspection.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.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 21 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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.Coxhill Manor Nursing And Residential HomePage 22 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 23 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 X X X X X X X 3Standard met?This standard was not fully assessed at this inspection and will be covered in more detail at the next inspection. The file on a recent, ongoing complaint was inspected and the documentation and procedures were seen to meet the requirements of Regulation 22 of The Care Homes Regulations 2001 and this standard. 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 24 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 Standard met? YES 0 3All required policies are in place to ensure that service users are safeguarded from harm or abuse. The home has a copy of the Department of Health `No Secrets document and the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. The inspector was advised that the senior staff have attended training courses in the protection of vulnerable adults, with this training being cascaded down to care staff. Basic introduction to the protection of vulnerable adults is included in the homes induction training.Coxhill Manor Nursing And Residential HomePage 25 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 26 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. 3 Key findings/Evidence Standard met? All rooms in The Gables unit were inspected and found to cater well for the service users accommodated. All rooms have alarm call facilities, which were all functional on the day of this inspection.Coxhill Manor Nursing And Residential HomePage 27 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. YES NO NO X X X X Standard met? 0 X XX X X XCoxhill Manor Nursing And Residential HomePage 28 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. 3 Key findings/Evidence Standard met? On the day of inspection The Gables unit was found to be tidy, clean and free from offensive odours.Coxhill Manor Nursing And Residential HomePage 29 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 XX X X Standard met? 1Coxhill Manor Nursing And Residential HomePage 30 Interactions observed between the staff member and service users on The Gables unit on the day of this inspection were seen to be caring and respectful. The staff rota for The Gables unit for the month of September was inspected and showed one carer on duty in the unit with a second carer allocated for the hours 0800-1030. The inspectors were advised that the carer allocated to the unit is able to call for assistance when needed from staff on other units. However, staffing levels on the unit must be calculated and provided to the unit in sufficient numbers based on the assessed needs of the service users accommodated. During this inspection the lunchtime meal was in progress. There were seven service users having lunch. Three were sitting at the table and eating independently in the dining room. All expressed their satisfaction with the meal. Of the remaining service users two required feeding and one needed encouragement to eat. With only one carer allocated to the unit at this time there were insufficient staff to assist service users that needed feeding and to provide adequate supervision in the dining room. Staffing on The Gables unit was discussed with the provider. The home must ensure that staffing levels are sufficient to meet the assessed needs of the service users accommodated on the unit at any one time. The assessed needs indicated by the care plans of all service users on the unit, should be used to calculate staffing levels for each shift and peak times (i.e. mealtimes, bedtime etc.) to ensure that service users health, care and safety needs are fully met. (see Requirement Number 9) 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? 0Coxhill Manor Nursing And Residential HomePage 31 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The staff files for the three staff members who usually work on The Gables unit were inspected and found to contain all information required of Schedule 2 of The Care Homes Regulations 2001. 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 32 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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.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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Coxhill Manor Nursing And Residential HomePage 33 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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.Coxhill Manor Nursing And Residential HomePage 34 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. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.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? This standard was not fully assessed at this inspection and will be covered in detail at the next inspection. Security of the premises on The Gables unit was inspected. The fire doors require break glass action to be opened. The lift can only be operated with a key and the entrance to the stairs is secured with a magnetic catch that requires the operation of a switch to be opened. The Gables unit was found to be secure for service users with dementia needs.Coxhill Manor Nursing And Residential HomePage 35 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 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 Mary Williamson Raj Gokhool 9th October 2004Signature Signature SignatureCoxhill Manor Nursing And Residential HomePage 36 Public reports It should be noted that all CSCI inspection reports are public documents.Coxhill Manor Nursing And Residential HomePage 37 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 would welcome comments on the content of this report relating to the Inspection conducted on 8th October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCoxhill Manor Nursing And Residential HomePage 38 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments 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 accurateYESYESNote: 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. D.2 Please provide the Commission with a written Action Plan by , 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. 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 planNOOther: enter details here Coxhill Manor Nursing And Residential HomePage 39 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 40 Coxhill Manor Nursing And Residential Home / 8th October 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.V190565.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!