Care Home: Coxhill Manor Nursing And Residential Home

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What the care home does well The home has a stable work force, which should benefit the service users. The Registered manager and staff continue to provide a good service to the residents living at the home. Contact with family and friends are encouraged and service users are able to entertain their visitors in the privacy of their bedroom if they so wish. The documentation of individual care plans is easy to read, gives the reader a full picture of the residents` likes and dislikes, communication needs and risk assessments and care needs. Observations of care staff interaction with service users indicated that service users are treated with dignity and respect. It was also observed that great care was taken in respect of the service users` personal belongings and standard of cleanliness in bedrooms ensured residents lived in a wellmaintained environment. The Registered manager has demonstrated her ability to cater for service users from ethnic minority and from different cultures by ensuring each member of staff gets the opportunity to attend the Equality and Diversity course, which is provided in-house. Currently, all carers undertaking National Vocational Qualification have Equality and Diversity as part of their course work. What has improved since the last inspection? The home is continuously working through their planned programme of refurbishment and improvements and this has resulted in a number of bedrooms, lounges, and day rooms being decorated and refurbished. What the care home could do better: Evidence gathered from the relatives` comments from the CSCI questionnaires indicated they would like the home to be more proactive in informing them of changes in their relatives` health. CARE HOMES FOR OLDER PEOPLE Coxhill Manor Nursing And Residential Home Station Road Chobham Woking Surrey GU24 8AU Lead Inspector Mavis Clahar Unannounced Inspection 30th November 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coxhill Manor Nursing And Residential Home Address Station Road Chobham Woking Surrey GU24 8AU 01276 858926 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Coxhill Manor Limited Mrs Janet Susan Varndell Care Home 74 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (74), of places Physical disability over 65 years of age (3) Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 disability. 14th September 2006 Date of last inspection Brief Description of the Service: Coxhill Manor Nursing and Residential Home is an extended Elizabethan Manor House, situated on the outskirts of Chobham. Caring Homes Ltd. purchased the home in November 2005. 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. The fee range for rooms is £750 to £1,165 per week and is inclusive of fortnightly hair dressing, twice weekly physiotherapy, chiropody service, daily paper and basic toiletries. All admissions are dependent on a satisfactory a pre-admission assessment. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the home’s key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was undertaken by Mrs Mavis Clahar on the 30th November 2007 and lasted for six hours and thirty minutes; commencing at 09:30 hours and concluding at 16:00. The first part of the visit was spent with the registered manager of the home, discussing and agreeing how the inspection process would be conducted. This was followed by discussion about the Annual Quality Assurance Assessment (AQAA) she submitted to CSCI, the training needs of the care workers and how these needs were being identified and met, and employment and induction of new care staff. A review of residents’ files and care workers records was undertaken and all found to be in good order. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with two visitors to the home, a number of service users, and are staff. Further information was gathered from records kept at the home and from relatives, service users, and professionals visiting the home. Also, from staff working at the home who all took the time to complete the pre inspection questionnaire sent out by CSCI. Information was also gathered from the Annual Quality Assurance Assessment (AQAA), which the registered manager for the home completed The second part of the inspection was spent visiting and discussing with service users and observing lunchtime activities. Service users were enthusiastic about their home and the service they receive. Service users spoken to said they enjoyed their lunch, which was prepared freshly in the home’s kitchen. We noted that service users were offered a choice of wine, sherry or fruit juice at lunchtime. Time was spent observing the presentation of the meal, care workers and residents’ interactions and to obtain feedback on the meal, its suitability, taste, texture and amount. The inspector observed that portions were varied to suit the appetite of the service user and that they all ate their meal in a very social gathering, all sitting at tables which were laid for four and six. A tour of the home was undertaken and it was observed that residents’ bedrooms were kept in very good condition, both decorative and clean and tidy. The bedrooms are attractively presented. Generally, the home presents as clean and tidy. No requirements were made on this visit. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 6 The inspector would like to thank all the residents and care staff who made the visit so productive and pleasant on the day. The final part of the visit was spent giving feedback to the manager about the findings of the visit. What the service does well: What has improved since the last inspection? What they could do better: Evidence gathered from the relatives’ comments from the CSCI questionnaires indicated they would like the home to be more proactive in informing them of changes in their relatives’ health. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. EVIDENCE: Review of service users documents, Annual Quality Assurance Assessment (AQAA) and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The manager who is trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out all pre admission assessments of service users prior to them being admitted into the home. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 10 Where the service user is assessed by social services a copy of the assessment and care plan is received into the home prior to them making a decision to admit the service user. Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out. This home does not provide intermediate care. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good and clear care plan in place for service users, which also includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that health and personal care needs were met. Care staff receives training to meet the assessed care needs of the service users ensuring that competent staff supports service users and their health and care needs are met. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 12 EVIDENCE: The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users and detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are fully met. The service user or relative and the Nurse in charge sign all care plans reviewed. Information contained in the care staff, relatives and service users response to CSCI pre inspection questionnaire supported this. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required. Service users are offered a monthly access to chiropody service, and twice weekly physiotherapy either in a small group or in a large group, and on a one to one basis. All new service users receive one to one physiotherapy, as a means of assessing their physio needs. It was noted that the home had a record of no pressure sores developing on service users in the home. In discussion with the registered nurse and care worker they were extremely proud of the high standard of care they provided to all service users in the home. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their medication record to reduce the risk of mistakes happening during medication administration. No service users were assessed as capable to self medicate. However, the Registered Nurse was able to discuss the management of this aspect of medication care, and this aspect of medication management was supported in discussion with the manager. Medication records were checked and found to be correct as documented on the Medication Administration Record (MAR) sheet and the Control drug Record. Eight relatives, six professionals, and sixteen care staff responded to the CSCI questionnaires and all stated they were happy with the care given to the service users. Relatives and professionals said the staff are always polite to them and they were free to visit any part of the home their relative/client was using. We observed that care workers did wear name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking with. We observed service users being treated in a friendly but respectful manner by care workers. It was noted that care workers communicated amongst themselves and with the manager and with the service users in English. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 13 In discussion with a number of service users we were told that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want. We have good staff here; they do not ill treat me. I choose my own clothing every day. Any issues I have I speak to the manager and it is sorted.” Another service user told us “ I can manage to do everything for myself. They are always asking if there is anything I want, but I can manage on my own.” Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. The home has sought the views of the service users and considered their varied interests when planning the routines of daily living and activities, which are service user, focused. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: The home employs one physiotherapist and one activity-co-ordinator who provides a range of activities based on the individual assessed and agreed needs of the service users. This activity can be one to one such as reading services, or in groups as observed on the day of the inspection. Activities includes reflection of the past, current affairs, painting/drawing, crosswords quizzes and trips to the garden centre and gentle stretching exercises. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 15 We were told the home has good contact with religious denominations and Holy Communion is provided for all service users who would like to participate. The home respects those service users who wish not to participate. The Church of England (C/E) Vicar visits every Thursday for individual chats, and twice monthly on a Sunday for church services. All other denominations visits on an as needed basis. Service users told us visiting is open, and that they can entertain their guests in their bedrooms in private or in the spacious communal areas of the home. The information contained in the AQAA and in the relatives response in the CSCI pre inspection questionnaires supported this statement Three of the service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather. We were told the Chef who has been at the home for a long time operates from a four-week menu and there is always a choice of three hot meals per day at mid-day, or salad at mid-day or the service user can choose their own food e.g. omelette etc. One service user told us “the Chef is very good and he comes around every day to make sure we are satisfied with our food. There is always a choice of two hot dishes for the evening meal, or we can choose to have sandwiches filled with our own choice”. There were ample amount of fresh fruit, available in the home The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. Sherry or wine or fruit juices were served with Lunch, which was served in the dinning room unless a service user requested to have their meals in their bedrooms. We observed care workers interacting in a friendly but dignified manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: CSCI received no complaints about the home. One substantiated complaint was logged at the home, and was dealt with satisfactorily according to the home’s records; and within the home’s time scale for dealing with complaints. The manager told us that she is in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users spoken to said they have no need to complain, as they are able to discuss everything with the manager. Two relatives said in their questionnaire that issues raised with the home are dealt with straight away, so that they do not have to make any complaints. It was observed that the home’s guest information pack situated in reception on the table below the notice board contained a complaints procedure and policy, whistle blowing policy, statement of purpose and a recent copy of the last CSCI inspection report for the benefit of all visitors to the home. It was noted that the home received a large number of compliments from relatives of Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 17 service users commending the staff on their kindness and understanding and for the high quality of work they perform. One relative commented, “The friendly atmosphere as one enters Coxhill is immediately apparent, makes residents feel valued, creates a very pleasant ambience”. In discussion with care workers, it was apparent they are aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they had a sound knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. We were shown documented proof that all members of staff are trained based on the Surrey multi-Agency course on Safeguarding Adults. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe, well- maintained and comfortable environment, which encourages independence, and protect their privacy and dignity. The home is pleasant and free from odours. EVIDENCE: The manager told us that the management and staff encourage service users to see the home as their own home. It presents as a comfortable, attractive home, which has all the specialist adaptations, needed to meet the service users needs were serviced and records kept verifying this. The home has attractive gardens, which is divided into a central courtyard garden and small areas of garden outside most patio doors and a larger garden. All the gardens are well maintained and there is good access to the gardens from various parts of the home. Some service users told the Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 19 inspectors that they try to go out daily weather permitting to enjoy the gardens. The home employs a gardener to maintain the grounds and garden in perfect condition for the use of the service users. We noted that adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs; specially the courtyard style garden and the personal garden by the patio doors of service users bedrooms. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. The home has a programme of planned training in place and we were told all members of staff have an individual training record this was verified by the randomly reviewed staff folder audited. Over 52 of care workers have obtained the National Vocation Qualification at Level 2 (NVQ L2). The manager is in position of the Registered Managers Award. Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training. . All newly appointed staff undertakes an induction programme as recorded and documented in their personal files. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records. The home has employed a training co-ordinator, who is based at the home. The co-ordinator’s role is to discuss training and developmental needs with individual care workers, and to provide the Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 21 necessary training to enable care workers to fulfil their roles and that of the home in providing a high quality of care for the service users. It was noted that staff turnover at the home is relatively low and service users relatives in the response to CSCI questionnaire supported this. All care workers are Criminal Records Bureau, (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and two written satisfactory references are obtained. Staff files sampled contained the required work history. Care workers are in receipt of terms and conditions of employment as evidenced in their randomly selected files. We were told that supervision records were up to date and this was verified during random sampling of care workers files. In discussion with care workers they were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. Staff files contained their up to date training records. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. The views of service users and their relatives are actively sought in the running of the home Service users financial interests are safeguarded. The service provides training on health and safety issues for all staff and service users are involved in the running of the home. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. In discussion with the manager, it was evident she was knowledgeable about the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. Regular residents meetings are arranged and minutes of the meetings are passed to the owners who will action requests as soon as possible. The home does not become involved in service users finance except for service users spending money, which the home oversees. Receipts are kept and logged for all transaction carried out on behalf of service users. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Further more they spoke about their understanding of promoting safe working practices based on their health and safety training. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practice with the service users, as the current service users are all Caucasians. Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coxhill Manor Nursing And Residential Home DS0000017601.V349662.R01.S.doc Version 5.2 Page 27 - 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. 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