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Inspection on 01/06/05 for Codnor Park Residential Home

Also see our care home review for Codnor Park Residential Home for more information

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides excellent social activities for residents that wish to be active or enjoy group activities. Quizzes, bingo, sing songs and regular evening entertainment were available. However several residents spoken to would prefer one to one chats rather than planned activities. Staff spoken to were very cheerful and positive about the work that they do. Residents praised the staff and said that they were hard-working, kind and regularly cheered them up. There was a strong supportive staff team that worked well together. One resident said that " staff are excellent, they always try to oblige". One resident said that they had spoken with the owners and they, "seemed to be very decent people". The environment was of a high standard with good quality fixtures and fittings. The home was clean and hygienic. Residents spoken to were happy with the standard of cleanliness. There is an excellent quality assurance system which included a monthly quality auditing system undertaken by the Care Home Groups quality assurance administrator. Any service users or visitors that make suggestions concerning improvements to the service are taken seriously and suggestions are taken up where possible.

What has improved since the last inspection?

At the last inspection there were several requirements concerning administration and recording of medication. There had been significant improvements in this area and medication was now administered and recorded to a high standard.

What the care home could do better:

Several residents` files were checked and it was found that there was not always a full written assessment undertaken where a resident was selffunding. Although care plans were in place for most residents they were not being completed when a new resident was admitted. Some but not all care plans were being reviewed and information in care plans were not always accurate, or being followed fully by staff. At the previous inspection it had been highlighted that staff were not adequately monitoring the oral health of all residents. This was still the case as one resident required dental attention that had not been noticed.

CARE HOMES FOR OLDER PEOPLE Codnor Park 88 Glasshouse Hill Codnor, Ripley Derbyshire DE5 9QT Lead Inspector Jill Wells Unannounced The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Codnor Park Address 80 Glasshouse Hill, Codnor, Ripley, Derbyshire DE5 9QT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01773 741111 Ashmere Care Group Ms Jane Phillis CRH 40 Category(ies) of OP registration, with number of places Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2004 Brief Description of the Service: Codnor Park is a purpose built care home. It is registered for up to 40 people. 5 of those places can be for people with physical disabilities age from 55 . On transfer from Local Authority registration to National Care Standards Commission/Commission For Social Care Inspection, the home was registered for 4 day care places. CSCI does not regulate day services. There are 36 single bedrooms and 2 double rooms. All but 2 bedrooms have en-suite facilities.The home is on two floors, and there is a passenger lift for access to the 1st floor. The home is close to the centre of Codnor.There is a variety of aids and adaptations around the building to allow residents to move about more independently. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 4.5 hours. Four residents were spoken to in private as well as other residents spoken to throughout the day. Five visitors were spoken to, including a care manager from Social Services. Staff were also spoken to and an observation was made of staff handover. The quality assurance administrator for the Care Home group was present during the inspection. What the service does well: What has improved since the last inspection? At the last inspection there were several requirements concerning administration and recording of medication. There had been significant improvements in this area and medication was now administered and recorded to a high standard. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 3 Potential residents were provided with adequate information in order to make an informed choice and know that the home will meet their needs, however thorough assessments were not undertaken for all service users. EVIDENCE: The entrance hall had a great deal of information on notice boards about the home. There was a brochure available, and up to date newsletter, as well as the homes annual development plan. New residents that were spoken to said that they had received a service user guide informing them about the home. Copies of contracts were seen in residents’ individual files, and one resident that was self-funding confirmed that they had received a copy of a contract/statement of terms and conditions. Several files that were seen had thorough written assessments undertaken by care managers from Social Services in place. Two files that were seen, where Social Services were not involved, did not have an assessment in place. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 Individual plans of care were not satisfactory, as they were not in place for all service users, were not always reviewed monthly, and did not always reflect up-to-date information. The service was generally meeting service users health care needs, and there were safe systems for administering medication. EVIDENCE: Although in most files that were seen there was an individual plan of care, one resident who had been at the home for six days did not have a written plan in place. This was highlighted at the previous inspection. Some but not all care plans had been reviewed monthly. One plan had not been reviewed since December 2004. It was of concern that on discussion with service users, changes had been made, but not reflected in care plans and reviews had stated no change. There was evidence that care plans were not being reviewed with residents. An example was one resident that said during the inspection that she did not wish staff to enter her room when she had left the room and had locked the door. The care plan stated that a year ago this resident had agreed to staff unlocking the door when she was not in the room. Reviews of this plan stated ‘no change’. Another example was an individual’s Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 10 care plan stated that they enjoy cornflakes/toast for breakfast. The resident said that they no longer ate breakfast. There was also evidence that staff were not always following the care plans. One example was a care plan stating how a resident liked to take their tea, and staff were not following this. One resident had a broken denture. None of the staff on duty were aware of this, and it was not recorded within records that any action had been taken. Two care plans that were seen did not have information concerning individuals mental state and cognition. One of these residents had significant memory loss, but there was no information concerning this in the plan. Generally residents’ records showed that GPs and other health professionals were contacted when required. Residents spoken to confirmed that staff were quick to call a GP if any resident was not well. Several records in the daily progress sheet stated that individuals had a particular health issue and staff had written please observe. However there was no record that staff had monitored the situation and whether there had been any improvement or further cause for concern. The medication systems and procedures were checked and found to be in good order. Requirements made at the previous inspection concerning improvements to the recording of medication had been met. There was a controlled drugs cabinet and register, which was used following good practice guidelines. There was a lockable fridge and appropriate medication was stored within the fridge. Medication administration records were in good order. There was a safe system for returning medication to the pharmacist. The medication room met the requirements and good practice guidelines. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 14 Residents have the opportunity to take part in social activities arranged by the home, maintain contact with whom they wish, and exercise choice and control over their lives. However some service users that do not wish to take part in social activities may not be receiving adequate stimulation. EVIDENCE: There was excellent provision of social activities. Bingo was taking place during the morning of the inspection and several residents went on a boat trip in the afternoon. Information displayed on notice boards showed that there were many other activities arranged including regular entertainers, themed evening, a ‘Cockney night’ in June, and a Summer fayre in August. Staff recorded any activities that individual residents were involved with, and these records showed that residents were offered regular manicures, walks around the ground, quizzes and sing songs. However activities records checked of the residents spoken to showed that several residents did not have an entry in this record since February 05. Several residents spoken to did not wish to take part in social activities but very much enjoyed one-to-one discussion with staff that did not seem too busy to do so. There were several residents that spend a great deal of time in their bedroom, and one resident said that they “only saw staff when it was time for a drink or meal times, no-one comes to chat”. They accepted that staff were “very busy”. Some staff did not seem aware that social needs did not necessarily mean taking part in activities. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 12 There were several visitors coming in and out of the home during the inspection and visitors spoken to felt welcomed. Several residents spoke of visiting their families, as well as family outings. There was a regular communion at the home which was very much appreciated by some residents. Several residents gave examples of how they were encouraged to have control over their lives. This included one resident that preferred their lunch at 1 p.m. rather than 12 noon, and this was accommodated. Several service users spoke of enjoying staying in bed until later in the morning. The minutes of residents meetings evidenced that the manager was encouraging residents to suggest ideas to improve the service generally as well as their independence and choices. An example was residents asking for new cutlery and lighter teapots to make using them easier. These had been purchased. Staff however need to ensure that they do not override a residents choice by agreeing to family members wishes. An example was a resident that had started to go into the dining room for meals at the insistence of their family. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 There was an effective complaints procedure in place EVIDENCE: The complaints procedure was displayed in the entrance hall. This procedure stated that the name address and telephone number of CSCI. Residents and families spoken to were confident that any complaints would be listened to and taken seriously. One resident spoke of talking to the manager about an issue that they were not happy with. This matter was dealt with effectively and resolved. This informal complaint however was not recorded in the complaint records. The records show that there had been no complaints since the last inspection. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The environment was clean and had good systems in place to ensure high standards of hygiene. EVIDENCE: The premises were clean, hygienic and free from offensive odours. Residents spoken to said that their rooms were regularly cleaned and they were pleased with the standard of kindliness. Laundry facilities were sited away from food and did not intrude on service users. The laundry floor was in permeable and the wall finishes were readily cleanable. There was control of substances hazardous to health (C.O.S.H.H.) information available in the laundry area. There were protective aprons and gloves available for staff use. Staff spoken to were aware of when to use these items. There was an industrial washing machine with a sluicing programme. Generally residents were very satisfied with the laundry service, although one resident was not happy with a badly ironed item of clothing. This resident felt able to return the item to be re ironed and was confident that this would be done. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 15 Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 There were sufficient staff working at the home in order to meet the needs of residents. EVIDENCE: Staff rotas were checked. There was a general pattern of one senior carer and three care staff working in the morning, and one senior carer with two care staff working in the afternoon, with an additional carer working 4 p.m. -- 9 p.m. Rotas showed two staff working overnight. Senior staff would take responsibility for the shift and undertake most of the written recording. Rotas showed that the registered manager would work some care shifts. This was usually to cover sickness or holiday, but also allowed the manager to observe practices. A staff handover was observed. This was a 15 minute unpaid hand over. Staff spoken to said that they did not mind coming in 15 minutes earlier unpaid in order to receive an update concerning residents. Residents spoken to said that staff responded quickly when they called for attention. It was evident from observations and discussions that staff worked very well as a team and individuals enjoyed their job. One member of staff said that they, would not swap my job for the world and it is good to go home and know that you have helped people Residents spoke highly of staff working at the home. Residents described staff as very kind. Residents said that staff are excellent and I do not know what I would do without them, they cheer me up every day. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 17 Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Service users financial interests are safeguarded by the homes procedures and practices. EVIDENCE: Where possible families were encouraged to support residents with their finances if required, although several residents managed their own money. The service held money for 8 residents. This was an amount generally no higher than £50. This money was securely stored with clear written records including double signatures and audits undertaken. However the care group policy is that this system is audited on a monthly basis, however the manager last audited the records in January 05. One balance was checked and found to be correct. At the time of the inspection the service was not holding valuables for safekeeping on behalf of any residents, however there was a system to do this if required. Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 19 Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x 3 x x x Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 21 yes 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. 1. Standard 7 Regulation 15(1) Requirement Each service user must have a service user plan in place (informed at the time of the inspection. This was a previous requirement The registered manager must ensure that staff follow all aspects of individual service user plans. (Informed at the time of the inspection) this was a previous requirement. The registered manager must ensure that all service users receive regular attention to promote oral health. (Informed that the time of the inspection) this was a previous requirement) All care plans must be reviewed on a monthly basis. This should be undertaken with the involvement of the resident where appropriate. The accuracy of the care plan should be checked during the review. Care plans must include information concerning an individuals mental state and cognition Registered manager must ensure that residents that do not wish to take part in planned activities Timescale for action Immediate 2. 7 15(1) Immediate 3. 8 13(1) (b) Immediate 4. 7 15(2) 30th June 2005 5. 7 15(1) 30 July 2005 30 July 2005 Page 22 6. 12 16(2)(m) (n) Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 7. 16 22 are offered other stimulation, and this is recorded. Informal as well as formal complaints must be recorded 30 June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 27 Good Practice Recommendations All rotas should have information concerning times of shifts. (This was a previous recommendation) Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Codnor Park C52 C02 S19962 CodnorPark V228594 010605 Stage 4.doc Version 1.30 Page 24 - 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. 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