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Inspection on 21/06/06 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 21st June 2006.

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

The inspector 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

All service users spoke positively of their experience at the home and of the staff group. Some service users said that occasionally they had to wait a little while for help if staff were busy but generally staff were available. The environment appeared to be well cared for and service users appeared to have their own established areas that they chose to use. The recording of complaints and minor concerns was being robustly implemented.

What has improved since the last inspection?

There is an ongoing redecoration programme and corridors and some bedrooms have been redecorated.

What the care home could do better:

Care plans were found to be incomplete, poorly documented with regards to them describing individualised needs and not always reviewed. There was insufficient information available in the sample of care plans examined to ensure that staff were aware of all service users assessed needs and that staff had information available to enable them to deliver care safely. Staff training records were being poorly completed with no training at all recorded for some long serving staff. The Acting Manager said some training had been completed but there was not evidence of this documented.

CARE HOMES FOR OLDER PEOPLE Codnor Park Residential Home 88 Glasshouse Hill Codnor Ripley Derbyshire DE5 9QT Lead Inspector Bridgette Hill Unannounced Inspection 21st June 2006 09:00 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 Codnor Park Residential Home DS0000019962.V299731.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. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Codnor Park Residential Home Address 88 Glasshouse Hill Codnor Ripley Derbyshire DE5 9QT (01773) 741111 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) Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (5) of places Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Forty as the number of residential places in the category Elderly Persons to include Five People with Physical Disabilities over the age of 55. Plus Four (4) Day Care Places Date of last inspection 5th December 2005 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 38 single bedrooms and 1 double room. All but 2 bedrooms have ensuite 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. The range of fees charged at the home are £338.50 - £770.00, this includes a top up fee of £30.00 which includes hairdressing, chiropody and physiotherapy services. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 7 1/2 hours. The focus of this inspection was to assess all key standards. At this visit service users were spoken to as a small group and on an individual basis. One visitor was spoken with A range of records were examined including a sample of service users care plans. The Acting Manager Jane Nyari and Area Manager Jane Phyliss were present throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 6 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 Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 7 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 the following standard(s): 2,3, Standard does not apply in this home Service users needs were assessed prior to admission to ensure that their needs would be met at the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The process of offering admission to service users was discussed and records examined. For all service users records examined there was evidence of a pre admission assessment being completed by staff from the home prior to admission being agreed. There were copies of other assessments in files relating to service users needs drawn up usually by Care Managers. Service users spoken to mostly said they chose the home due to its location as it was near to the area where they had previously lived. All service users said there choice had been a positive one. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 8 Terms and conditions of residency contracts were found to be in place for the service users whose care was assessed. These included notice periods and a list of services included. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10,11 There were not sufficient care plans in place to provide staff with information on how to deliver care, this had the potential for service users and on occasions staff to be placed at risk. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service EVIDENCE: A sample of three service user files were examined to assess how standards were being met. A lengthy and repetitive format was in place for recording the plan of care. The headings of this were however not always based on recording assessed needs. The headings did not encourage staff to consider service users assessed needs as some were based on actions to be taken for example ‘specialist equipment’ rather than considering the needs of the service user and why equipment was necessary. Care plans were found to be incomplete for one service user with nothing recorded for continence, mental state, or falls when there were identified needs for this service user. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 10 Not all care plans viewed had been reviewed monthly as was required by the documentation in place. For one service user there was not a skin integrity risk assessment tool in place or care plan despite this being a significant area of need requiring input from the District Nurse. In one file there was a tissue viability tool where the scoring of it described that monthly review was required. This had not been reviewed for 4 months. In one care plan there was key information that staff would require to enable them to safely undertake care of a service user. This was not documented in a plan of care and had the potential to place staff at risk. Care plans were seen with a number of assessed needs recorded as one plan however the action to be taken section concentrated on only one area in giving staff the instructions on how to deliver care. Some risk assessment tools were available for staff to use. This included moving and handling, tissue viability and a new nutritional assessment was being introduced. Correction fluid was found to be used in one file obliterating the written entry beneath it. In general care plans were found to be poor, incomplete, areas of risk to staff were poorly documented and therefore not communicated to staff and risks to service users were evident where there was poor monitoring through risk assessment tools and a lack of care delivery plans in place. For each shift worked by staff an entry was made into the log notes to record how service users had been. It was from these notes that a number of identified needs were found for which no care plan was in place. This lack of care delivery planning had the potential for needs to remain unmet or inconsistent or inappropriate approaches to be used by staff. The care files had a dedicated section to recording any visits from healthcare professionals such as GP’s. There was input from District Nurses where this was required and the notes made by the District Nurse were held in the home. One deficit identified was where medications were administered by District Nurses such as injections a full record of the treatment was not entered onto the medication administration record. The medication administration records should be a complete record of medications given as staff may need to know this to pass on to doctors should the service user become ill. The storage and administration of medicines was examined at this visit. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 11 All medication administration records had a photo of service users on them for identification purposes. A monitored dosage system was in use and all senior staff who had responsibility for administering medications had received training. The drug reference book in the home was dated 1999 one was borrowed from the sister home to refer to during the inspection. It is recommended that a book not dated more than one year old is obtained. There was some inconsistencies found in the administration of drugs. Some but not all handwritten entries had been doubly checked and verified by staff by signing. One entry which was doubly signed also had a spelling error in the name of the drug. Where variable dosages were prescribed there were again inconsistencies with the actual dosage being given not always being recorded. The drug fridge was found to be reading a higher than acceptable temperature on a regular basis. The setting should be raised and closer monitoring instigated to ensure appropriate storage of refrigerated items. Eye drops and topical preparations were dated when opened and all in date. Records of the disposal of drugs were retained. A list of staff specimen signatures was available. In the service users files viewed there were records of service users post death wishes. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12,13,14,15 Service users are routinely offered choices in their everyday lives and a choice of regular activities. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: A general structure for activities was in place although it was said by the Acting Manager that this was not always strictly adhered to. All care staff in the home had a responsibility for doing activities. Bingo was held on the morning of the visit. A record of what activities were offered was recorded. Some service users preferred there own company and spent time in their rooms. Discussions were held on what leisure and social stimulation was offered to these service users. The Acting Manager said that staff would go and spend time chatting, doing nails or reading the newspapers with these service users. The Acting Manger acknowledged that recording of this was not always completed; it is listed as a recommendation that this improved. Whilst care plans were in place for social needs there was scope to improve the preferences and previous interests that service users had in order that these Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 13 could be considered when planning activities. Minutes of service users meetings confirmed that social activities were discussed. Typical activities offered are external entertainers visit monthly, movement to music each Thursday, an organist visits fortnightly, themed nights re held ( a cowboys and Indians one was recently held), nails and manicures are offered on occasions. A trip out on a boat is being planned as is a Summer fayre. A library was located on the first floor and was well stocked with books including some in large print. Two service users had books at the side of them in the lounge area and said they used the library. The Acting Manager said there was also a range of talking books available. Service users spoken to said that staff organised bingo and board games. A church service was held in the home on a fortnightly basis and this was said by staff to be popular with the service users. Some service users went of the home regularly with friends or family. Some service users had high degree of independence and went out to local shops, libraries, churches, and pubs Service users spoken with said staff were ‘kindly’ and one said they liked to enjoy a joke with staff. Service users said that staff knocked before entering their bedrooms. Whilst the food at the home was not observed discussions with the cook confirmed that there was a choice of meal routinely offered to service users. All service users spoken to said that the food offered was good. Cooked breakfasts were routinely offered. The dining room was spacious with adequate seating for all and dining tables were attractively presented. Discussions with service users on daily routines confirmed that service users were given a choice of time to get up and going to bed. One service user requiring help to move by hoist said they felt safe when being helped by staff. There were a number of pets at the home including a cat, an aquarium of fish and a bird. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16,18 There was good recording of concerns and complaints being implemented. There is the potential for any allegations of abuse to be mishandled due to the lack of appropriate procedures being available to staff. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: The complaints procedure was displayed in the entrance of the home and included timescales for the resolution of complaints and the address of the Commission for Social Care Inspection. Complaints were being robustly recorded and this was reflected in the number of complaints held on file. Complaints recorded included many easily resolvable matters such as service users complaining they were not offered a biscuit with their coffee. Where complaints required more investigation written responses were given to complainants. The form used to record complaints had a section for closing the complaints including whether the complaint was upheld many of these were found to be incomplete. The Protection of vulnerable adults procedure advocated internal investigation of complaints. There was no reference made to locally agreed statutory procedures as must be accepted by the Provider when accepting service users funded by Local Authorities. It is also a statutory right of service users living Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 15 within Derbyshire to have access to Social Services Protection of vulnerable adults procedures as implemented in response the Department of Health ‘No Secrets’ document. Whilst some staff had certificates on file to record that they had received in house Protection of vulnerable adults training staff on duty were unable to tell the Inspector about the procedure in place at the home. Positively they were aware of the principles of the whistle blowing policy even though they were vague about the policy in the home. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 19,26 The communal areas offered a range of comfortable well maintained areas for service users to use. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: At this inspection only the key standards were assessed. A large dining room was available with well presented tables covered with cloths had cruets placed on them. Three lounge areas were available two on the ground floor which appeared to be well used and one on the first floor which was said to be rarely used. The communal areas of the home appeared to be homely and service users were observed to have particularly areas where they sat and had their own personal belongings around them. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 17 Since the last inspection the redecoration programme had been ongoing with corridors being redecorated and some bedrooms. Service users spoken with said they liked the home and their bedrooms. One service user offered to show the Inspector their bedroom. This was well personalised with photographs and ornaments. Some service users were especially positive about the setting of the home with its open well-tended grounds and mature trees. Service users said that in good weather tea was served outside under gazebo’s. All parts of the home seen at this visit appeared to be clean. The laundry was not viewed on this occasion. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staff were regarded positively by service users spoken to although staff training records were poorly maintained and there was insufficient evidence to confirm that staff were receiving adequate training in order to meet service users needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The staffing rota’s indicated typical staffing levels as follows for the current occupancy level of 32 service users: 4 care staff between 7.00am – 2.30pm. 3 care staff between 2.30pm and 10.00pm with an additional staff member working a 4.00pm – 9.00pm shift. On night duty there was 2 care staff. On all shifts one of the staff on duty was a Senior Carer. The Acting Manager of the home worked two shifts per week above these levels in order to undertake their managerial role. In addition to the care staff employed there were domestic staff, kitchen staff, a handyman and a gardener. Some administrative support was also available from staff at adjacent home owned by the same Provider. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 19 There were 21 care staff employed at the home this included some bank staff who worked typically worked a few shifts each week. Of these staff 11 held at least NVQ (National Vocational Qualification) level 2 qualifications in care. Staff spoken appeared to have good knowledge of service users needs even when it was found that care plans were insufficiently detailed. A sample of two staff personnel files were examined. These confirmed that all pre recruitment checks had been completed prior to staff commencing in post. Staff training records were checked. These indicated that various staff had completed a range of training which included moving and handling, health and safety, first aid, dementia, nutrition, control of substances hazardous to health, infection control, and death and bereavement. Records however were being poorly maintained with some staff who have worked in the home for many years having no recorded training or certificates available to indicate any training had been completed. It could therefore not be established from the evidence available that all staff were receiving sufficient training for them to undertake the role for which they were employed. There was also no overview available of staff training to allow the Acting Manager to establish when training updates were due. Staff spoken said they were given opportunities to participate in training. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality assurance processes implemented were found to be responsive to the findings of the quality audit and suggestions of service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: An Acting Manager is in day-to-day charge at the home having taken up post at the end of March 2006. An application has yet to be submitted to the Commission for Social Care Inspection to formally register the Manager. The Acting Manager has achieved a NVQ (National Vocational Qualification) level 3 in care and is approximately a quarter of the way through a NVQ (National Vocational Qualification) level 4 in Management. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 21 A monthly quality control audit is completed by the Providers Area Manager. This covered a wide range of aspects. Visits on a monthly basis were conducted by/on behalf of the Provider and documented. There were clear examples of action being taken in response to the findings in these reports for example corridors had been decorated. Some questionnaires had been given out to staff, service users and relatives during the monthly audit completed in April 2006. Six forms, two each from staff, service users and relatives had been returned. The feedback given in all of those returned was positive. No feedback had been sought from visiting professionals. An analysis of falls was completed on a monthly basis. A significant rise in the number of falls/accidents was evident in May 2006 but this was partly attributed to improved recording. Minutes of staff and service user meetings were available. On checking if action had been taken to suggestions recorded at these it was established that there had been a generally positive response examples of these are outdoor furniture was purchased and a tea held to celebrate the Queens 80th Birthday. Some monies are stored safely on service users behalf. A sample of these records was examined. Receipts for purchases made were retained and records of transactions made were signed and verified by a second person which was sometimes the service user. Monies were stored separately for each service user and balances checked correlated with the available records. The provider does not act as appointee for any service users. In response to a previous requirement individual risk assessments of bedrooms had been completed. The records relating to the servicing of systems and appliances in the home were checked. These were all in order with systems in place for the handyman to complete ongoing checks on the water temperatures and fire system. Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 22 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 2 Standard OP7 OP7 Regulation 15 15(2) Requirement Care plans must be in place for al assessed needs The reviews of care plans must be undertaken with the involvement of the resident where appropriate. The accuracy of the care plan should be checked during the review. Previous timescale 30/01/06 Care plans must include information concerning an individuals mental state and cognition Previous timescale 30/01/06 4 OP9 13 Medication administration records for each service user must record all medications administered and who administered them to provide a complete record of treatment received by the service user Where medication administration records are hand written these must be signed, checked and counter signed by a second staff member DS0000019962.V299731.R01.S.doc Timescale for action 31/07/06 31/07/06 3 OP7 15(1) 31/07/06 31/07/06 5 OP9 13 31/07/06 Codnor Park Residential Home Version 5.2 Page 24 6 OP9 13 7 OP18 13 8 OP18 13 9 OP30 18 10 OP31 8 Where a variable dosage of a medication is prescribed the actual dosage administered to the service user must be recorded All staff must receive training on the multi agency protection of vulnerable adults procedures form Derbyshire County Council The home must have a procedure for the handling of allegations of abuse that respects service users statutory rights. This should refer to the Derbyshire Protection of Vulnerable Adults procedures which are there to protect the service users residing in Derbyshire Training must be provided to staff and sufficient records held to demonstrate that staff are sufficiently trained in order to meet service users needs A manager must be appointed and an application made to formally register the manager with the commission for Social care Inspection 31/07/06 30/09/06 31/07/06 30/08/06 30/08/06 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 2 3 Refer to Standard OP15 OP9 OP9 Good Practice Recommendations Correction fluid should not be used within care planning or other documents A drug reference book not dated more than one year old should be obtained The drugs should be monitored to ensure it is functioning DS0000019962.V299731.R01.S.doc Version 5.2 Page 25 Codnor Park Residential Home 4 5 6 OP12 OP30 OP33 sufficiently well for the storage of refrigerated drugs It is recommended that there is improved recording where service users have social/leisure time offered where they have declined to take part in planned activities An overview of staff training should be available to ensure that a system is in place to identify when statutory training is completed when due Feedback should be formally sought on the home from visiting professionals Codnor Park Residential Home DS0000019962.V299731.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office 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 Residential Home DS0000019962.V299731.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. 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!