CARE HOMES FOR OLDER PEOPLE
Codnor Park Residential Home 88 Glasshouse Hill Codnor Ripley Derbyshire DE5 9QT Lead Inspector
Jill Wells Unannounced Inspection 5th December 2005 10:00 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.V262392.R01.S.doc Version 5.0 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.V262392.R01.S.doc Version 5.0 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 Homes Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Vacancy 1 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.V262392.R01.S.doc Version 5.0 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 1st June 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 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 Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5.5 hours. Three residents were spoken with in private as well as other residents spoken with throughout the day. Two visitors were spoken with as well as staff and the deputy manager who was in charge that day. Records were inspected including some servicing records, staff files, training records and residents files. What the service does well:
Residents spoke positively about the service provided. They said that staff gave them all the help they needed and responded to the call system as quickly as they were able. Training and induction was generally of a good standard, although moving and handling training needed to be organised for new staff. Staff worked hard to provide planned activities and often worked in their own time to ensure that outings worked well. Tombolas, raffles etc regularly organised provided money for the residents funds to assist with the cost of activities and trips. Comments about the food was positive, both in the amounts provided and the quality, although one resident would have preferred warmed plates. The cleanliness and maintenance of the premises were of a good standard. Domestic staff worked hard to ensure that rooms were cleaned to residents’ satisfaction, and residents spoken with were pleased with this. The environment was pleasant, there were no unpleasant odours and bedrooms that were seen were personalised. Observations were that staff were clearly very committed to their work. One example was a care worker that told the deputy manager that she was going to take an item of residents clothing home to repair. Staff were observed chatting, and joking with residents. One resident said that “All the staff here are very kind”. Several comments from staff indicated that staff generally work very well together as a team. Ashmere Care Group place a high emphasis on self-audit in order to identify any shortfalls and rectify them. Residents and visitors believed that if they are unhappy about anything they will be taken seriously and responded to appropriately. Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 6 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.V262392.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 the following standard(s): 3 Residents were only admitted into the home when a competent person had assessed that the home could meet their needs. EVIDENCE: New residents were admitted only after an assessment had been undertaken in order to ascertain whether the home could meet individuals needs. The deputy manager was arranging to visit a potential resident in order to undertake an assessment at the time of the inspection. Three residents files were seen and each of them had an assessment in place. Visits were made at a service users home or in hospital in order to ensure that their needs could be met at the home Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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, 10. Although service user plans were in place, the quality of the reviews needs to be improved. Residents’ healthcare needs were met and privacy and dignity were respected. EVIDENCE: Three residents’ care plans were checked during the inspection. A detailed plan of care had been drawn up for each resident. The plan set out the action that needed to be taken by care staff to ensure that each resident’s health, personal and social care needs were met. The care plan was reviewed on a monthly basis. However the inspector talked with the three residents about the details of their care plans and found that there were some inaccuracies within them. Examples of inaccuracies were one plan that stated that the resident needed assistance with some washing and dressing, however the resident was now fully able to wash and dress herself. Another plan which stated that the resident had expressed wishes to attend the religious service held at the home. The residents said that she had no interest whatsoever in a church service. These and other examples evidenced that the care plans were not always being reviewed carefully or with the involvement of the resident. There was
Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 10 one care plan seen that was detailed, reviewed regularly and fully reflected the needs of the resident. Daily records were written for each resident, identifying any specific issues that had arisen that day. There were two care plan seen which stated that residents had received a key to their bedroom door and lockable drawer. Both residents spoken with said that they had not received a key. The staff member on duty was unable to clarify this. It was advised that residents sign that they have received keys. Residents spoken to said that they could see their GP whenever they wished to do so. There were detailed records of visits made by the GP and outcomes of the visits. Residents that were at risk of developing pressure sores were identified and contact was made with relevant health professionals to ensure that appropriate equipment was available to minimise risk. Residents were encouraged to keep as mobile as they were able. There was a physiotherapist employed by Ashmere Care Group who visited any residents identified as possibly benefiting from physiotherapy. Residents have access to opticians, dental services and chiropodists as required. Staff spoken with were very aware of the importance of treating residents with respect and their right to privacy. These issues were part of the homes induction training. Residents spoken with confirmed that staff considered residents dignity when they were assisting them with their personal care. One resident said that, staff are very kind, they stop you feeling embarrassed. Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 15. Regular activities were organised, and visitors were welcomed at the home. Residents were provided with a wholesome appealing diet in pleasant surroundings. EVIDENCE: There continued to be a good variety of organised activities. These included bingo, quizzes, dominoes, a monthly service and monthly communion. There was a Christmas party planned which included a pantomime performed by an outside company. There had been a competition organised between residents within different homes within the care group to design Christmas cards or write stories or poems about Christmas. There was tombola and raffle organised for Christmas that was displayed in the entrance hall. Social activities were recorded for each individual. There seemed a low take up of organised activities amongst residents. Two residents spoken with said that they were often very bored. Residents may benefit from a review of their social interests, although it was acknowledged that many residents just preferred to have company and chat. Visitors were encouraged at any reasonable times. Staff were observed being very welcoming towards visitors. Residents could see their visitors privately if
Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 12 they wished to do so. One resident spoken with was waiting to go on a trip with a relative. The menu was displayed in the dining room. There were two choices of main meal available including a vegetarian option. There were also two choices of sweet as well as fresh fruit and yoghurts. The records of the tea showed that there was a wide choice, which included sandwiches, as well as a light cooked meal. One resident spoken to said that she occasionally very much enjoyed the cooked breakfast that was available. Resident spoken with were very satisfied with the quality of the food, although one resident said that they would prefer warmed plates. The dining room where meals were taken was very pleasant area. The dining tables had tablecloths, napkins and table decorations. Staff were observed assisting any residents with eating when this was necessary. Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 the following standard(s): 16, 18. Recording of complaints had greatly improved, and staff were aware of their responsibilities within the adult protection guidelines. EVIDENCE: There was complaints procedure posted in the entrance hall and residents spoken with were aware what to do if they had a complaint. One visitor said that, if ever I have a complaint I just go to the manager and they sort it. There had been a complaint made to CSCI in September 2005. This was investigated with full cooperation from the home owners and manager. Some issues within the complaint were upheld or partly upheld. Changes have been made as a result of this complaint. For example staff now record any assistance given with fingernail and toenail care. The biggest improvement in this area is that staff were now recording all complaints including informal complaints. There have been nine complaints since the last inspection, which included a resident’s television too loud, cream crackers being served that were soft and resident reporting that the toilet area near to the dining room had an offensive odour. These records evidenced that the managers and staff were taking all complaints seriously and dealing with each complaint appropriately. This improvement should be commended. Training records showed that most staff had undertaken adult protection training. The care assistant that had worked at the home for four weeks had a clear understanding of adult protection issues as a result of attending an induction day. The worker was not however aware of the whistle blowing policy at the home.
Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 14 Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 15 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 The home provides residents with a safe, well-maintained environment. EVIDENCE: The home was purpose-built and suitable for its stated purpose. It was accessible, safe and well maintained. There was a passenger lift to the first floor. There was a maintenance person employed at the home and routine maintenance work was carried out. Renewal of the fabric and decoration of the premises was implemented as required. The grounds were kept tidy and safe. Residents spoken with were very satisfied with their rooms and the standard of cleanliness. One resident said that, I have trained the staff to leave my room as I like it. The general manager,which was a new post (see standard 31) had undertaken an audit of the service that included the premises and had highlighted any minor shortfalls, which were quickly rectified. Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 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): 29, 30. Residents are protected by the homes recruitment policy and practices. Appropriate training is available to ensure that staff are competent to do their jobs. EVIDENCE: Two staff files were seen during the inspection. Both files were new staff recently employed. Within each file were written application forms, two written references and a health declaration. There were copies of individuals’ birth certificate and or passports. Ashmere Care Group had recently written to CSCI to confirm their practice concerning criminal record bureau and protection of vulnerable adult checks being in line with the requirements, as the criminal record bureau office had recently audited them. Training records were inspected. The mandatory training had been provided for staff, which included fire safety, moving and handling, health and safety, first aid, and medicine administration. Training available that was appropriate to the needs of the residents, included dementia awareness, death and bereavement, and nutrition for the frail elderly. The care assistant spoken with that had worked at the home for four weeks had not undertaken specific training in moving and handling, although from discussions she was notusing any unsafe practices. Training in this area had not yet been planned for the new worker. The worker described a good induction process which included shadowing experienced staff for the first two weeks and an induction day which included issues around resident rights, confidentiality, fire safety, food hygiene, privacy, dignity and adult protection.
Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 17 Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 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, 38. The service undertakes self monitoring in order to identify improvements needed. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager had recently been promoted to general manager and was now responsible for three homes within the care group. There was an acting manager at the time of the inspection. There had also been a deputy manager post created. The care group were to advertise the post of registered manager. There were effective quality assurance and quality monitoring systems in place. This included seeking the views of residents at residents meetings. As stated previously the general manager had recently undertaken a detailed audit of the whole of the service and identified issues to be resolved or
Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 19 improved upon. There was also a record of monthly audits of care records undertaken by the manager. As previously stated mandatory training was provided for staff. There were no concerns identified around safe storage and disposal of hazardous substances. Records were seen of design solutions to control risk of legionella and records of monitoring of water temperatures. There were written risk assessments in place covering communal areas, the kitchen, maintenance work and domestic/laundry work. There were also risk assessments on each bedroom. Many of these risk assessments were dated January 2003 and had not been reviewed. Some risk assessments were not dated. There were records of checks undertaken of emergency lighting, the aid call system, fire alarms, and smoke detectors. Accidents were recorded and there continued to be an analysis of accidents undertaken, however the analysis document had not been fully completed after August 2005 and did not identify measures to be taken to reduce risk. Record showed several residents that had a number of falls. Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 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 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X x X x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 2 Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15(2) Requirement 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. 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 are offered other stimulation, and this is recorded. (A requirement at the previous inspection) A review of residents social needs and interests in order to try to further meet individuals needs who do not take part in the already planned activities should be considered. New staff must receive moving and handling training before they assist residents that require assistance in this area. Written risk assessments for safe working practice topics and the
DS0000019962.V262392.R01.S.doc Timescale for action 30/01/06 2. OP7 15(1) 30/01/06 3. OP12 16(2)(m) (n) 30/01/06 4. OP38 13(5) 30/01/06 5. OP38 13(4) 30/01/06 Codnor Park Residential Home Version 5.0 Page 22 environment must be reviewed. Dates must be displayed on all risk assessments. 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 Refer to Standard OP27 OP10 Good Practice Recommendations All rotas should have information concerning times of shifts. (not inspected) The manager should consider a system of recording keys given to residents where they/or their representative can sign that they have been received or refused a key as appropriate. Consideration should be given to including the issue of whistle blowing into the induction programme. The analysis of accidents should include measures to be taken to reduce risk. 3. 4. OP18 OP37 Codnor Park Residential Home DS0000019962.V262392.R01.S.doc Version 5.0 Page 23 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.V262392.R01.S.doc Version 5.0 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. 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!
