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Inspection on 05/02/07 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 5th February 2007.

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

Service users had a number of positive comments to make about the staff saying they are `marvellous` The meals offered routinely included choices and a range of special diets were catered for. Service users spoken to said that the staff tended to be aware of any preferences and offered foods accordingly.

What has improved since the last inspection?

A drug reference book has been obtained and standards relating to medication administration have been met at this visit. A new care plan format had been introduced which was in the early stages of being implemented. Staff said this was a positive move although the changed format was taking some time to get used to.

What the care home could do better:

Care plans were not in place for all assessed needs on files examined but were completed during the inspection. There is not a system in place to ensure care plans were completed There appeared to a lack of attention to some general cleaning and housekeeping tasks. There were some gaps in staff recruitment files had some gaps which included references, photographs Staff training files were incomplete for some staff and were generally inconsistently being maintained.

CARE HOMES FOR OLDER PEOPLE Codnor Park Residential Home 88 Glasshouse Hill Codnor Ripley Derbyshire DE5 9QT Lead Inspector Bridgette Hill Key Unannounced Inspection 5th February 2007 08:55 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.V328922.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.V328922.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) www.ashmere.co.uk 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.V328922.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 21st June 2006 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 . 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 are 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.V328922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with management, staff, service users and visitors. The Acting Manager Linda Bexton was present for the majority of the visit. What the service does well: What has improved since the last inspection? What they could do better: Care plans were not in place for all assessed needs on files examined but were completed during the inspection. There is not a system in place to ensure care plans were completed There appeared to a lack of attention to some general cleaning and housekeeping tasks. There were some gaps in staff recruitment files had some gaps which included references, photographs Staff training files were incomplete for some staff and were generally inconsistently being maintained. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 6 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. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 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.V328922.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs were assessed prior to admission and relevant information obtained from other professionals but limited information record which had the potential for service users needs to be unmet. EVIDENCE: The care file of a recently admitted service user was examined. This confirmed that pre admission assessments were completed by staff from the home. A format was available for recording the assessment however there were some aspects on the form where no information was recorded. This included some key aspects such as communication. Very often the pre admission form had limited information recorded on it and the forms were found to be unsigned or dated. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 9 Information from Social services Care Managers was available including the care plans generated by the Care Managers. Positively where delays in admission occurred from the original anticipated date reassessments of service users had been undertaken. Some service users had used the home as a respite placement before choosing to reside permanently in the home. The home was on occasion chosen by relatives for service users. The reason given was often as the home was near for relatives and friends to visit. One relative said the home was chosen as it was clean and did not have any odours. The home does not offer intermediate care as defined by National Minimum Standards 6. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 10 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 content of care plans where they were in place was generally good and descriptive of service users needs. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. Some were assessed in part to explore different aspects. The care planning format was in the process of being changed to a new one. Staff said that they were getting used to this but finding it a little different to complete though improved from the previous format. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 11 Three care plans were examined however two of the care plans for recently admitted service users had some gaps, which were rectified during the inspection. Generally where care plans were in place and in the ones written during the inspection the content was found to be personalised and descriptive of how care needs were to be met. A form for recording reviews of care was in place and where these were due they had been completed. Records of how service users had been was recorded for each shift worked by staff. These were informative and generally well written. Some risk assessment tools were in place including moving and handling, nutrition, and general risk assessments for any individual concerns. A risk assessment format for tissue viability was available but was not complete in some care files. Moving and handling risk assessments were supported by a plan of care, which considered different situations and recorded what assistance the service users required. The general standard of record was found be poor in a number of areas with correction fluid found in varying places within every care plan examined. There was a lack of signatures and dates of completion in order to verify the documents. One document did not have space for the service users name to be included or the name of the completing staff member or the date. There were also no signatures to confirm service users had been consulted regarding their plan of care. Staff spoken to said that some service users had the capacity to be involved and had signed. One service user spoken to said they had not seen their plan of care but weren’t really bothered about seeing it. Service users spoken to said that where they could do things for themselves they did and staff assisted with the tasks they needed help with. The files examined confirmed that service users had documented visits from GP’s, opticians and chiropodist. The staff said at the home said that there was also a positive working relationship with District Nurses two of whom visited during the inspection. The storage and administration of medicines was examined at his visit. Specimen staff signatures were evident and a drug reference book dated March 2006 was available. Photographs of service users were included at the front of the medication administration records along with any known allergies or Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 12 restrictions due to taking medications. The system for storing and recording controlled drugs was examined and all balances correlated with available records. A significant number of out of date dressings were found in the treatment room and there did not appear to be a system in place to check these. The drawers and cupboards in general were untidy and required cleaning. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The service provided by the home appeared to be respectful of service users abilities and offered them choices in their everyday lives. EVIDENCE: All care staff took some responsibility for ensuring activities were offered to service users. The regular activities that appeared to be offered to service users tended to be externally facilitated such as Communion, Movement to Music, an organist and other entertainers. Records indicated that the activities offered by staff were typically quizzes, bingo, and manicures. A minibus was available and some outings were arranged. Prior to Christmas there had been a pantomime held at the home. Occasional coffee mornings and themed evenings were held. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 14 A hairdresser visits the home twice weekly and a separate hair salon was available. Contact with families was recorded and some service users appeared to regularly spend time out with family members. Where service users had the ability to go out independently this did happen. A kitchenette area was available for relatives to make drinks. Some service users spoken to said they enjoyed the privacy of their own room to watch television, DVD’s or read. The home has a pet cat and fish tank. Service users said they had getting up and going to bed times of their choice and were asked which clothes they would like to wear. Part of the lunchtime meal was observed during the visit. The dining room was spacious with the tables laid with cloths and coordinating napkins. The menu was written on a board in the dining room and a choice of main meal and pudding was routinely offered. Staff were observed to wear aprons whilst serving meals. Special diets for diabetic, gluten free and vegetarian service users were being offered. Whilst there was generally a positive opinion expressed by service users about the food everyone also said they had their own preferences and positively said that staff appeared to be aware of these and meals were given accordingly. An example of this was a service user said they didn’t like a particular vegetable so this was not served to them. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 15 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. Whilst policies and procedures were in place and staff appeared conversant with these the lack of formal training had the potential to adversely affect service users. EVIDENCE: The Commission for Social Care Inspection had received no complaints since the last inspection on 19th June 2006. Records at the home indicated that there had been 5 complaints received which had been dealt with on an informal basis (one of these was a duplicate complaint from a different source). These included issues about shrunken laundry, soap being available in dispensers and some issues relating to service users. Outcomes of the complaints were recorded and where necessary actions were taken. Relatives spoken to said that the management of the home was approachable and they would raise any concerns they had. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 16 The Protection of vulnerable adults policy had been updated since the last inspection and now referred to locally agreed multi agency procedures. These were available in the home. There have not been any investigations relating to safeguarding adult concerns since the last inspection. Staff spoken gave a good account of what the whistle blowing policy was about and said they would report any concerns they had to the Management of the home. The training records examined confirmed that whilst some training in safeguarding adults had taken place over a period of time since 2003 some staff had not received any training. The home has a member of staff who has completed the Trainers course in safe guarding adults to enable them to train others but no sessions have yet been offered to staff. This is an outstanding requirement from previous inspections Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The majority of the home appeared to be clean and well maintained however there some areas where staff had not ensured good general housekeeping standards were maintained. Some of these had the potential to place service users at risk of infection. EVIDENCE: Codnor Park is a purpose built care home, which has a choice of lounge areas and a spacious dining room. Service users appeared to have their own areas of the home that they preferred to use. There was a garden at the rear of the home. This was open plan with mature trees. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 18 Fire safety records were examined which indicated that were weekly checks of the alarm made and equipment was serviced at appropriate intervals. A fir risk assessment of the building was in the process of Whilst the majority of the home was considered to be clean and without odours there some aspects regarding general housekeeping and infection control issues that were observed: • • • • • • The hair salon was somewhat untidy and was being used by staff to store their personal belongings despite designated facilities being available. The nail care box was found to be dirty and had some old nail clippings in amongst the other items in the box The floor in the treatment room where medications were stored was dirty. The drawers and units in the treatment room were generally untidy and not very clean with a wide range of items in them. Used razors were found in two areas openly accessible to service users. The medication trolley was dirty and required cleaning. Service users and relatives spoken to said they were happy with the standard of cleanliness at the home. The laundry area was secured by a number lock and had 2 washers and 1 dryer. One complaint had been received about the laundry and this was resolved by compensating the service user. Staff spoken to said the laundry was adequate to ensure clothes were washed promptly. One relative said that occasionally other service users clothes were placed in wrong bedrooms. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff were well spoken of by service users who said they had confidence that they were accessible and able to meet their needs. EVIDENCE: The occupancy of the home on the day of the visit was 37 service users. Staffing levels were recorded on the duty rota as follows: 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. There were 18 care staff employed at the home of which 6 held NVQ (National Vocational Qualification) level 3 qualifications and 7 held at least NVQ (National Vocational Qualification) level 2 qualifications. This exceeds the 50 of staff advised by the National Minimum Standards. One further staff member was enrolled on an NVQ (National Vocational Qualification) course. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 20 A sample of staff personnel files were examined. These indicated that there are some deficits such as photographs of staff and references. One verbal reference was recorded as being taken but there were no records to indicate what had been asked and the response given by the referee. Criminal Records Bureau were in place for all staff. There appeared to relatively good staff retention with some staff working at the home for many years. A skills based induction package was seen although no completed examples were available as staff retained these personally. Staff training records indicated that range of statutory and additional training was offered to staff although the recording for individual staff was variable. Courses had been completed by some staff in moving and handling, fire safety, infection control, first aid, medication management, Duty of Care (including dementia, Abuse, diabetes, and medicines), Nutrition, Basic Food Hygiene, health and safety and catheter management. The individual staff records ranged from being well completed with a wide range of training documented to some which had no training recorded. As a result of the lack of recording for some staff it was not possible to evidence that all staff were appropriately trained. This is an outstanding requirement from previous inspections. A schedule of training for the coming year was currently being arranged with Age Concern. Service users spoke positively about the staff group and said they had confidence in them. Staff were said to respond quickly to the staff call system even if it was to say they would be a slight delay before attending to the request. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 21 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 home appeared to be generally well managed with systems in place to ensure that health and safety of service users is considered. EVIDENCE: The homed does not currently have a permanent Manager who is registered with the Commission for Social Care Inspection. An Acting Manager has been in post since October 2006 and the post was said to be being advertised shortly. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 22 The Acting Manager in post has experience of being a Deputy Manager and has started a Registered Managers course. A valid employers liability certificate was on display. The schedule for this was examined which confirmed this met the required level of cover. Records for establishing financial liability were not requested at this visit. Monthly visits to assess a range of aspects in the home were available and documented. This also included periodic surveys sent out to staff, service users and relatives. The staff spoken to said one form had been given to a visiting professional but so far no formal feedback from visiting professionals had been received. A catering survey had also been completed which consistently recorded that whilst service users were happy with the quantity of food there were issues with quality. Some of these appeared to be related to service users personal likes and preferences. Periodic staff and service users meetings were held and minuted though the frequency was irregular. Small amounts of service users monies were stored safely on behalf of service users. A sample of records were examined. Monies were stored individually and a sample of balances correlated with the amounts recorded. Some auditing of the amounts had been completed and most transactions had two signatures to verify each A range of service records relating to gas, electrical systems and appliances, equipment and health and safety checks such as monitoring and recording water temperatures were examined. These were all in good order and were in date. A handyman is employed at the home who confirmed that he took responsibility for many of the checks as part of his day-to-day work. Accidents were recorded and where these had occurred the forms were stored with the daily logs to alert staff to observe and be vigilant for delayed complications that may occur. Codnor Park Residential Home DS0000019962.V328922.R01.S.doc Version 5.2 Page 23 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x 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 3 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 4 29 2 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.V328922.R01.S.doc Version 5.2 Page 24 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 Standard OP7 Regulation 15 Requirement An audit of care plans must be completed and a system implemented to ensure care plans are in place for all assessed needs All staff must receive training on the multi agency protection of vulnerable adults procedures form Derbyshire County Council Previous timescale 30/09/06 3 OP26 13 There must be adequate standards of cleanliness and housekeeping maintained to ensure service users are protected from risk of cross infection or injury The provider must ensure all required pre recruitment checks a have been competed and recorded prior to staff commencing employment Training must be provided to staff and sufficient records held to demonstrate that staff are sufficiently trained in order to meet service users needs DS0000019962.V328922.R01.S.doc Timescale for action 31/03/07 2 OP18 13 30/09/07 31/03/07 4 OP29 19 31/03/07 5 OP30 18 30/06/07 Codnor Park Residential Home Version 5.2 Page 25 Previous timescale 30/08/06 6 OP31 8 A manager must be appointed and an application made to formally register the manager with the commission for Social care Inspection Previous timescale 30/08/06 30/07/07 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 4 5 Refer to Standard OP3 OP9 OP15 OP15 OP30 Good Practice Recommendations The recording of preadmission assessments should be expanded to ensure all assessed needs are recorded A date checking system for dressings should be introduced Correction fluid should not be used within care planning or other documents Standards of record keeping should be improved to ensure all records have a signature and date from the completing person 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 6 OP33 Codnor Park Residential Home DS0000019962.V328922.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: 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 Codnor Park Residential Home DS0000019962.V328922.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!