Codnor Park Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders demonstrated they were aware of the overall vision, strategy and culture of the provider. The conversations we held with leaders showed they were aware of, and working towards, the goals that had been set in the provider’s action plan. Staff we spoke with also demonstrated a knowledge of the provider’s goals.

Audits completed by leaders showed a high level of transparency and an emphasis on quality improvement. Where issues were identified in audits, an action plan for improvement was in place.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders demonstrated strong knowledge of the health and social care sector and their roles and responsibilities. Leaders knew people and staff well and understood their needs. Leaders held a, ‘Coffee and cake’ session every month where staff were invited to meet with leaders for an informal session and discuss anything they wished to raise about their work.

There was a positive staff culture in evidence where staff in all roles were comfortable with speaking openly with colleagues, including those in leadership positions.

One staff member said, “The Leaders are very good at letting me be involved with things that aren’t necessarily my role, but will help me to develop my skills and give me opportunities for the future”.

Leaders told us that new staff members were given a week of induction training with the training manager, followed by two weeks of shadow shifts in the home where they shadow experienced members of staff. Before concluding the induction process, the new staff member met with the registered manager who discussed their induction and identified any further areas of development that were required - inductions could be extended if it was necessary to do so.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a confidential, external whistleblowing contact phone number that they, staff and leaders could ring if they had any concerns. Information about whistleblowing was displayed in the staff room. Staff told us they felt confident to speak up and they would be listened to if they ever had a concern.

Staff and leaders told us they were supported and encouraged by the provider to learn new skills and develop their career. Several staff in senior positions had progressed from carer roles.

Staff supervisions were held approximately every 3 months, and one staff member said, “I don’t have to wait for my supervision to bring things up, they are there for me if I need anything”.

Staff told us they felt supported by leaders and they could go to leaders with any concerns that they had. Leaders said they hold an open door policy for all staff. There was a mental health support line which staff could call, and the provider had designated “menopause champions”.

Most of the staff who we spoke with commented on the strong teamwork and shared goals which they felt made for a positive working environment.

Staff told us the provider had additional perks which made them feel valued – in addition to an employee of the month award, all staff were entered into a monthly raffle to win a prize. Staff could earn points if they did overtime or additional shifts which could be exchanged for rewards.

The provider had action plans which showed a clear strategy for the quality and improvement of the service. Goals had been set in key areas and individual staff were identified as being responsible for ensuring the provider was working towards these goals and ensuring that evidence was provided that each goal was met. A detailed business continuity plan was in place to anticipate and minimise the impact of any emergency or disruption to the service.

Monthly audits were conducted by leaders and these linked into the electronic systems used by the provider, so that individual entries made by staff on care planning systems could be looked at as data and analysed for themes and trends. Leaders demonstrated an understanding of data analysis by providing examples of where they had identified concerns by spotting themes in the monthly audit data.

Complaints and compliments were logged in a central database where the actions taken were recorded, and an anonymous relatives’ survey was sent out which had a strong response rate. Responses were analysed and turned into a, “You said, we did” document, where the provider published the number of people who had responded positively or negatively to a question, with a breakdown of the actions they planned to take for any concerns that were raised as part of the survey. A log of any notifications that needed to be sent as a concern to CQC was kept – leaders demonstrated they understood what kind of events would be classed as notifiable events to CQC.

The provider had strong relationships with the GP, district nursing teams and advanced nurse practitioners. These relationships were important for ensuring people with complex health conditions received medical support on a consistent basis. Leaders were involved in communicating with partnership services, for example by attending weekly ward round and monthly MDT meetings where people’s care was discussed. There was evidence of leaders being proactive in making referrals to partnership agencies when this was required. Leaders told us that when analysing monthly audits, they would make a referral to the falls team for anybody who had suffered from 3 falls, regardless of the cause or the time that had elapsed between each one.

Leaders had worked with the advanced nurse practitioner to ensure that extra focus had been placed upon reviewing the medication needs and end of life care plans for all people under the provider’s care.

Activities included regular trips out and external partners coming into the home to entertain people. Community activities, such as local schoolchildren coming to visit the care home and sing songs to people, showed that strong links with the local community had formed. The provider parent organisation held a weekly dementia ‘tea dance’ which was open to the public. Several people were supported by staff to attend these events on a regular basis, with relatives also encouraged to attend with their family members. Residents and relatives meetings were held every month, and the parent provider was currently running a series of awards which people who used the service and relatives were encouraged to vote in.

Staff and leaders told us they were supported and encouraged by the provider to learn new skills and develop their career.

Leaders worked in partnership with the company’s training manager in order to identify training needs for staff. Leaders confirmed staff were undertaking additional training to support people with dementia. All staff were being enrolled onto an immersive dementia eating experience training, where staff would eat a meal in conditions which were designed to replicate how a person living with dementia might experience mealtimes.

Leaders told us about their approach to end of life care. Each month, a review was held for any people who had passed away, and to identify anybody who may be coming towards the end of their life. The emphasis of these reviews is on learning, and to ensure that people who are at the end of their lives are provided with compassionate care. Care staff were encouraged to contribute to this. Leaders also told us the provider held memorial services for people who had passed away, with the person’s family encouraged to attend and reflect on the time that their relative spent at the home with photographs and stories shared.