Inspection on 19/01/10 for Divine Lodge

This is the latest available inspection report for this service, carried out on 19th January 2010.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Divine Lodge 6 Mayflower Road Chafford Hundred Grays Essex RM16 6BE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Alan Thompson     Date: 2 8 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Divine Lodge 6 Mayflower Road Chafford Hundred Grays Essex RM16 6BE Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Dorothy Bello Type of registration: Number of places registered: care home 5 Sebott Solutions Limited Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: 1. The registered person may provide the following category of service only: Care home only -Code PC to service users of the following gender: Either whose primary needs on admission to the home are within the following category Learning disability Code LD. 2. The maximum number of service users who can be accommodated is: 5. Date of last inspection Brief description of the care home Divine Lodge is a care home providing 24 hour accommodation and personal care support for up to five adults with learning disabilities. Each service user is provided their own single room within this detached three storey house. Communal space comprises a lounge, a dining room and a conservatory all on the ground floor. There is also a separate activities room on this level. 5 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home The home is located in a residential area of Chafford Hundred. Public transport links are close by with a bus route passing the home and Chafford Hundred railway station a short walk away. The home is also situated close to local shops and a library, and the Lakeside shopping complex is within walking distance. There is a garden to the rear which is available to all the service users. This has seating and a barbeque area. Fees for service users are assessed according to individual needs as agreed with the commissioning agency. Inspection reports can be obtained from the home or from the CQC internet website on, www.cqc.org.uk . Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: We started this inspection with an unannounced visit on 19th January 2010 and completed it on 4th February 2010. This report reflects our findings along with information provided by the manager and feedback by service users and staff. The manager completed and returned their Annual Quality Assurance Assessment (AQAA) to before the inspection. This is a self-assessment required by law which gives homes the opportunity of recording what they think they do well, what they could do better, what has improved as well as their future plans for improving the service. Some of the information and detail provided within the AQAA has been included in this report. We spoke with the manager, service users and staff on duty. CQC survey questionnaires were also provided to service users, staff and stakeholders. We received four completed surveys and reference to feedback from these and from discussions Care Homes for Adults (18-65 years) Page 6 of 30 with people has been made within this report. We looked at some records, policies and procedures and were shown around parts of the home and grounds. All matters relating to the outcome of the inspection were discussed with the manager of the home, with full opportunity for discussion given and/or clarification where necessary. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Adults (18-65 years) Page 8 of 30 order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering moving into Divine Lodge can be confident that the admission processes ensures that the home can meet their needs. Evidence: The current service users are placed and funded by local authorities. Records seen confirmed that these organisations had provided an assessment of needs to the home as part of the referral process. The homes manager then arranges to visit the prospective new service user to carry out the homes own pre-admission assessment prior to confirming that Divine Lodge is a suitable placement. No new service users had moved into the home since registration, however two people were already living there when the service provided supported accommodation only. These people had been re-assessed when the home became a registered care home and the manager said that this was to ensure that Divine Lodge continued to be a suitable placement for them. We looked at the format used to assess people. This included recording information on Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: the individuals background, the details of any existing care plan, and what support had been identified as required under headings of practical support, personal abilities, learning skills, personal aims and any future needs and preferences. The manager carries out a risk assessment when visiting the referred service user which covers areas of healthcare, environment, risks to self, to others and from others. Identified risks were shown with the perceived level of risk and what measures are needed to minimise these. The overall assessment of need prior to admission also included medication, nutrition, sleep, personal care, mobility, communication, activities and behaviours. The assessments we looked at contained the information necessary for service users needs to be met at Divine Lodge. Discussion with service users confirmed that they were asked if they wanted to live in this home. One said I like it here. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information in care plans mostly ensures that peoples needs could be met in a way they would wish. Evidence: At the time of this inspection there were two service users living at Divine Lodge. Both of their support/care plan files were looked at. Support plans were person centred with a lifebook document which had been completed by the service user and their key worker. Lifebooks included pictures and text to show the persons likes and dislikes, their perceived strengths, people important to them and the things they wanted others to know about them. Overall the support plans seen were detailed and covered all the areas necessary to ensure staff could meet peoples needs, such as health, diet and nutrition, personal care, medication, domestic, social and leisure, communication and behaviours. Some staff had been trained on responding to challenging behaviours but we will recommend that this is extended to include all support staff to ensure they have the skills and knowledge to respond appropriately to people using the service. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: Support plan reviews are scheduled for every three months and plans seen had been signed as agreed by the service user and their key worker. Support plans are also discussed at weekly meetings between the service user and their key worker. Care reviews included recorded notes of the service users views and those spoken with confirmed they were included in the care planning process. They also confirmed that staff provided then the support they wanted. Risk assessments were also in place following the format mentioned earlier in this report. These showed the actions staff should follow to minimise risks to people. The manager said that service users healthcare issues were recorded on their files. However records we looked at did not confirm to us that visits to healthcare professionals, social workers, hospital visits, GP consultations, dentists, opticians and chiropodists had been recorded in a way that ensured staff are kept fully informed on peoples ongoing healthcare needs. We discussed this observation with the manager who undertook to update the recording process in the home. We did see notes of reviews of placement undertaken with the placing authority and the service user. The manager confirmed that the meetings held at least every week between the service user and their key worker also included discussion on house issues, food, shopping, complaints and activities. This was to ensure that their views and opinions about the service are listened too and taken account of. Service users spoken with confirmed that they thought they are fully included in day to day decision making within the home, with staff offering choices around routines and events. This two way interaction was evident throughout our visit. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Divine Lodge can expect to be offered a lifestyle to meet their expectations. Evidence: Staff support service users to access community facilities and interests. At the time of this inspection one service user had a voluntary job working three days a week at a childrens club. Both service users were also waiting for voluntary work options through the Basildon and Thurrock advocacy service (BATIAS). BATIAS also offer regular outings and a weekly club for service users to attend. There is a weekly drama workshop that they may go to and both service users were on a waiting list for a place at a local adult education college. Each service user had a suggested weekly activity programme that included shopping Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: trips, voluntary work and 1 to 1 trips with staff to the service users chosen venues which may be swimming or bowling. Daily activities offered in the home included puzzles, arts and crafts, cards and indoor games. The home has an activities room which ensures ample space is available for games and interests. Regular outings are also offered using volunteer low cost community transport for visits to places such as pubs for meals, the coast and to the theatre. Service users confirmed that they regularly attend many of the activities available and that they enjoyed what they did. They also said that staff suggested activity ideas to them. All service users see their families regularly, with relatives coming to Divine Lodge to collect them. However if this were not possible then staff would drive service users home to ensure that regular contact is supported. Contact includes regular visits home, including overnight stays and going on holiday with their family. Records had been kept of family contact. The manager confirmed that staff enter bedrooms only with the individuals permission, unless the welfare or well being of the service user is in question. All are offered keys to their rooms but currently none choose to hold keys. One service user confirmed to us that they did not want to have their room key. Throughout this inspection staff were observed to interact appropriately with service users and appeared to always use the individuals preferred form of address. Discussions between service users and staff about routines and choices were taking place throughout the inspection and the atmosphere in the home was supportive and friendly. Service users appeared confident about making their views and opinions known to staff. Menus were looked at and evidenced a varied and balanced diet. Menus are on a four week rotation and the manager confirmed that service users food preferences and likes/dislikes form the basis of menu planning. Service users usually accompany staff on weekly food shopping trips and one person likes to take part in meal preparation and cooking as part of a planned activity. The main daily meal is taken around activities and daily routines, and service users usually eat this together in the dining room. Other meals are taken when people wish according to their individual routines Service users told us that they liked the food at Divine lodge, and that they liked eating out as well. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can expect to receive personal and healthcare support in an appropriate and dignified way that meets their needs. Evidence: Care records and discussion with service users and staff confirm that service users are fully supported in making their own choices around clothing styles, hairstyles and general appearance. Assessment records included preferences around daily routines, and details of the levels of personal care support required were also seen documented. Service users spoken with confirmed that they liked the staff and were satisfied with the care provided them in the home. Care plans contained assessment of healthcare needs. The current service user group are offered staff support and guidance in recognition of their individual healthcare needs and to access community healthcare facilities. Service users regularly visit community based healthcare services including their GP, optician, dentist and hospitals appointments, all with staff support. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: Some records were seen of service users healthcare appointments however we did not see consistent evidence to show that records had been kept of the outcomes of these to ensure that staff are kept informed of peoples changing needs. We looked at service users medication needs and what support the home provide in this area. The manager told us that the current service users only need minimal verbal prompting, or no assistance from staff regarding their medication needs. The manager also confirmed that staff were not administering any medication to people currently living at Divine Lodge, but that if people who did need this level of support move into the home then the manager would ensure that staff had the appropriate training to meet peoples needs and adhere to good practice. The manager did have a written medication procedure/policy in place ready for staff to follow when needed. This clarified the registered providers policies on the principles of medication good practice, ordering, checking in, homely remedies, the storage of medicines and of administering prescribed dosages. There was also a written protocol on administering PRN (as required) medications. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Practices in the home may not ensure that service users are protected but does indicate that their views on the service are listened to and addressed. Evidence: The manager had a complaints procedure in place, which clarified the complaints process and the timescales that the manager should respond to the complainant. There was also information in service users rooms which included pictorial guidance on abuse and complaints. This clearly indicates to service users that they have a right to feel unhappy and they should tell somebody if they are concerned or not satisfied with the support they are offered. This document also had advice for people on what constituted abuse and of the different types of abuse that may occur. Comments made by service users verbally confirmed that if they were unhappy they would speak with staff or the manager. Both service users have active involvement with their respective families and had regular contact with external health/social care professionals. The home has links with local advocacy services and was able to demonstrate that these have been used to ensure that service users wellbeing is paramount to any given situation. Some service users also attend a weekly group run by the advocacy service away from the home. There was a set template form for recording complaints and a complaints record book. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: There had been one complaint recorded in the time leading up to this inspection. Discussion with the manager confirmed to us that the issue raised had been properly dealt with. Policies and procedures in the home included written guidelines for staff on types and definitions of abuse and what actions they must take if abuse is suspected, as well as a whistleblowing policy to remind staff of their responsibility to report suspected poor practice. Also available was a flowchart document showing guidance for staff on the adult protection procedures and on types of abuse that may occur. We looked to see that staff had been trained on adult protection awareness. The manager said that all staff had this training however records we saw did not confirm this. Some had received this training when doing their NVQ awards and some had certificates from a previous employer. We need to see evidence to show that all staff are trained on adult protection and abuse awareness, and have made a statutory requirement to this effect. We also noted from looking at staff records that some staff only had a CRB disclosure from a previous/other employer, and not though Divine Lodge, and records seen did not show that all staff have received training on dealing with aggression and challenging behaviours. We regard both issues as best practice shortfalls and have made recommendations on these under the staffing outcomes. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live in a comfortable, clean, homely and mostly well maintained environment. Evidence: During the inspection a partial tour of the home was made accompanied by staff and the manager. The communal areas and bedrooms seen looked comfortable and clean. They were also well furnished, decorated and most areas were well maintained. We did note that the shower in the top bathroom was broken. We mentioned the fault to the manager who confirmed that she was aware of it and had already arranged for repairs to take place. The kitchen was well equipped and maintained, and had an adjoining utility room where the homes washing machine and tumble dryer were situated. The equipment seen looked suitable for the size of the service. All private rooms are singles with three of these on the first floor and the remaining two on the second floor. Rooms seen had wardrobes and adequate storage facilities. One bedroon had private en suite wc. Bathing facilities and toilets for service users comprised of two bathrooms, both with Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: wc. One bathroom is on the first floor and the other is on the second floor. Service users spoken with showed the inspector around their rooms and said they liked their rooms and that staff helped them keep their rooms clean and decorated. They also said that they were involved in choosing their furniture and the colour of their rooms. Staff spoken with confirmed that service users are provided opportunities to personalise their rooms to their own tastes and preferences, and rooms inspected included various items of personal possessions according to individual choices. The home has a rear garden which could be accessed directly from the conservatory or from the kitchen. The garden looked well maintained and had seating and a barbeque. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service cannot be sure that they are supported by a team of properly recruited and trained staff team. Evidence: A staff rota was available for inspection. On the day of the inspection two service users were living at Divine Lodge. Daytime staffing was a minimum of one support worker on duty, with the manager working 9 to 5, and available on call outside of these times. The manager said that sometimes an extra support worker is brought in to ensure service users can attend their activities outside the home. At night there is one sleeping in member of staff at the home with the manager on call. The manager also advised us that as the number of service users living at Divine Lodge increases staffing levels would be increased to ensure there were sufficient staff to meet peoples assessed needs. We will check staffing levels when we next review this service. Monthly staff meetings take place at the home. We looked at the minutes of some meetings held and areas covered included service user issues, activities, events, care plans, menus and rotas. We looked at staff recruitment procedures and records seen included an application form, photograph and proof of ID. However records did not include evidence that at Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: least two references had been obtained for all staff employed at Divine Lodge, or that staff are issued with terms and conditions of employment (Contracts). We also noted that although staff had CRB disclosure checks some of these had been brought with them from their previous/other employment. References must be obtained for all new staff employed and Contracts should be issued to all staff. It is also recommended that new CRB checks are undertaken on all staff when they apply to work at Divine Lodge. These shortfalls are included in the requirements and recommendations section of this report. There are also shortfalls on staff training as records looked at did not confirm to us that all staff are trained on adult protection awareness, fire safety, health and safety, first aid and dealing with challenging behaviours. We did note that the majority of staff had completed their NVQ level 2 or 3 awards before they commenced working at Divine Lodge. The manager advised that new staff receive induction training and produced an induction policy that states induction is provided over one month and includes, orientation of the service, policies and procedures, roles and responsibilities and training. The manager also said that new staff double up with existing staff for three short and one long shifts before they work alone. We saw evidence of this type of working for new staff and staff confirmed in surveys returned to us that they had induction training when they started working at the home. However we did not see any proper records of the timescales and content of the induction training given to new staff and we need to see this before we are able to judge that the training provided is sufficient for the service provision. Staff spoken with were friendly and the observed rapport between staff and service users was relaxed and inclusive. Service users told us they liked the staff and would tell someone if they did not. The home had a staff supervision policy which stated the objectives, function, frequency, content and recording procedures relating to staff supervision support meetings. We looked to see that regular staff supervision support meetings had taken place since the home was registered in August 2009, but records did not sufficiently evidence that this had happened. There had been some recorded discussion between the manager and some staff but this had focused mainly on employment issues for new starters. Regular supervision support meetings need to be offered to all staff with records kept of the areas covered. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that they live in a home that is run in their interests but may not be sure that their welfare and health and safety are best protected. Evidence: The manager is an experienced and qualified social work manager who has worked with adults and children with disabilities. During our inspection the manager displayed as having full understanding of the needs of the service users at Divine Lodge. We asked staff if they felt that they had been supported properly by the manager. Comments in surveys returned to us confirmed that those who responded thought they received the day to day support they needed. Divine Lodge was first registered as a care home in August 2009 and at the time of our inspection the manager had not yet implemented formal Quality Assurance (QA) procedures. We expect to see an effective quality monitoring system review by the manager or registered provider at least annually, but as the home had only been operating for five months will check implementation of this at our next review of the Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: service. We did note at this inspection that service users have weekly meetings with their key worker and that service users views on the support they receive are recorded. Service users spoken with confirmed that they thought they were fully included in the decision making process in the home, and that staff listened and acted on what they said. Random samples of records required to be kept by regulation were inspected. These included the staff rota, visitor book, menus, assessments, care plans, staff recruitment, complaints, fire procedures and fire drills. There were shortfalls with staff recruitment records which are detailed under the staffing outcomes. Discussions with staff and inspection of records confirmed that some staff had been trained on fire safety, first aid and health and safety. The manager said that all staff had been trained on these subjects but unfortunately we did not see records to confirm this, and so have made a statutory requirement on this shortfall. Service records were seen to show that the homes fire alarms, electrical installation supply and portable electrical appliances had been tested. The gas safety certificate seen by us was out of date. The manager said this had been retested on time and confirmed to us in writing on 11th February 2010 that the indate certficate was now displayed in the home. The manager also confirmed that hot water supply in the home is regulated at a temperature of or near to 43 degrees celsius to reduce the risk of scalding. This was not tested by us at this inspection. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 23 13 Evidence must be available for inspection to show that all staff have been trained on adult protection awareness. This is to show that service users are protected and that staff are trained for their roles. 30/04/2010 2 34 19 Records must be kept for inspection to evidence that at least two written references have been obtained for all staff who work at Divine Lodge. This is to ensure that proper recruitment procedures are followed and that service users are protected. 31/03/2010 3 35 18 Staff training records must include evidence to show that new staff had received structured induction training when they commenced working at Divine Lodge. 31/05/2010 Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to evidence that new staff are trained for their roles. 4 36 18 Evidence must be available to show that all staff are appropriately supervised. This is show that staff are supported in their roles. 5 42 13 All staff must be trained in First Aid, Health and Safety and Fire Safety. This is to ensure that staff are trained for their roles. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/09/2010 31/05/2010 1 19 Care records should include better detail relating to healthcare and medical appointments attended by service users. This is to ensure that all support staff have easy access to updates on peoples ongoing healthcare needs. All staff should be trained on understanding and responding to aggression and challenging behaviors. Staff should have new CRB disclosures undertaken as part of the recruitment checks carried out at Divine Lodge. All staff should receive written terms and conditions of employment relating to their roles at the home. 2 3 4 32 34 34 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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