Inspection on 22/06/09 for Melbourne Lodge

This is the latest available inspection report for this service, carried out on 22nd June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Melbourne Lodge 30/06/06

Melbourne Lodge 25/11/05

Melbourne Lodge 12/05/05

Melbourne Lodge 29/09/04

Melbourne Lodge 21/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Melbourne Lodge 73-75 Greens Lane Hartburn Stockton-on-Tees TS18 5HT Lead Inspector Jackie Herring Key Unannounced Inspection 22nd June 2009 09:00 Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melbourne Lodge Address 73-75 Greens Lane Hartburn Stockton-on-Tees TS18 5HT 01642 587519 01642 586791 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) David William Milbourne Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 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 care needs on admission to the home are within the following category: Mental disorder, excluding learning disability or dementia - Code MD, maximum number of places: 19 The maximum number of service users who can be accommodated is: 19 27th June 2007 2. Date of last key inspection Brief Description of the Service: Melbourne Lodge is an 18 bedded care home providing personal care to younger adults with mental health problems. The home is a converted Victorian property, which provides single room accommodation, fourteen of which have ensuite facilities. The care home is situated close to Hartburn village, which provides a range of shops, public houses and is on a bus route, which has improved recently. The fees for Melbourne Lodge are £368 per week for people funded by Stockton Borough Council and £400 for people funded by Middlesbrough Borough Council. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars – good service. This means the people who use this service experience good quality outcomes. This Key Inspection was to check that the home meets the standards that the Care Quality Commission say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. This inspection was conducted in one inspection day. During the inspection, a number of records were looked at, including care records of people who use the service, along with staff recruitment and training records. The medication system was also looked at. Time was spent with people living at Melbourne Lodge and there was discussion about their lives. Discussion also took place with the manager and staff. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. We have reviewed our practise when making requirement to improve national consistency. Some regulations from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. What the service does well: Melbourne Lodge provides people with a safe and comfortable environment in which to live. The home is a good place for people to live, there is a positive atmosphere and clearly very good relationships. People are provided with a good standard of care by understanding and supportive staff who ensure consultation takes place. People said, “I have a good keyworker and I am more confident since being here”. “I have a periodic assessment with my keyworker, there is discussion about how I am doing, I have read my assessment and understood it and I have signed it”. Staff are well trained, have the necessary knowledge and skill for their job roles and are very positive about the work they do. Staffing levels are Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 6 sufficient to support with their care and lifestyle needs. Staff spoke knowledgeably about the people they support. One person spoken to said, “There is no better home than Melbourne Lodge, I can voice my opinion, I came here to get well and I am much better”. A further person said, “I really like this place, it is about the help and support and I am doing OK”. One person said, “It is not a them and us, we are all equal”. A member of staff spoken to also said, “We have good working relationships, we value each other, we can have a laugh and joke but we are still professional”. The home is well run and managed and people living at the home speak very positively about the staff team and the manager. 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 order line – 0870 240 7535. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of people who are to use the service are carried out before they move into the home; this ensures that individuals needs can be met. EVIDENCE: The AQAA contained information about the process for admitting people to Melbourne Lodge. It was stated, “Give prospective users opportunity to spend time in the home, including overnight staffs, before making the decision about living at Melbourne Lodge”. Two files of people living at the home were looked at, one of which was for a person recently admitted to the home and one for a person who had lived at the home for a number of years. There was a pre admission assessment in place for the recently admitted person. Discussion also took place with this person and they confirmed that they had visited the home prior to moving in. In both care files looked at, there was also evidence of reviews undertaken by the relevant person such as care manager. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 who use the service are involved in everyday decisions and choices about their lives. EVIDENCE: The care records of the two people were looked at in more depth. They contained a range of assessments, covering activity of daily living assessments, behavioural and mental health assessments. A number of appropriate risk assessments were also in place where needed. There was also a completed self assessment that covered areas such as housing, finance, medication, occupation and leisure. Care plans are being well evaluated and it was good to see the individual people are, where possible being involved in the evaluations and are also signing them. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 10 It was identified that for people who had lived at Melbourne House for some time, there is the need to ensure that the full assessment is reviewed and updated, which will ensure that it reflects the person’s current needs. In one of the files looked at, this had not been updated since 2005. The manager accepted this and said that work is continuing in regard to the care records and this is now being looked at nationally within the organisation with the aim of developing a more person centred approach within the assessment records and care plans. Updating of the assessment records will also be considered through this national review. People spoken to said they were aware of their care plans, that they are discussed with them by their keyworker. There was evidence that people had been consulted and they had by signed by the individuals concerns. A member of staff was spoken to about the role of the keyworker at Melbourne Lodge, they said, “It is helping them if there is a problem, supporting them, attending CPA’s and doing the care plans and assessments”. People said, “I have a good keyworker and I am more confident since being here”. “I have a periodic assessment with my keyworker, there is discussion about how I am doing, I have read my assessment and understood it and I have signed it”. People also confirmed that the staff treated them with respect, one person said, “Staff are good, helpful and civil and very approachable”. Another person said, “There is no better home than Melbourne Lodge, I can voice my opinion, I came here to get well and I am much better”. A further person said, “I really like this place, it is about the help and support and I am doing OK”. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the 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 who use this service are enabled to make choices about their life style and are supported to develop their life skills. Social and recreational activities meet individual expectations. Food provided is varied and enjoyed by people living at the home. EVIDENCE: People who lives at Melbourne Lodge have a number of opportunities for recreational and social activities, if they so choose. The AQAA contained the following information, “Our service users are encouraged to take part in activities, including employment, within the home and community. We offer a range of organised outings and activities as well as unplanned everyday activities in and around the home”. There is a dedicated activities person who arranges all of the events in consultation with the people living at Melbourne House. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 12 People were observed to freely come and go throughout the day spent at the home. People said that they were able to make their own day to day decisions. They also said that there were opportunities to be involved in outings and activities, some on a small group basis such as weekly bowling and others that they do as individuals, such as snooker at a local snooker club which is a personal interest. Some people are involved in attending day centres, whilst others determine their own day to day lifestyle activities, some preferring to spend private time, while others go out quite a lot. One person spoken to said, “They are really trying hard with activities, we have had trips to Whitby, Barnard Castle and the Sealife Centre”. One person spoke of the work they do in the home, which includes helping in the kitchen with meal preparation as well as helping with the cleaning in the home. Through observations that took place on the day of the inspection and discussions with people living at the home and staff, it is clear that the home provides and environment that is flexible to individual’s needs, as well as being supportive in promoting independence, within a risk managed way. It is clear from the discussions that took place and through observation that people are valued as individuals and are able to express themselves. One person said, “It is not a them and us, we are all equal”. A member of staff spoken to said, “We have good working relationships, we value each other, we can have a laugh and joke but we are still professional”. Improvements had been made to the lounge areas since the last inspection; there is a new TV, DVD and CD. On the day of the inspection a snooker table had also been delivered which was purchased after consultation with the people living at the home. People also confirmed that they maintained contact and relationships with family and friends. One person spoke of a weekly visit to their relatives. People spoken to said they were very satisfied with the meals they are provided with. One person said, “The food is good, there is a choice and they are sufficient, I am quite happy”. Another person said, “There is always tow choices and you get enough to eat”. One person spoken to did however think that the supper could be improved as it was sometimes cereal. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 receive health and personal care which ensure their individual needs are met. Support provided is flexible, consistent, reliable and responsive to their changing needs. EVIDENCE: The AQAA contained the following information about meeting people’s personal healthcare needs, “Service users are encouraged and supported in making their own arrangements to access medical and psychiatric services”. The files looked at contained information about the involvement of other health care professionals such as consultants, GPs and district nurses. There was evidence of CPAS, hospital appointment and GP appointments. People were satisfied that they were supported in the way they wanted to be. One person spoken to they had a recent personal medical problem, that they felt had been dealt with really well by the staff, with no embarrassment to them personally, which gave them the support they needed. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 14 Staff also confirmed that appropriate reviews and checks take place to promote people health and wellbeing. The medication system was looked at and discussed with staff. It was confirmed that staff who are involved in the administration of medication have been trained to do so and have the required certification. There were risk assessments and monitoring arrangements in place for those people who choose to self-medicate. A file containing patient information leaflets for medication in use within the home was kept, it was agreed that this would be checked to ensure it was complete and current with the medication in use. It was identified that there was the need to strengthen some aspects of the ordering system. There should be records kept of all of the medication ordered for individual people. Staff should then have sight of the prescription prior to it going to the supplying pharmacist, to ensure that there are no discrepancies, which could potentially result in medication not being in stock. There is also the need to improve the record keeping for control drugs in respect of people who self-medicate. They need to be recorded within the Control Drug book as being received and then recorded when they are issued to the individual person. When entries are handwritten on the medication administration records (MAR), there is the need for it to be signed and checked by two people. The temperature of the room in which the medication is stored needs to be monitored to ensure that medication is being stored at the correct temperature. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 who use the service are confident that their complaints would be listened to, taken seriously and acted upon. Staff working at the home receive adult protection training which will help to ensure the safety of people living at the home. EVIDENCE: The AQAA detailed that there had been no complaints since the last inspection and that policies and procedures are in place to give people living at the home and staff the correct guidance should it be needed. Each person had a copy of the complaints procedure in their rooms. The complaint procedure has been review and updated, however there is the need to ensure people have been provided with the updated version. People spoken to said that if they had any concerns they would raise them either with their keyworker, the manager or any staff member. One person said, “If I was unhappy I would speak to my keyworker and I would also inform my family”. Another person said, “I would speak to my keyworker but then I could go to anyone”. A further person said, “I have no worries or concerns, if I did I would mention it to the staff”. The records looked at showed that a number of staff had received training in regard to No Secrets and protection of vulnerable adults and staff also confirmed this to be the case. In discussion with the manager, it was Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 16 confirmed that all staff have been trained in respect of POVA, however not everyone has a certificate. Further POVA training is to take place and the manager said that there is a move to incorporate some E_Learning, which will include the POVA training. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Melbourne Lodge provides people that live there with an attractive, homely and comfortable place to live. EVIDENCE: Melbourne House provides a warm and comfortable home for people to live. In two of the bedrooms visited, there was evidence of personalisation of individual bedrooms and other people also confirmed that they People living at the home all have their own rooms, each with a lock and people are provided with their own key. A number of improvements have been made to the environment since the last inspection. The ground floor corridor has been redecorated and new flooring has been laid. The appearance of this area is much warmer, lighter and spacious and significantly improves it. The ground floor and first floor lounges Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 18 have also been redecorated and there is new furniture in place. There are further plans to continue with the redecoration programme. Improvement to the bathroom and shower room has not taken place as planned due to other works that needed to take priority to ensure safety within the home, relating to the fire doors. This work will however be carried out when the budget is available. Work is also underway to repair the roof as there has been some leakage on the top floor. The outdoor smoking room has also been decorated since the last inspection; however it is not the best of environments in terms of ventilation. The manager is in the process of looking at alternative provision for people who wish to smoke and this is being piloted in one of the other homes. Externally, the front of the home is pleasant, with a pebbled area with seating and shrubs. To the side of the home, is a large grassed area, with additional unused car parking. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 homes recruitment procedure is good, which helps to ensure that people are protected. Mandatory training and other training relevant to the job staff do is provided ensuring that staff are knowledgeable and experienced to meet the needs of people using the service. EVIDENCE: People who live at the home and staff said there was sufficient staff on duty to meet peoples needs. Two staff files were looked at during the inspection, one for the most recent person appointed and one for a longer standing member of staff. The records were in good order and contained the required information such as fully completed application form and appropriate references. Criminal Records Bureau checks are also in place and it was confirmed that no one commences employment until this has been fully issued. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 20 It was confirmed that a week long induction is completed, which is in line with Skills for Care Common Induction Standards. Staff spoken to confirmed that the mandatory training was on a continuous rolling programme but that they also had opportunities of other training that relating to mental health and medical conditions of people living at the home. They also said that there was also training to keep you up to date with new legislation, such as the Mental Capacity Act and Deprivation of Liberties. A training matrix was made available, which was not fully up to date but it is acknowledged that training is in the process of being updated and rolled out to staff. Further training this week includes breakaway training. It was also confirmed that there had been recent health and safety training, moving and handling training and first aid training. It was also confirmed that there is regular supervision and that this is carried out by the manager or deputy manager and that the manager conducts and annual appraisal. People spoken to believed they were being supported well by the staff. One person said, “They really make you feel at home, I have a good keyworker and I am more confident since being here”. A good percentage of staff are trained to NVQ Level 2 or above and a number of staff are in the process of completing this qualification. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 manager provides very strong leadership to the staff team and continuously strives to improve standards within the home ensuring that residents needs are well met. Good service and maintenance arrangements are in place and in good order ensuring health and safety are promoted. EVIDENCE: The manager is registered with CQC and has substantial experience in this field of care. They have considerable knowledge, experience, qualification and skill to and are highly competent to manage Melbourne Lodge. Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 22 People spoken to about the home believed it to be a well run home that had the needs of the people living there at the centre of what it does. People living at the home said, “Bill, the manager is really good, he is approachable, you can talk to him and he listens”. “Bill is absolutely brilliant”. Of what the service does well a member of staff spoken to said, “The success at rehabilitation and people now living independently. The staff team and relationships and that it is more like a family home and is relaxed”. Monthly regulation 26 visits are taking place and detailed reports are written, which contain informative information about the home and identifies areas for further improvement. Meetings take place for people living at the home and the staff. Audits take place which contain the views of people living at the home and feedback is given at future meetings. A range of systems are in place to ensure that the environment is safe. The AQAA detailed that the servicing of equipment such as fire alarms were up to date. A sample of these records was looked at and it was confirmed that water temperatures are recorded weekly and that the fire alarm is also tested on a weekly basis. Melbourne Lodge DS0000000012.V376145.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 Adults 18-65 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 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X Version 5.2 Page 24 Melbourne Lodge DS0000000012.V376145.R01.S.doc No 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 YA20 Regulation 12/13 Requirement Records for ordering medication must be kept and accurately show what has been ordered. This will ensure that discrepancies are identified and that people have the medication needed to ensure their wellbeing. All controlled drugs must be recorded within the control drug register and these records should also be updated when issued to people who self medicate. This will ensure accurate records are maintained. Timescale for action 31/07/09 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. Refer to Standard YA6 Good Practice Recommendations The work that has commenced on developing the resident’s individual plans with them being more person centred and demonstrating achievements should continue. DS0000000012.V376145.R01.S.doc Version 5.2 Page 25 Melbourne Lodge 2. YA20 Handwritten entries and changes to MAR charts should be accurately recorded and detailed. This makes sure that the correct information is recorded so a person receives their medication as prescribed. The temperature of the room in which medication is stored should be monitored to ensure that it is the correct temperature. The planned refurbishment of the showers/bathrooms should take place. Improvement should take place to the smoking facility, improving ventilation. 3. 4. YA27 YA24 Melbourne Lodge DS0000000012.V376145.R01.S.doc Version 5.2 Page 26 Care Quality Commission North East Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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