Inspection on 06/03/06 for Corben Lodge

This inspection was carried out on 6th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Corben Lodge 07/06/07

Corben Lodge 08/11/06

Corben Lodge 10/05/06

Corben Lodge 27/07/05

Corben Lodge 05/01/05

Corben Lodge 01/06/04

Corben Lodge 01/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Corben Lodge Moorings Way Milton Portsmouth Hampshire PO4 8QW Lead Inspector Mrs Clare Hall Unannounced Inspection 6th March 2006 10:00 Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 Adults 18-65. 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. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Corben Lodge Address Moorings Way Milton Portsmouth Hampshire PO4 8QW 023 9273 1941 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.portsmouthcc.gov.uk Portsmouth City Council Mr Michael Paul Collinge Care Home 19 Category(ies) of Physical disability (19) registration, with number of places Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to 19 male and female service users in the PD category between 18 and 65 years of age. 27th July 2005 Date of last inspection Brief Description of the Service: Corben Lodge is a local authority run home situated in a residential area on the eastern side of Portsmouth. The home, built over twenty years ago, is a purpose built single storey building with 24 hour staffing originally aiming to provide rehabilitation to enable adults with a physical disability to achieve greater independence and to move on into specialist housing provision in the community. At the time of this inspection there was a high proportion of permanent residents, one of whom spoken to had lived at Corben Lodge for over 18 years. The remaining accommodation was offered to people living in the local community to recieve short stay, respite care, weekend programmed care, and one person was staying in the purpose built rehabilitation flat at the home. In addition there are some care packages available for people living in the community who may need use of Corben Lodge facilities, for example assisted bathing, in order to sustain them living independently. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook the inspection over one day. An inspector spoke to one permanent and one temporary resident in depth, in addition to seven other service users. Three care staff members, one agency staff member including the deputy manager and the maintenance person were spoken with. Staff were spoken with individually and observed throughout the day assisting and supporting clients. A visiting social worker was also interviewed. Three resident quality assurance questionnaire responses were sampled and indicated that those clients were satisfied with the services and the support they were receiving. Service users were found to be aware of their personal records. Service users were observed making use of shared facilities and taking a communal meal. No letters in respect of the service were received but three responses to the home’s recent service user questionnaires were audited. Case tracking was undertaken as part of the evidence gathering process, with the involvement of service users. The homes’ records and documents were accessible throughout the day, and a sample of these was inspected. What the service does well: What has improved since the last inspection? Staff have updated and expanded some information regarding the service users. Quality assurance questionnaires for clients have been formulated and the views of service users are now beginning to be sought formally. Some client care records identified discharge plans on ad hoc record documents made up by staff. Staff identified knowledge of the longer stay clients and their current needs and long term goals despite not being fully recorded. Some areas of Corben Lodge have benefited from development and refurbishment since the last inspection visit. These much needed investments and improvements included provision of some double glazing, repainting of some external window frames and the updating of the heating system which is nearing completion. The inspectors were advised there are further plans to develop other areas of the provision that now fail to meet the national minimum standards (NMS) for a service providing care to people with physical disabilities. The heating system is ready to be upgraded, with appropriate Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 6 sized piping to make the heating efficient, laid ready to fit. This work will be completed when the weather is warmer, and should take approximately three days. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 The admission procedure for the home does not ensure that only service users are admitted whose needs can be met. Residents’ health , personal and social care needs are not supported by personal centred planning. EVIDENCE: Discussions with staff and records indicated that care documents are kept in relation to each client. It was discussed with senior staff that plans of care have been improved but lack consistency and uniformity. The documentation used to record information is haphazard with different staff using their own individual systems and formats. Folders are bulky, information is not archived and so a clear audit trail of current issues is not always apparent. Staff spoken with shared valuable information regarding their clients, they demonstrated that they were well informed and described how certain clients have the manual dexterity to safely undertake kitchen tasks i.e. putting on the kettle after filling it with water, but this was not reflected in the care records, or risk assessments. It was established from the deputy manager that the organization is addressing the need for better recording tools. This need has been identified by the CSCI during previous inspections. The home’s philosophy of care towards person centered practice and for the emphasis of care being on the individual’s abilities rather than their disabilities Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 9 was not clearly evident. The current documentation does not encourage this approach and is in need of significant improvement. Overall the care assessment does not meet the minimum standard required. The service user’s assessments did not adequately inform the care plans in detailing needs wishes and the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met nor did they indicate or reflect a goal based programme to achieve skills for independent living, long term goals to promote and maintain a level of independence or assessments in such essential areas as the promotion of mobility, exercise and nutrition. Residents did identify at the last visit that they had concerns regarding weight gain whilst wheelchair dependent and its effects on mobility. One client visited by the inspector appeared severely underweight but had not had a nutritional risk assessment undertaken. The manual handling risk assessments were audited and had been completed in full. It was indicated in the minutes of the residents meetings that key workers were to discuss with clients and note in their individual plans of care peoples choices regarding how much they would like to be involved in participating and managing their own household tasks, shopping, self medication, washing, cleaning, cooking etc. Records of a recent residents’ meeting stated this was having to be promoted because the Commission wanted service users to do it rather than the emphasis being put on empowering individuals and allowing them to utilize their skills and have more control of their lives with the promotion of their abilities rather than disabilities. It was noted that more than one resident did raise concern that they had been prevented from doing things due to risk. The manager did discuss plans to improve care planning and assessment documentation and record keeping on the last visit, and a new system was shown to the inspector at this time. The deputy manager confirmed that this has not been implemented. All records held were stored in lockable cabinets inside offices, and residents were aware of information held about them. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 The home fails to adopt a consistent system for person centred planning. The home fails to promote meaningful goal planning, and adequate realistic, service user led, independent living opportunities for residents to experience participation in the running and control of their home and their daily lives. Confidentiality appeared to be promoted. EVIDENCE: Person centered planning is necessary to record the plan of ongoing support and rehabilitation with short and long term goals so as to clearly identify a discharge plan based on the clients rehabilitation goals, and their wishes with time scales leading to their integration back into the community. The care plans are still not consistently reflecting the wishes, needs, aims and goals of the clients. There was little evidence of any meaningful person centred planning. Due to an apparent lack of leadership, key workers had developed their own formats with key clients. This leads to a mixture of systems in place, and the potential for inconsistency and confusion. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 11 There is little emphasis on the promotion of independence or residents’ using daily living skills. Facilities available in the home to enable residents to be more independent are not utilised to their full potential. Inspectors were advised this is due to inadequate staffing levels. There appears to be a cultural reticence at the home in supporting residents to take acceptable risks as part of achieving a more independent and adult lifestyle. There was little evidence of residents being supported to take responsibility for such areas as self-medication, budgeting for food, shopping, food preparation and cooking. All meals are provided via the communal kitchen that is staffed by a cook. Foodstuffs are delivered to the home in bulk orders, with little or no direct involvement of the residents individually or as a group. Domestic staff members are employed to clean for residents rather than with them. Residents’ laundry is done for them. The ethos of the home should be such that staff are providing support and encouragement to residents, enabling them to develop and maintain independent living skills. The degree to which residents are enabled to take up their individual and collective rights to have full involvement in the running of their home is limited. Service users have been consulted recently. It is unclear how consultations with service users are going to influence the ongoing development and improvement of the provision. Residents generally said they were contented, but some younger residents and a person admitted as an emergency said they felt that they were not stretched at Corben Lodge and often felt frustrated at overprotective attitudes in the home. One resident said he would like to consider moving on from Corben to a smaller group living environment in the City, and would also like to look into the possibility of gaining employment. There was no mention of these aims and goals in the plan of care, and no evidence of linking with other agencies that could offer guidance and information to the resident concerned. Residents had been encouraged and supported to personalise their bedrooms and had their own audio-visual equipment in their rooms. Residents are enabled to attend education courses at local colleges. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The home fails to fully promote opportunities for residents’ personal development. Staff adopt overprotective interventions, with insufficient involvement/consultation with residents, accepting their adult status, or utilising adequate risk assessment. The home fails to fully acknowledge the rights and responsibilities of residents to lead full and meaningful lives, and overlooks how responsible risk taking may inform an individual’s quality of life. Service users are enabled to feel part of their local community, and to engage in activities outside of the home of their choosing. Service users are supported and encouraged to maintain and develop relationships inside and outside of the home. EVIDENCE: While residents are engaged in frequent and varied activities outside of the home, there was little evidence of meaningful daily living experiences with in the home. There was a lack of opportunity for personal development at the home. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 13 One resident had been given a capped beaker to drink from, and explained that he felt this was demeaning. He had been given the cup due to spilling a hot drink on himself and sustaining an injury. The resident said he had not been fully consulted, had not done this often and used to live independently with no problems in this aspect of daily living. Risk assessments had not fully involved the resident concerned in the decision to use a capped plastic beaker to serve his tea in. An additional concern from the resident was that staff often made his hot drinks “luke warm”, as well as serving them in a “kiddies cup”. While he understood this was due to a staff belief that they were acting in his best interest, he felt it was overprotective, and also led to the outcome of him feeling devalued as an adult and not being able to have a hot drink in a cup of his choosing. One staff member felt it was futile for the inspectors to ask service users specific questions about information they had received about Corben Lodge, as they were unlikely to remember. Another resident confirmed that he had close relationships with his family members, and had also managed to make a number of friends at Corben Lodge. Another resident, who was seeking to move on from Corben Lodge approximately a year ago, was still awaiting feedback about this move. Two residents shared concerns with inspectors about a staff member; the deputy manager advised these matters were being looked into. The staff member concerned had been a cause for concern at an earlier inspection visit, from a different source. The deputy manager advised the issue was being monitored. As identified above all food is provided via the commercial style kitchen area. This does little to promote ordinary living, or the abilities of residents in this aspect of daily living. However, residents did say that they were happy with the choice and variety of the food provided. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Practices in the home do not ensure the comfort and wellbeing of residents. There are serious deficiencies in the practice for the safe administration of medicines and care of a resident requiring palliative care. Care plans do not adequately focus on a person centred approach or fully inform staff practice. EVIDENCE: A resident had been admitted to the home whose care needs were associated with a terminal illness, and this is the subject of correspondence between CSCI and the provider. It was evidence during this visit that staff were unable to meet the needs of this resident. Senior staff were not aware of guidance for the treatment and support of people with a terminal illness or where the information could be found. It was established during this visit that staff lacked the knowledge regarding adequate pain management and this was identified when the staff had failed to monitor the site and severity of pain and establish the need for appropriate forms of analgesia to support the client. The service user’s care plan did not identify pain as a problem and it was therefore not identified or monitored in any form, nor was the service user encouraged therefore to report sequence and severity of any pain. A lack of enhancing pain management by the lack of pain assessment tools in the home was noted. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 15 The controlled drug cabinet keys were attached to the main bunch of keys given to staff to access other areas of the home, contrary to best practice. The deputy manager was advised that the person in charge must be responsible for the controlled drug keys at all times and keep them on their person. A number of other serious concerns were noted and evidenced at the time of the inspection and a letter of serious concern has been sent to the provider in respect of these. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected – see previous report 27/7/05 EVIDENCE: Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 and 30 The home is clean and hygienic and free from offensive odours. Insufficient use is made of group living facilities available in the home to promote independence of residents and increased control over their daily lives. Improvements are being made to the maintenance of the home and the heating system. EVIDENCE: Staff were observed making use of individual alcohol gel rubs and sinks within the sluice and laundry areas had an adequate supply of gloves and waste units appropriately prepared with colour coded bags. Surfaces were clear and laundry organised away from dirty receptacles. Walls and floors were in a good state of repair and clean. One washing machine was out of order and still held the dirty part washed laundry. The deputy manager stated that there were two machines currently out of order but this was being dealt with. One service user described the homes process for collecting and returning laundry. A resident spoken to stated his laundry was always returned to him without delays. He stated things were never lost as he had his initials in all his clothes including his socks. It was noted that no residents were undertaking their own laundry as part of promoting independence; the deputy manager advised this was due to insufficient staff to support such activities at Corben Lodge. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 18 Action had been taken to provide a number of replacement double glazed windows to the home, including double-glazing to the central forecourt area that has improved the warmth of this area of the home. Other windows and frames had been decorated, and the external aspect of the building appeared to meet the standards, and residents explained that they felt the home was better presented now. However, due to the design of the building large areas of wood cladding now need painting. New piping for the central heating system has been laid ready to connect to the boiler system, to remedy historical heating problems at the home. This work will be completed when the weather gets warmer as it will take approximately three days to complete the process. Aids and adaptations are provided throughout the home as required of a service for people with physical disabilities. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 35 There are insufficient staffing levels to fully promote the independence of the resident group on a daily basis, and to achieve the home’s stated purpose. There is a culture of doing things for residents as opposed to doing things with them, or supporting them to do things for themselves. Long-term sickness, and insufficient staff numbers are adversely affecting the effectiveness of the staff team. EVIDENCE: There are insufficient staff members to enable residents to achieve greater independence, choice and self-determination. The staff team appear to lack coherent leadership and adequate resources in a number of areas such as promoting service user independence, and need further training in this area as well as risk assessment and person centred planning. The staff team need to be supported and developed to encourage them to empower the resident group. This needs to be promoted by the registered body and manager. Over 50 of the permanent staff team have received NVQ training. Staff members spoken to stated that they received regular training and development opportunities. There was a high use of agency staff noted. A number of staff members are currently off work due to long-term sickness. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42 The home has started to actively seek the views of service users but this requires further development and monitoring. The home is not run for the benefit of and in clear consultation with residents. Residents’ safety was compromised by the practice of holding open fire doors. EVIDENCE: Three responses to questionnaires provided to clients were audited. These responses by clients indicated that they had been provided with information regarding the service and that they had been involved in some aspects of decision making. They stated that they were satisfied with the majority of the staff. Support was of a good quality and the home provided activities, and opportunities to pursue activities externally from the home. All three responses stated satisfaction with the accommodation provided and stated that they were aware of how to complain. One response did identify that the first room he had was gloomy and cold. It was further discussed with the deputy manager that the process for seeking the views of service users needed now to expand to all service users including respite and/or short stays, and other stakeholders. The Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 21 results would also need to be audited and a clear trail of actions taken in respect of the results, it is also essential that action be taken to use service user consultation in regard to the ongoing improvement and development of the services provided. Further development and staffing resources are needed for the home to meet its own stated purposes. Staffing levels were insufficient to promote service user independence to a meaningful level. The operational manual for the home, which contains the policies and procedures, was not organised in a manner that made it possible to locate guidance quickly. There was no method of indexing the contents of this very large file. The deputy manager was unable to locate information requested by an inspector, including a procedure required from the last inspection report. At the time of the visit a brick was holding open the fire door to the laundry area. This practice puts service users and staff directly at risk and must stop immediately. Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 22 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 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 1 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 3 LIFESTYLES Standard No Score 11 2 12 3 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 1 x 2 2 2 2 X 1 x Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 23 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 YA1 Regulation 4(1) Requirement The statement of purpose must clearly describe the service provided. A copy of the revised statement of purpose must be sent to CSCI by the given date. Timescale for action 17/04/06 2 YA3 14(1) 30/04/06 The assessment process for prospective residents must be reviewed to ensure the home accommodates only those people whose needs can be met, in accordance with the statement of purpose and the conditions of registration for the home. Service users 17/04/06 independence must be fully promoted through the assessment and planning process, and in consultation with the individual residents. 3 YA7YA17 12(1)(a) 4 YA18 12(1)(b) There must be a written policy on same gender DS0000044248.V281819.R01.S.doc 30/04/06 Corben Lodge Version 5.1 Page 24 care. Procedures must be developed and residents consulted. This is repeated from the previous inspection. 5 YA39 24(1) Feedback must be actively 30/04/06 sought through a quality assurance process to seek the views and comments of residents, healthcare professionals, care staff/managers and relatives and other stakeholders of the services provided, must be used to develop and improve the quality of service and the outcomes for service users at the home.This has been raised again as it has only been partially met. Service users must receive specialist support and advice as needed from physiotherapists and specialist health care workers. Care records must be clear, factual, easily audited organized and user-friendly working documents. They must reflect current and ongoing needs with agreed short and long-term goals. Care plans must reflect clear discharge plans for those service users on short-term /respite stay or in a process of rehabilitation. Opportunities for education, work and other DS0000044248.V281819.R01.S.doc 6 YA18 14(1) a, b 30/04/06 7 YA6 15(1) 30/04/06 8 YA6 15 30/04/06 9 YA12 15(1) 30/04/06 Corben Lodge Version 5.1 Page 25 activities must be fully recorded as part of the on going person centred care planning process. 10 YA19 13(1)(b) Service users nutritional status must be monitored through assessment, regular weight checks and appropriate referrals made to dietetic services when needed. 30/04/06 11 YA24 23(2)(b) Windows, doors and 17/04/06 window frames not already redecorated and/or replaced, including wooden cladding areas must be fit for purpose and adequately maintained. Please provide an action plan by the given date. The registered person must advise the CSCI of the action they intend to take in order to ensure that staffing levels are in line with the identified support needs of the resident group, in order to implement person centred planning and the full promotion of independent living for residents. This has been raised in the last three inspection reports. Failure to comply will result in further action being taken. Medicines must be handled and administered in accordance with the requirements of the Medicines Act 1968,guidelines from the DS0000044248.V281819.R01.S.doc 12 33 YA3318 17/04/06 13 YA20 13(2) 17/04/06 Corben Lodge Version 5.1 Page 26 Royal Pharmaceutical Society of Great Britain,the requirements of the Misuse of Drugs act 1971 and the National Minimum Standards. be referred to the 14 YA42 23(4)(c)(i) The practice of wedging open strategic fire doors (example the laundry area door) puts residents at risk and must cease with immediate effect. 17/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Corben Lodge DS0000044248.V281819.R01.S.doc Version 5.1 Page 28 - 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. 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