Inspection on 12/05/05 for Melbourne Lodge

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Melbourne Lodge 27/06/07

Melbourne Lodge 30/06/06

Melbourne Lodge 25/11/05

Melbourne Lodge 29/09/04

Melbourne Lodge 21/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Melbourne Lodge 73-75 Greens Lane Hartburn Stockton-on-Tees TS18 5HT Lead Inspector Jackie Herring Unannounced 12 May 2005 10:00am 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 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 Stationary 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. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Melbourne Lodge Address 73-75 Greens Lane, Hartburn, Stockton-onTees, TS18 5HT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01642 587519 Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Mrs Michelle Cox CRH 18 Category(ies) of MD Mental Disorder (18) registration, with number of places Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29/9/04 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 accomodation, fourteen of which have an 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. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection, which took place over two inspection days, six hours of inspection time in total. Five residents, two staff and the manager were interviewed during the inspection. A range of records was examined and a tour of the environment took place. There was also some informal discussion and indirect observation during the inspection. On the first day of inspection, the manager and deputy were not in the home; the support worker who dealt with the inspection was very proficient and knowledgeable and handled the situation extremely well. What the service does well: What has improved since the last inspection? What they could do better: The internal environment at Melbourne Lodge is in need of internal redecoration and refurbishment as identified at previous inspections. The garden also continues to be in need of attention to make is more accessible to residents and a more attractive and safer environment. A clear plan is needed for this, which details the refurbishment and timescales for action as some of this work has been outstanding for some time. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 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 standard(s) 4, 5 Trial visits take place enabling residents to make informed decision about moving into Melbourne Lodge and they are provided with a written contract detailing what they can expect from the home. EVIDENCE: It was confirmed through discussion with staff and residents that trial visits took place prior to admission to Melbourne Lodge. The visits were said to commence with one or two hours to overnight stays. The inspector was also informed that there is an informal consultation system in place for seeking view of other residents about the admission of prospective residents. It was also confirmed that the manager always completes a pre-admission assessment. It was confirmed that residents receive a written contract, which included the required information of room number and cost of fees. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 Residents are able to make decision about their lives and take control over their lives in Melbourne Lodge. EVIDENCE: Residents confirmed through interview that they took control and made decision about their daily lives in the home. One resident said, “I make my own decisions about my daily life, I am free to go out when I want to, I can make myself tea/coffee when I want to”. Residents also confirmed that their assessment of needs and care plans had been discussed with them, were involved in reviews and had signed the documentation. Residents confirmed that there were regular meetings and they were involved and participated in aspects of life within the home. It was recommended to the manager that the minutes of the residents meeting be more readily available to them rather than be kept in the manager’s office. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 13,14,15,17 Residents benefit from a good range of leisure and social activities and are a natural part of the local community of Hartburn. Personal relationships are maintained, as residents want them to. Meals are provided to a good standard within a suitable environment. EVIDENCE: During discussion with the staff and residents, it was confirmed that residents had a flexible life with opportunities for social and leisure activities. One member of staff discussed activities ranging from cards, jigsaws, ten-pin bowling, barbecues, going to the local pub and meeting friends and family. It was confirmed that there was an activity budget and one of the support workers also co-ordinated a number of the activities. It was confirmed through discussion with residents that they were encouraged to make decision and be independent; one gentleman talked proudly of his recent purchase, he said, “I have just bought a bike and am enjoying going out on it”. Another resident said that he had been to Prague last year on holiday, which he had enjoyed. Another resident spoke of their interests in aircraft and said that he had been Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 11 to one of the air shows. Residents said they visited the local shops and local public house. A small number of residents access a day centre, one resident has completed a self-confidence and assertiveness course and another is waiting to hear about a possible City and Guilds course. Residents discussed how they were free to move around the house and some resident preferred to spend time in their bedrooms. Residents also described contact with friends and family. One resident said, “my mum visits once a week”. The manager said that contact is encouraged, however this very much depending upon the individual and their relationships. The inspector joined residents for an evening meal. There was evidence of choice, the meals were very well presented and the residents spoke very highly of the cook and the choice and variety. One resident said, “The meals are always good and there is usually a choice. “. Resident also said that they sometimes help the cook prepare meals, which they enjoyed Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 21 Systems are in place to ensure physical and emotional needs of residents can be met and the required policies and procedures are in place. EVIDENCE: Through discussion with staff and residents, it was confirmed that they could access the GP when they wanted to, there was regular involvement from consultant psychiatrists and outreach workers. A policy for ageing and illness had been developed since the last inspection, as this had been a recommendation. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 13 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 standard(s) These standards were not examined during this inspection. EVIDENCE: Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24, 27, 28, 30 Several areas at Melbourne Lodge did not provide a safe, well-maintained environment for residents. The garden needs to be developed further to ensure a safe and accessible environment for all residents. EVIDENCE: A number of areas still require attention from the last inspection such as, the outhouses remain in a state of disrepair; bedroom 17 although work has been carried out has not been completed; the garden continues to need further development and there continues to be trip hazards and garden rubble. The grey cabling around the doors and skirting boards was still evident and the ground floor corridor, particularly the ceiling was in need of redecoration. The bathrooms and showers continue to be in need of upgrade. No action had been taken to repair or replace some of the windows. Inappropriate signage in resident areas, such as first aiders, out of date fire training and labelling of the bathrooms, was also in evidence around the home. Some of the lounge furniture was in need of replacement as it had holes in it. On the day of the inspection the home was clean and odour free. The staff upstairs sleepover room is currently used as storage and one of the vacant ground floor bedrooms is being used for staff sleepover. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 15 The small quiet lounge at the front of the home was now the manager’s office, which did not impede on resident space. There was discussion with the manager that some of the work would be undertaken with some planned structural alterations and a possible extension is developed. It was discussed that there is the need to have an action plan for those outstanding areas with realistic target dates. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 36 A competent staff team who are regularly supervised meets residents’ needs. EVIDENCE: Staff informed the inspector that the training provided was “excellent” and gave details of both mandatory training, including moving and handling and fire training, a three-day induction covering the core values of care, medication training and more client specific training, two staff are currently completing some mental health training. The required NVQ training is also in place. Staff supervision records were contained within the two sets of staff files examined during the inspection. During discussion with the manager and staff, it was confirmed that regular supervision sessions take place with all care staff. Review and further development continues with the appraisal systems. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 Melbourne Lodge is a well run home with open and approachable management. Additional service certificates are needed to ensure the health and safety of residents. EVIDENCE: Residents and staff stated that Melbourne Lodge was a well run home. One resident said, “It’s as good as being at home”. The manager was described as very good, approachable and supportive. A requirement from the previous inspection was an up to date certificate for the electrical installation, this remains outstanding. The fire alarm system had received attention since the last inspection, however an up to date fire certificate was needed. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 2 x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Melbourne Lodge Score x 3 x 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 19 YES 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 YA24 Regulation 23 Requirement The outhouses must be repaired or demolished. (Previous timescale of 20 July 2004 was not met) A number of windows must be repaired or replaces. (Previous timescale of 30 March 2005 was not met) A programme of redecoration and refurbishment with realistic timescales must be developed and implemented. This includes general decoration as well as attention to bathrooms and showers. The refurbishment work to bedroom 17 must be completed. The garden must be developed further to ensure that it is safe and accessible to residents. (Previous timescale of 30 March 2004 was not met) The external repairs to the ventialation covers for the cellars and old gas meter cover must be undertaken. (Previous timescale of 30 March 2004 was not met) A number of chairs must be Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 20 Timescale for action 30 September 2005 30 September 2005 31 July 2005 2. YA24 23 3. YA24/YA27 23 4. 5. YA26 YA28 23 23 31 July 2005 30 September 2005 replaced in lounge areas. 6. YA42 23 An up to date electrical installation certificae and fire alarm cetificate must be obtained. (Previous timescale of 30 November 2005 was not met) 31 July 2005 7. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA36 Good Practice Recommendations The use of cetain signage around the home should be reviewed. The appraisal system should be developed and introduced. Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection St Marks Court Teesdale, Stockton-on-Tees TS17 6QX 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 Melbourne Lodge B51-B01 S12 Melbourne Lodge V226481 120505 Stage 4.doc Version 1.30 Page 22 - 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. 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