Inspection on 27/06/07 for Melbourne Lodge

This inspection was carried out on 27th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 09/07/2008.

CARE HOME ADULTS 18-65 Melbourne Lodge 73-75 Greens Lane Hartburn Stockton-on-Tees TS18 5HT Lead Inspector Jackie Herring Key Unannounced Inspection 27th June 2007 09:30 Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 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 Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 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. Melbourne Lodge DS0000000012.V344487.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) Mrs Michelle Cox Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named individual over the age of 65 years in the home. 30th June 2006 Date of last 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 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. The fees for Melbourne Lodge are £343 per week. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed in one inspection day, four and a half inspection hours in total. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. On this occasion, there were two visits to the home. Resident’s records were looked at, along with some medication records, staff records and training records. Discussion took place with residents, staff and the manager to find out what life was like at Melbourne Lodge. A number of resident’s surveys had been completed, as had one relative survey. This was a very positive inspection and the inspector felt very warmly welcomed by the residents, staff and management team. What the service does well: Melbourne Lodge continues to provide a pleasant, warm, relaxing and welcoming place for the residents. The staff are enthusiastic about working at the home and clearly have very good relationships with the residents and are good at supporting them to meet their needs. This home continues to be extremely well managed offering a high standard of care to the residents. Residents are clearly very happy and said, “I like it here, it is a good a place as I would ever have, I can even get a good nights sleep now, it is warm and clean”, “I love it here, the security of it, and have overcome some of my past stress and anxiety”. Staff are very well trained with 75 of care staff having achieved or in the process of completing National Vocational Level 2 in care and 50 will have achieved National Vocational Level 3 by the end of this year. There is a good training programme in place, which is developed around providing staff with the knowledge to meet the resident mental health needs. The individual assessments of needs are well written and residents are included in the assessment and care planning process. One residents said, “My keyworker took me through everything, discussed my assessment and there is ongoing discussion about my plan”. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 6 Residents clearly make their own decisions and have choices about the life within Melbourne Lodge. One of the residents surveys stated, “The service and support has been excellent and very friendly, they have helped me get through”. Staff said, “Life for the residents, it’s their choice, if they want to go out we don’t stop them, they can come and go as they want to as long as they tell us and what time they will be back”, “It is a relaxed and flexible life for the residents”. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Melbourne Lodge DS0000000012.V344487.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.V344487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s individual aspirations and needs are assessed before they are admitted to the home. EVIDENCE: Two sets of residents records were looked at, both of which contained a copy of the care manager’s assessment. Of the records looked at, one was the most recent admission and the other was a longer standing resident, selected at random. It was confirmed through the AQAA, examination of records and discussion with staff that resident’s needs are fully assessed prior to moving into Melbourne Lodge. The homes own pre admission assessment was very detailed and personal and had been completed by staff of the home prior to admission, which the individual residents were involved in. The home is well able to demonstrate it’s capacity to meet the full assessed needs of individual residents admitted to the home. A good process was described with residents having the opportunity to visit on several occasions including overnight stays prior to any decision being made about moving in. One resident described having visits to the home and said, “I looked around prior to moving in and had a choice of rooms”. Melbourne Lodge DS0000000012.V344487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are well identified and met through the assessment and care planning systems. Residents are consulted about all aspects of their life and are supported to be as independent as possible. EVIDENCE: All of the residents have assessments and plans of care in place within Melbourne Lodge. Observation during the inspection, conversation with residents, the manager and staff as well as examination of care planning documentation and daily records evidenced that each resident received good personal and individual support. Two files were looked at in detail, both of which contained a good level of assessment information, which was very personal. One of the files contained a clear care plans and risk assessment documentation and the other was still in the process of being developed, this being the most recent admission to the home. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 10 There had been some delay due to the staff attempts of trying to consult with the resident and get their agreement about their assessment and plans of care. As this consultation and agreement had not been obtained, the keyworker was in the process of meeting with staff from the multi-disciplinary team to agree the plans that will be in place. This is needed; as there are identified risks that need to be assessed fully and care plans need to be in place. A further set of records was looked at to confirm the level of detail and information and resident involvement with this process. Work continues to be underway to develop the records yet further with more person-centred planning to take place for which some training has taken place. The care plans in place were also very well evaluated, contained a very good level of information which clearly related to the specific care plan and was being evaluated on a monthly basis. Very informative and detailed daily records are in place. The documentation continues to contain a psychiatric, family, social and medical history, has clear links to multi agency involvements and clearly demonstrates that individual residents mental health, emotional and physical health needs were being met. During discussion with residents, they confirmed that they were actively involved in discussion with their key worker or co-key worker about their care needs, plans for the future, areas for risk management and activities. One resident said, “My keyworker does my care plan every month, he talks to me about it and ask me how I am doing and if there is anything I need”. Another resident said, “My keyworker took me through everything, discussed my assessment and there is ongoing discussion about my plan”. A staff member said, “I am a keyworker and it is about being there for them, to attend CPA meetings, hospital appointments and to discuss their assessments and care plans, which we both sign”. “I have really seen improvement with one of the residents I am keyworker for and we are in the process of changing and discontinuing some of their care plans”. Residents continue to speak of an environment in which there is very good communication, with everyone being treated very much as an individuals who were able to express views and opinions. It was confirmed that there were opportunities for both informal and more formal discussion with residents meeting taking place. One resident said, “The staff are very good, I can talk to them and discuss any issues I might have”. Another resident said, “I get on with all of the staff, they speak respectfully to me, everything is just right, I couldn’t find anything better”. Melbourne Lodge DS0000000012.V344487.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): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their lifestyles are very much individualised and there are appropriate social and recreational activities as well as opportunities for personal development. Residents’ benefit from maintaining personal relationships and have their right respected. Meals are provided to a good standard within a suitable environment. EVIDENCE: During discussion with residents and staff it was confirmed that there are a number of opportunities for activities and personal development, both on an individual basis or group basis. One resident said, “I like to watch TV, read and I try to walk for an hour each day. We go out on trips to the cinema, ten pin bowling, have been on the Teeside Princess and to Whitby”. Another resident said, “I go to town every Monday, sometimes go to the betting shop and the library and last year I went to Whitby and York. I am interested in going to Blackpool this year and this is being arranged”. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 12 The manager confirmed that the organisation funds an annual holiday and other social outings for residents. Residents have been consulted about holidays and so far there are planned holidays to Blackpool and two residents are going to Portugal with staff. Staff also confirmed that a key member of staff organises outings and activities and that there are also a range of inhouse games such as cards, dominoes and scrabble. The care records did not fully record the range of activities that individual residents were involved in and the progress made, however work is underway in developing more person centred care, which will tie into this. As well as holidays and outings, a small number of residents are involved in attending day centres, going to college to do cookery or computer course or doing some unpaid work at a local charity shop. The Annual Quality Assurance Assessment detailed that contact with friends and family is encouraged and that previous lifestyle is taken account of when planning care and that support is given to maintain involvement in activities that residents were involved in prior to admission to the home. Staff said that family contact and friendships were encouraged, with some relatives visiting the home, residents visiting their relatives in their own homes and regular telephone calls. The manager said that the residents had opportunities for involvement and decision making, that residents meetings take place and that they are also consulted about the meals and menu planning. The meals were discussed and residents said, “The meals are very good, the portion sizes are good and there is fresh fruit available”, “Very good meals, there is choice and healthy meals”. Staff said that there was a choice and alternatives available; that residents could help themselves to breakfast and that the residents had their own kitchens where they could make tea/coffee when they wanted to. Melbourne Lodge DS0000000012.V344487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s healthcare and personal care needs are met by staff that provide support in a sensitive and flexible manner in accordance with the wishes of the individual residents. Appropriate healthcare professionals provided advice and additional support. The systems for managing residents medication are very good and residents are supported where appropriate to manage their medication. EVIDENCE: Residents described a fairly relaxed life within Melbourne Lodge and one in which they were able to make their own decisions. One resident said, “I love it here, the security of it, I can make my own decisions, I can do my own washing and ironing and make tea/coffee when I want to”. One of the residents surveys stated, “The service and support has been excellent and very friendly, they have helped me get through”. Staff said, “Life for the residents, it’s their choice, if they want to go out we don’t stop them, they can come and go as they want to as long as they tell us and what time they will be back”, “It is a relaxed and flexible life for the residents”. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 14 The residents records looked at continue to be well-written and contained detailed information about the individual resident and their assessed needs. The records detailed involvement of GP, Consultant Psychiatrists, Care Programme Approach reviews and all health related matters. The home works closely with external professionals and specialists for advice and support to help the service user, their family and the homes’ staff. The medication system was looked at and of the records looked at they were well written with clear directions, there were no gaps in the medication administration records. The system for ordering was well described by the manager as were the systems for administration and storage, which were also confirmed by members of the staff team, all of whom are responsible for the administration of medication and have been appropriately trained. The system in place for administration within Melbourne Lodge is a two-person system with one being a witness to what is administered to residents. A number of resident continue to manage their own medication and there are clear risk assessments in place for this. Melbourne Lodge DS0000000012.V344487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a suitable complaints system and policies and procedures to protect residents from abuse. All staff had received training in the Protection of Vulnerable Adults. EVIDENCE: The AQAA detailed that there had been no complaints within the last twelve months and that there had been one adult protection issue that was an situation that had occurred in the community and not directly linked to the home, the home manager did however take the appropriate action in regard to safeguarding. The manager confirmed there are policies in place for the handling complaints and this had not changed since the last inspection at which time it contained all of the required information. A resident said, “I have no worries or concerns, if I did I would go to Michelle, the manager and she would sort it out”. The residents surveys showed that 60 of those residents who responded were clear about how to make a complaint should the need arise. Staff were clear about what to do in the event that a resident was unhappy about anything and referred to the procedure and the complaints book. Staff also confirmed that they are received training on Protection of Vulnerable Adults/No Secrets and Abuse and they again were clear about the procedure to follow. This training was evidenced within the individual staff files that were looked at. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well-maintained, comfortable and homely environment in which to live. EVIDENCE: Melbourne Lodge was visited on two occasions during this inspection and the home was walked around on both occasions. It was observed to be clean, homely and well maintained. Furniture was comfortable and domestic in design. Bedrooms that were visited were comfortably and appropriately furnished and had been personalised by the inclusion of personal effects such as pictures and photographs, TV, CD player etc. One resident said, “I am very satisfied with my room, I chose the colour and the window has been replaced with double glazing and this cuts out the noise”. The AQAA detailed that since the last inspection, all bedrooms had been decorated, and a number of new windows installed and improvements had been made to the outside areas including the construction of a barbeque. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 17 This was all confirmed during the visits to the home and was a significant improvement to the home. The AQAA also detailed plans for improvement within the next twelve months, including refurbishment to the kitchen and bathrooms, replacement of more window, replacement of more windows and one of the stair carpets. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill mix are appropriate for the resident’s needs. Staff are well competent to do their jobs and residents are protected and supported through the home’s recruitment procedures. EVIDENCE: Two staff files were looked at, one of which was the most recently employed staff member. The files contained the required information and checks, demonstrating the home is following the recruitment policies and procedures, for the protection of the residents. There is proactive management of the staff team, with a clear commitment to training and development. Staff spoke highly of the training that takes place and comprehensive training files containing a range of certificates was looked at. A staff member said, “I have done more training since being here than I have ever done before”. Currently, 75 of staff have achieved or working towards NVQ Level 2 and 50 of staff will be qualified to NVQ Level 3 by the end of the year. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 19 In addition, on of the more senior care staff is completing the assessor award and will then be working towards NVQ Level 4 and the Registered Managers Award. Staff said they had received a range of training as well as the mandatory training that is ongoing every year. The additional training includes Mental Health and Challenging Behaviour, Schizophrenia, Bi-polar disorders, Breakaway and Safe Handling of Medication, all of which supports the staff in meeting the mental health needs of the residents. It was also confirmed through discussion with the manager that the appropriate induction takes place, which is adapted from the Skills for Care within the company, completed within the required timeframe and then new staff commence the NVQ Level 2 in care. Contained within individual training files was the induction portfolio and workbook. Staff who were spoken to confirmed they had completed a detailed induction programme. The AQAA also detailed further plans for staff training, which included equality and diversity, investigation training and further mental health training including the Mental Capacity Act. Staff believed that one of the strengths of Melbourne Lodge was the staff team who were described as being extremely supportive of each other. One staff member said, “Brilliant staff team, supportive of each other and are flexible and friendly”. Residents said of the staff team, “I get on with all of the staff, they have been nice to me”, “The staff team are very good, I like them all, I can talk to them and am able to go to them and discuss any issues”. Staff who were spoken to believed there were sufficient staff on duty to meet the needs of the residents. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run and well managed home, which provide consistently high standards. There is good leadership and support ensuring resident needs are met. Good systems are in place for the handling of resident’s personal allowances and there is also a good range of quality assurance systems. The service and maintenance arrangements are in place and in place and appropriate to ensuring health and safety is promoted. EVIDENCE: The manager has the required qualification, experience and knowledge and is highly competent to run the home. She provides strong leadership and operates a very open management style, which is inclusive and enabling. One of the members of staff said, “Michelle does a really good job, if there are any problems, it is rare that she can’t sort out, she deals with matters immediately”. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 21 Residents spoke positively about the home. They said, “I like it here, it is a good a place as I would ever have, I can even get a good nights sleep now, it is warm and clean”, “I love it here, the security of it, and have overcome some of my past stress and anxiety”. The resident’s personal finance systems was looked at and found to be a well managed, well-recorded and robust system. The AQAA stated that as part of quality assurance, regular resident and staff meetings take place and audits take place monthly. During discussion with the manager it was confirmed that medication and care plan audits take place and that a new systems for internal audit had been developed and was to be introduce next month. This was said to look at systems such as meetings, administration, clinical care and the environment. The manager said they were also in there had been a redeveloped resident questionnaire as well as staff and visitors questionnaires. The results of these continue to in a graph format and the manager confirmed that they were in the process of reformatting them into a more accessible way for the residents. The AQAA detailed that the required servicing and maintenance of equipment had been serviced or tested as recommended by the manufacturer or other regulatory body. Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 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 3 3 X 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 4 33 X 34 3 35 4 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 3 X X 3 x Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA6 YA6 Good Practice Recommendations One of the care files should have the risk assessments and care plans completed. The work that has commenced on developing the resident’s individual plans with them being more person centred and demonstrating achievements should continue. The activities should be linked to individual social and lifestyle assessments and effectiveness of these detailed within residents records. The planned refurbishment of the showers/bathrooms should take place. The quality assurance systems in regard to residents and staff surveys could be developed further to provide a written report of the surveys, which is accessible to the residents. DS0000000012.V344487.R01.S.doc Version 5.2 Page 24 3. YA12 4. 5. YA27 YA39 Melbourne Lodge Melbourne Lodge DS0000000012.V344487.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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