Inspection on 30/06/06 for Melbourne Lodge

This inspection was carried out on 30th June 2006.

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 1 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 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 30th June 2006 09:30 Melbourne Lodge DS0000000012.V301301.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.V301301.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.V301301.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 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Melbourne Lodge DS0000000012.V301301.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. 25th November 2005 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. Melbourne Lodge DS0000000012.V301301.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 inspection and completed across two inspection days, six inspection hours in total. A pre-inspection questionnaire was submitted prior to the inspection along with four residents surveys. A tour of the home took place, residents were engaged in discussion about their lives and care within Melbourne Lodge, discussions took place with staff members and a number of records were examined. These records included, residents documentation/care files, medication records, staff records and a small number of service records. This was a very good inspection in which the inspector was warmly welcomed and it was evident that the residents were very comfortable and were well able to talk freely about life within Melbourne Lodge. The current fees for accommodation and care in Melbourne Lodge are £343 per week. What the service does well: Melbourne Lodge provides the residents with a comfortable and homely environment, offering a high standard of care to the residents and is a very supportive and enabling environment for residents to live and staff to work. The staff are well trained , very knowledgeable and can competently meet the needs of the residents. Residents are clearly very happy and said “My keyworker is very understanding, very, very helpful”. “My keyworker reviews my plan of care with me”, “I am happy here at Melbourne Lodge an the staff are friendly and I get on with all of the other residents. I don’t know where I would be without here, it is a brilliant home and staff really work hard with me to keep me well”. The staff team are happy, clear about their job roles and speak highly of the training and of the support they received. One staff member said, “There is boundless support for me as an individual”. 66 of staff are trained in NVQ Level 2 or above and there is a very good training package in place to support the staff in delivering care to the specific client group at Melbourne Lodge. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 6 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. Melbourne Lodge DS0000000012.V301301.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.V301301.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 It is evident that assessment of resident needs are paramount to any admission to Melbourne Lodge and robust procedures are in place. EVIDENCE: Two sets of resident’s records were examined during the inspection and they contained a copy of the care management assessment and also the pre admission assessment, which had been completed by staff of the home prior to admission. It was clear from the details obtained that individual needs are fully assessed and that the home can well able provide the care and environment to meet those assessed needs. Residents spoke of visiting Melbourne Lodge prior to moving in. Melbourne Lodge DS0000000012.V301301.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Residents are well aware of their assessed needs and care plans, they are active in decision making, as a result their independence is promoted and care needs are clearly met. This will be further enhanced by the planned implementation of a more person centred documentation. EVIDENCE: The manager discussed the care records during the inspection and informed the inspector that they were in the process of developing them further to focus more on a person centred plan. Two sets of records were examined during the inspection which a good level of detail, there was clear information flow, assessments of needs were in place along with a range of care plans. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 10 There was evidence in both of the files that residents are involved in their individual assessment process and plans of care. A range of assessments were completed and part two of the assessment process is completed with the residents and their views are incorporated into this assessment. Residents were able to discuss the needs and the care received at Melbourne Lodge, they were very clear about their individual keyworkers and spoke of regular meetings with keyworkers to review their care. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 11 One resident said, “I have regular meeting with my keyworker, I can bring up any problems I have, I can talk to them, they listen and are extremely supportive”. Risk assessments were in place and certainly within one of the files, these were observed to be very personal to the individual and incorporated their agreement of a care management plan in areas of risk such as going out of the home unaccompanied. Whilst the records that were in place were very good, they did not fully demonstrate the progress that residents had made whilst living in Melbourne Lodge and the effectiveness of the care and support that had been given, this particularly related to individuals who had made clear achievements. There was agreement with the manager that the records would be enhanced further by the introduction of the new plan and would then clearly demonstrate the achievements made by the residents and staff in terms of their rehabilitation. Residents said, “I feel a lot better since being at Melbourne Lodge”, “My keyworker reviews my plan of care with me”, “My keyworker is very understanding, very very helpful”. Another resident said that their experience at Melbourne Lodge had been really positive, they talked about their personal development and progress and great improvement in their mental health. During discussion with residents they confirmed that they were well able to make decision about their daily lives, both within Melbourne Lodge and in the community. Residents meetings take place, residents are consulted about planned activities such as outings and holidays, and they are generally encouraged to take control of their daily lives with support from the staff. This was also confirmed through discussion with staff who said that Melbourne Lodge offered a very relaxed environment fro the residents, that they could make decisions, have choices and were consulted about a range of matters such as activities and meals. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 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): 12, 13, 15, 16, 17 Resident benefit from a good range of leisure and social activities. This could be further enhanced by a more person centred focus through the assessment and linked to social and lifestyle preferences. 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 they said the there were opportunities to be involved with a range of activities. One resident had recently commenced a computer course, another is in the process of undertaking National Vocational Qualifications, two residents are involved in a walking group, a number of residents are involved in day care activities and other residents choose to take part in their own hobbies and interest such as church or going to the betting shop. One staff member is also undertaking the role of activities co-ordinator has a very keen and enthusiastic attitude to activities and occupational therapy and is working with residents both on an individual basis and group basis. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 13 There have been programmes of art work in which ink paintings have been made, card making, gardening as well as board games such as scrabble and cards. There has been a recent successful quiz night which was run by the residents and also a recent trip to Whitby with a further trip to York soon to follow. During discussion with the manager and the activities co-ordinator it was agreed that the social and recreational activities could be enhanced further by linking to social and lifestyle assessments and maintenance of supporting records. Melbourne Lodge is a natural part of the natural local community and the residents access all of the local amenities and facilities. Residents spoke positively about relationships and friendships within the home and also with family members and boyfriends/girlfriends. Residents firmly believed they were treated with respect and very much as individuals. They said, “As an individual I feel well respected”, “I am free to come and go, I like to spend time in the quiet lounge listening to classical music”, “The staff listen to you, they are very good, very supportive”. Assessment were in place for daily living activities such as cooking, household chores, leisure, and work. Residents assisted in activities such as cooking, laundry and cleaning of their rooms and there are also small kitchens on each of the floors enabling residents to freely make drinks for themselves. A copy of the menus was made available prior to the inspection. Residents were very satisfied with the meals, confirmed they had choices which the inspector observed during the inspection. Residents said, “The food is varied, always cooked very well, always hot”, “The meals are very satisfactory”. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 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, 20 Residents receive personal and health care support appropriate to their needs and preferences, which ensure their privacy and dignity is respected and independence promoted. The medication systems are in the main robust, some additions to the record keeping would enhance this further. EVIDENCE: Residents and staff continue to describe Melbourne Lodge as a relaxed and friendly place to live. Residents said, “I have found it great here”, “I am chuffed to bits, looked at a few other places, no comparison to here, it is really great”. One staff said, “It is very much like home, not that many rules, very comfortable, flexibility is the aim as is making friends and encouraging independence”. Another member of staff said, “Melbourne Lodge is like a big extended family, it has a good friendly atmosphere and everyone is looked after equally”. Residents confirmed that they were also supported by Community Psychiatric Nurses or Social Workers, that they visited their GP when needed and also had involvement with Consultant Psychiatrist or Psychologists. Residents records also confirmed this and there were clinical notes in place as well as physical needs being attended to. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 15 During an examination of the resident’s files, it was clearly identified that residents are given the opportunity to manage their own medication and this was also confirmed through discussion with residents. A very good and clear process for assessing this was in place, which is carried out over a five day period. There was detailed discussion with the manager about the administration of medication within Melbourne Lodge and very good procedures were described along with confirmation of formal staff training and also in house updates undertaken on a regular basis by the manager. The individual medication administration records were examined and in the main contained the required information. It was however discussed with the manager that where items are hand-written onto the record that there should be a second signature. The actual storage of medication was appropriate and through discussion with the manager, it was confirmed that a number of staff are involved in the administration of medicines and received in house training and updates as well as the open learning certificated safe handling of medicines course. Evidence of this was available within a training file that was examined along with the update training. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 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): 22, 23 Residents are aware that if they had any concerns or complaints, these will be dealt with quickly and effectively and robust procedures are in place to protect residents from abuse. EVIDENCE: The complaints information was made available during the inspection and there had been no complaints recorded since the last inspection. The records did however contain all of the relevant information. One resident said during the inspection, “If I had any concerns or complaints I would speak to a member of staff about it, depending on what the concern was would depend upon who I spoke to and it would not necessarily be Michelle the manager”. The pre inspection questionnaire detailed that the complaint procedure was in place and had been reviewed in July 2005. There was clear evidence that the correct procedures are followed in the event that there was any concerns in relation to protection of vulnerable adults and these are also notified to CSCI. The pre inspection questionnaire also detailed that Protection of Vulnerable Adults training takes place. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 256, 28, 30 Residents generally benefit from a well-maintained, clean, comfortable and homely environment in which to live. The shower rooms would benefit from updating and the garden development will enhance the home for the benefit of the residents. EVIDENCE: Since the last inspection, a number of areas within Melbourne Lodge have been redecorated and refurbished, including the hallways, landing and stairs which were observed to be much brighter and airier. Some internal restructuring has also taken place with the development of a fully fitted one bedroom flat. The flat had been completed to a very high standard and consisted of a large bedrooms/lounge, a fully equipped kitchen, utility room and shower and toilet. This area will undoubtedly provide an excellent environment for individuals who are progressing on to independent living. There is a new residents lounge at the front of the house, which is very pleasing and comfortable. One of the other lounges has also been refurbished and is homely and comfortable and includes a computer area for residents use. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 18 During discussion with the manager, it was confirmed that there continues to be a maintenance, repairs and renewal programme in place and plans for the future is the replacement of some of the carpets and the refurbishment bathrooms and showers which are a little dated with one or two broken tiles. Remedial work has been undertaken on the windows however some continue to show signs of wear and tear. Developments have also taken place externally, with the outhouses having been repaired and work underway in improving the gardens. A lovely rockery had been developed at the front of the house which contained shrubs and a seating area had been built in, which was observed to be well used. Work was also taking place in the back/side garden and all of the garden work had been completed by one of the staff members as well as one of the residents who were taking great pride in this. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Robust recruitment and selection procedures and regular training opportunities ensure that residents are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Three sets of staff files were examined during the inspection all of which contained the appropriate information such as application form, references, job description and Criminal Record checks. The files were well presented with a good flow of information and demonstrated very good recruitment practices. The pre inspection questionnaire detailed that 66 of the care staff were trained to NVQ level 2 and it was confirmed with the manager that a further two staff are trained to level 3. A thorough induction programme was described by the manager who said that this continues to be a three day induction delivered in one of Care UK’s training rooms and completed prior to commencement of work within the home. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 20 Other training was detailed within the questionnaire and described by the manager and staff. Included in this is the mandatory training such as fire and first aid as well as more client specific training including, Dementia Care awareness, Mental Health Introduction, Risk Assessment, Challenging Behaviour, Breakaway techniques, Safe Handling of Medicines. The manager also confirmed that training was provided to develop skills in terms of management such as Investigating Complaints. Individual training records are also in place and contained copies of all certificated courses. Within a file examined it contained detailed training records for the staff member concerned and included evidence of No Secrets training, NVQ Level 2, Safe Handling of Medicine and other training as described above. Staff were very clear about their job roles and said when asked about the role of a keyworker, “It is to ensure residents well being is ok, that they are well looked after and their needs are met, this is the ethos of the home”. “There is loads of training, I have my NVQ Level 2 and will be starting my Level 3 in September, my training needs are well met”. Residents said, “All staff are very, very pleasant, they are polite, caring and helpful and understand my needs”. Staffing levels had been increased within Melbourne Lodge and there are now two waking night staff. Supervision records were also contained within all of the files examined and demonstrated that formal supervision is carried out on a regular basis. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Residents benefit from a well managed home, which provides consistently high standards with sound leadership and support to the staff team ensuring residents needs are met. EVIDENCE: During discussions with residents and staff, Melbourne Lodge was described as being a very well run home. Residents who were spoken to spoke highly of the home, one resident said, The manager runs the place really well. Another resident said, Melbourne Lodge is very well run and organised , “This is a very calm place, excellently run with excellent staff, certainly a good environment in which to get better”. One staff member said, There is boundless support for me as an individual. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 22 Quality assurance systems were discussed in detail with the manager and residents surveys and staff surveys were made available for examination. It has previously been identified that the analysis of the surveys could be improved to make more accessible to residents and staff. The analysis is currently numerical and graphical and could be enhanced further by having a written report to support it which should included some of the positive comments detailed such as, “I am very happy her in Melbourne Lodge and the staff are all friendly and I get on with all the other residents. I don’t know where I would be without here, it is a brilliant home and staff really work hard with me to help me keep well”, as well as detailing any action points. Self audits are also taking place within the home and regular visits are undertaken by a senior member of staff within the organisation to monitor standards. The residents personal finance systems was looked at and found to be a well managed, well-recorded and robust system. A small number of service and maintenance records were examined including the certificate to show that the five year periodic electrical installation had been checked and completed, the pre inspection questionnaire detailed that other equipment servicing such as the fire alarm, gas installation and emergency lighting was up to date. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 3 X Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement When it is necessary to handwrite on the Medication Administration Records, this must be witnessed and signed by two people. Timescale for action 06/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA6 YA12 YA24 YA27 Good Practice Recommendations The residents individual plans would be further enhanced by being more person centred and should demonstrate achievements made by individuals. The activities should be linked to individual social and lifestyle assessments and effectiveness of these detailed within residents records. The windows of the home should be monitored to ensure they are suitable and effective in colder weather as they are showing some signs of wear and tear. The planned refurbishment of the showers/bathrooms should take place. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 25 5. YA39 The quality assurance systems in regard to residents and staff surveys could be developed further to provide a written report of the surveys. Melbourne Lodge DS0000000012.V301301.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Tees Valley Area Office Advance 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 DS0000000012.V301301.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!