Care Home: Corben Lodge

What the care home does well The home is warm and welcoming and homely. There is good access for wheelchair users and the home has a variety of equipment to enable and support the service users` independence. The meals at the home are well managed and the service users said meet with their satisfaction. We received positive comments from the service users in relation to the care and support that they are receiving. The service users are supported in maintaining links with the community and for developing independent living skills. The staff facilitate and support the service users in their social and leisure activities as well as attending college.Corben LodgeDS0000044248.V375124.R01.S.docVersion 5.2The AQAA tells us that as part of listening to the service users the home has renewed their front fence and additional seating has been provided in the garden. There is an ongoing programme of activities that met with the service users` satisfaction. What has improved since the last inspection? The service continues to review the support to the service users to access and be part of the community. According to the AQAA the home has developed links with a local sports college to introduce a variety of sports based activities to the service users. There is a programme of refurbishment to ensure that the home meets the diverse needs of people living there. The home has refurbished one of the kitchens to enable the service users to develop their skills in independent living. What the care home could do better: The care plans and assessments would benefit from regular reviews to ensure that they reflect the current needs of the service users. The staff must ensure that arrangements are in place and all aspects of medication management are carried out safely at all times. Procedures should be developed to ensure that as required medication is managed appropriately. Key inspection report CARE HOME ADULTS 18-65 Corben Lodge Moorings Way Milton Portsmouth Hampshire PO4 8QW Lead Inspector Anita Tengnah Unannounced Inspection 22nd April 2009 09:30 Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 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 (0) registration, with number of places Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION ditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability (PD). The maximum number of service users to be accommodated is 19. Date of last inspection 7th June 2007 Brief Description of the Service: Corben Lodge is situated in a residential area on the eastern side of Portsmouth. Portsmouth City council owns and runs the service. The home is a purpose built single storey building registered with the Commission to provide residential care for adults aged 18 to 65 years with a physical disability. The home has a registered manager who is responsible for the day-to-day management of the service. The home is centrally located and easily accessible to the surrounding areas and local amenities. The service benefits from a large well-established garden and level access suitable for people with limited mobility and wheelchair users. The current fee charged ranges between £798-£1141. Information about any extra charges that are not included in the fee is available at the service. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one Star. This means the people who use this service experience Adequate quality outcomes. An unannounced visit to the service was undertaken as part of the inspection on the 22nd April 2009. The process included looking around the service where a number of the bedrooms, communal areas and bathrooms were viewed. As part of case tracking staff and service users views were sought, care, staff and other records were looked at. We sent out our Annual Quality Assurance Assessment (AQAA) to the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This is included in this report, as was information gathered by the Commission since the last inspection to contribute in assessing judgements in this report. We have sent out some surveys to the service and we spoke to the staff and the service users, as part of this visit. We received positive comments in relation to the care that people were receiving and these will be reflected in this report as appropriate. What the service does well: The home is warm and welcoming and homely. There is good access for wheelchair users and the home has a variety of equipment to enable and support the service users’ independence. The meals at the home are well managed and the service users said meet with their satisfaction. We received positive comments from the service users in relation to the care and support that they are receiving. The service users are supported in maintaining links with the community and for developing independent living skills. The staff facilitate and support the service users in their social and leisure activities as well as attending college. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 6 The AQAA tells us that as part of listening to the service users the home has renewed their front fence and additional seating has been provided in the garden. There is an ongoing programme of activities that met with the service users’ satisfaction. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Corben Lodge DS0000044248.V375124.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 Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There preadmission assessment process in place ensures that the service users’ needs are assessed prior to care provision. Information is available to enable people to make an informed choice. EVIDENCE: We looked at the care records of two service users who had recently started receiving care at the home. The manager stated that there is a variety of information that is available to the prospective service users. The AQAA states that information shared included that the service users are given a copy of the Statement of Purpose, the Service User’s Guide and the last inspection report. The service users are showed an album of photographs of the Unit including rooms and facilities. The AQAA states that these documents can be provided in a number of formats depending on the requirements of the individual. The assessments were detailed and a care manager’s assessment was also sought as part of the process of gathering information about the service users’ needs. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 9 The service users are offered the opportunity of visits prior to moving in and a senior staff also went out and assessed the service users in the Community as appropriate. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a system of care planning that supports the assessed needs of the service users. The service users are supported to take risks as part of independent living and make choices. EVIDENCE: We looked at the care plans and assessments for three service users as part of case tracking. There was detailed information relating to the physical and mental assessments, behaviour, nutritional, medication, and pressure risk assessments. The care plans for a service user who has regular respite care showed that detailed reviews, that staff said are undertaken on each admission so that any Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 11 changes in their needs are recognised. There was evidence that the service users are involved in the formulation of their care plans. Another service user’s records showed that they were receiving a Percutanous Endoscopic Gastrotomy (PEG) feed. The swallowing assessment has been completed and a record of this was maintained. Detailed instruction was available for the medication administration via the PEG and flushes. Care plans relating to PEG feeds such as the type of feeds, amount administered were not available and must be developed to inform practice and ensuring continuity of care. Evidence of care plans reviews must be put in place to ensure that these reflect the current needs of the service users, as these were not available in the records seen. One of the record showed that the person was not having a bath, however staff reported that this had changed following an occupational therapist assessment and care plans had not been updated to reflect this. Risk assessments were carried out for residents’ behaviour and specific activities such as going out. The service has a key worker system in place and the manager reported that staff have 2-3 key workers allocated to the service users to ensure that they have and they can maintain continuity of care. Information from the AQAA states ‘Key-workers actively provide one-to-one support, maintain care plans and ensure that other staff always know the current needs and wishes of the individual.’ Corben Lodge DS0000044248.V375124.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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good system in place that supports the service users in developing independent living skills. The social and leisure activities are well managed that offer the service users choices and met with their satisfaction. EVIDENCE: We looked around the home and the home has developed two units where the service users are supported to develop independent living skills. This included adaptations in the kitchen and washing machines that were all accessible to wheelchair users. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 13 One of the service users was seen in the kitchen area having prepared their lunch. The home has another self- contained unit that the manager reported would enable a service user in preparing to returning home or more independent living. One of the service users comments were ‘I am going to be moving into my own home sometimes this year.’ We spoke to a number of the service users as part of the visit and they tell us that they are supported to take part in social activities and be part of the local community. One person commented that ‘I go to the pub and have support to get there but would like staff to stay with me sometimes’. Another person said ‘I go out sometimes but nowhere near what I would like.’ The staff reported that as part of the monthly residents’ meetings, planned activities included visits to Birdworld, shopping trips, barbeque, and picnic at South sea. Some of the service users also attended the local college and were undertaking course in computer, drama. Eight of the service users also attended day care. Information from the service showed that one of the long-stay service users represents service users in the City to the Partnership Board and is employed on the Self-Advocacy Group. We observed the lunchtime meal and the staff were available to offer support with meals as required. The service users reported that they had a light meal at lunchtime and a cooked meal in the evening. All those spoken to at the time of the visit say that the food was ‘always’ good and plentiful. They were offered choices and hot and cold drinks were available at all times. The AQAA indicated that the service continues to enable service users to be involved in an increasing range of activities of daily living and to make choices about their own lives. This included four service users who had been resident for more than six months have been supported to move into their own flats in the community. Corben Lodge DS0000044248.V375124.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a system in place that supports the service users accessing and meeting health and personal care needs. The medication management in relation to Insulin was inadequate and poses risks to the welfare of people living at the home. EVIDENCE: We looked at the care records of three service users and this showed that detailed moving and handling assessments are completed and records of these are maintained. These gave the staff clear guidance relating to transferring the service users such as for one service user it stated that all transfers with hoist, sling and two staff. Specialist equipment was provided to ensure that resident’s are moved Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 15 and handled safely. The manager reported that slings were allocated to individual service users to promote safe practice. The staff are aware and support the service users to access the external health care as required. A referral to an Occupational Therapist (OT) was seen in one of the care records that we looked at. The AQAA indicates that a more consistent physiotherapy support for all service users would benefit the service users and the service will continue to work towards this goal. We looked at the medication management that the staff undertook on behalf of the service users. The staff maintained a record of all medicines received into the care home. The Medicine Administration Record (MAR) records seen showed that records of medication administered were maintained. The staff were aware of the procedures for medication that are administered as controlled drug. There was a dedicated cupboard for controlled medication at the home. We noted that medication that should be maintained in the fridge were stored appropriately. Daily monitoring of the drug fridge temperature was available; staff were made aware that records should include the minimum and maximum temperatures. The home has one service user who was receiving Insulin at the time of the visit. The staff reported that the district nurses drew the Insulin for a week at a time. This person was receiving Insulin twice a day at the time of the visit. The staff stated that they took the pre filled syringes to the service user who then self- administered their Insulin. The pre-filled Insulin syringes were kept in two plastic boxes and the lids labelled as the morning and evening Insulin. The pre-filled syringes did not contain the dosages, type of Insulin that was in the syringes or the name of the service user. This has the potential of posing high risk to the service users. The NMC Guidelines for the Administration of Medicines (April 2002) state “It is unacceptable to prepare substances for injection in advance of their immediate use or to administer medicines drawn into a syringe or container by another practitioner when not in their presence.” We raised our concerns with the manager and we wrote to him following our visit, to tell us of the action, as the registered person has taken to ensure that medicine is managed safely for the welfare of people living at the home. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 16 We also observed that the drug fridge was unlocked at the time of the visit and contained a quantity of medication that poses risk to the welfare of people. The manager took immediate action and the drug fridge was locked when we brought this to his attention. Development of clear procedure for the administration of as required medicine should be put in place in order to inform staff’s practice and ensuring that this is managed in a consistent way and meets the needs of the service users. The record showed that medication that consists of variable dosages did not show what dose was administered such as whether one or two tablets were administered. Medications that were transcribed onto the MAR charts did not have two signatures and should be developed as good practice. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a satisfactory process for dealing with concerns raised and training is available for the staff in adult protection. The process for dealing with the service users’ personal allowance is well managed. EVIDENCE: The home has a complaint procedure and this was also available to the service users in the information pack as provide by the home. The city Council provided the service users with their own complaint leaflet and a copy was seen at the service. The home also provides the service users with information about the advocacy service that is available to them. The manager stated that the complaint procedure could be made available in other formats and languages as required. The staff and the service users we spoke to and the comments we have received indicated that they were satisfied with care. Comments included: ‘Every one is very caring ‘ ‘I would tell the staff’ when asked what they would do if they were unhappy. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 18 We looked at past records of complaints that dated 06/07. This indicated that any concerns were dealt with and records maintained. We were unable to access the current log as the manager said this was kept on the computer and we did not get to view this. Arrangement must be in place to ensure that this is available for inspection as required. The AQAA states: ‘our induction training outlines what staff are expected to do if they are aware of an adult protection issue or complaint. During this induction staff are also made aware of our whistle blowing policy.’ Staff that we spoke to confirmed that they were aware of what constituted abuse and they would report to the manager as required and training in safeguarding is included as part of the induction process. A random sample of the personal allowance as managed by the home showed that accurate records were maintained. These included the dates of any amounts withdrawn or deposited plus a corresponding balance. Staff should ensure that two signatures are kept for all transactions that are undertaken on behalf of the service users. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users are provided with a homely and well-maintained environment that meets their needs. EVIDENCE: We walked around the home and looked at the communal areas and a number of the service users’ bedrooms and communal bathrooms. It was evident that they are supported to make their bedrooms their own. These were highly personalised and equipped to a high standard to enable the service users to maintain and further develop their independence. Several of the bedrooms have direct access to a bathroom with specialist facilities. A number of bedrooms have direct access to the garden via a ramp and patio door. Some of the service users were observed in the ground and others were supported in the garden areas. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 20 The home is clean, homely and well maintained and the residents commented, “The home is always fresh and clean.” Another service user told us that they liked their rooms and “the staff keep it always clean”. The service also benefited from a covered area where the service users were growing tomatoes. We noted that the garden would benefit from some attention. There is an ongoing renovation programme in place and recent work carried out included the main boilers being fitted with water softeners and other refurbishments. A new dishwasher had been fitted in the main kitchen. A new Unit sign has been supplied and fitted – service users were consulted about colours. Four bedrooms and a lounge/kitchen area are to be re-carpeted and redecorated as part of the maintenance cycle introduced by the Department. The fire alarm system has been replaced with a new modern system. The emergency lighting system is currently being brought up to revised standards. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is adequate staff to meet the current needs of the service users. The recruitment process protects the service users. There is an ongoing training programme, however evidence of mandatory training should be developed and recorded. EVIDENCE: The home maintained a duty roster for the carers and a separate roster for the ancillary workers and the kitchen staff. Information indicated that there are one senior staff and 5 carers on the morning shift, 1 senior and 4 carers in the evening, and night duty has 1 senior sleeping and 2 carers. The manager discussed that the county was looking at the staffing structure that would replace current senior sleeping in staff. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 22 The home has a complement of staff including some that have been at the home for a long time. The staff we spoke to stated that they felt that there were adequate staff to meet the needs of the service users. Comments from the service users included: “They are all very kind indeed, helpful and kind and I like it here.” “From the manager down to the cook. We are like a happy family.” One service user commented ‘Because not enough staff, to spend quality time with me or support me to go out’. Comments from the staff were positive and included: ‘All information is recorded in client files.” ‘Staff cover sickness and there are always adequate staff.’ One staff comment on what the service does well was ’ It meets the needs of the service users and also staff training and manager support: Another said ’ Have regular supervision.’ The service also has dedicated hours allocated to maintenance person, laundry, chef and kitchen assistants, domestic staff to support the other staff and ensuring that the service users’ needs are met. We looked at the recruitment records for three recently recruited staff and found that all necessary checks were completed and references were sought as required. Evidence of Criminal Record Bureau (CRB) checks was not available in two of the records. The Human Resource office sent confirmation of this to the home at the time of the visit. Staff we spoke to said that that there is an induction programme in place and this was informative. There is an ongoing training programme in place and recent training included ongoing National Vocational Qualification (NVQ) at levels 2 and three. A large number of the staff have completed refresher course in moving and handling. It was unclear from the training records available of the number of staff who had completed mandatory training in health and safety and fire. A training matrix that accurately reflects the training completed would be beneficial in identifying any training gaps. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a management structure that supports the staff and the service users. There is a monitoring system that looks at improvement in the care and service delivery for the service users. EVIDENCE: The home has a registered manager who has been at the service for twelve years. The manager holds an NVQ at level 4 and a diploma in management. Staff and the service users we spoke to said that they would be happy to approach the manager with any concerns. The AQAA tells us that the management team adopts an open door policy and Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 24 promotes good communication between all parties at all levels that include service users; staff and senior meetings are held regularly. Information is circulated within the staff team by e-mails and memos and at staff handovers. A Health and Safety Audit was carried out across the Department on 28th April 2008. The AQAA says that the staff performance is monitored to ensure that they follow the policies and procedures of the home and the Department. Staff have their own development portfolios to record their own training and development in a structured way within supervisions. Practice and performance are also discussed during supervision. The manager confirmed that as part of their internal audit, a representative of the council undertook regular monthly- unannounced visits. The last visit was completed in January 09 and none has taken place due to sickness and the County Council was looking at addressing this at the time of the visit. The manager stated that an audit of the service users’ views is planned for later on in the year. Records to support the mandatory training in health and safety that staff have completed should be developed and put in place. Information from the AQAA shows that there is a programme for the regular servicing of equipment. Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 25 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 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 26 Corben Lodge DS0000044248.V375124.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) 17 Requirement The registered person must ensure that arrangements are in place for the handling, safe storage and administration of the service users medication at all times. Timescale for action 30/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Corben Lodge DS0000044248.V375124.R01.S.doc Version 5.2 Page 27 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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