Care Home: Derwent Lodge

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What the care home does well Staff supported each person to make decisions about their own lives by respecting them as individuals and ensuring that their rights to make choices and decisions was upheld. Risk assessments enabled individuals to conduct their lives as they chose to, by supporting and encouraging them to take and manage risks as part of their care and recovery plan. People using the service have benefited from a stable staff team with the majority of the staff having worked at the home for some considerable time. What has improved since the last inspection? The majority of the requirements from the previous inspection have been met. Staff supervision was taking place on a regular basis to ensure staff were supported and appropriately supervised within their role. Derwent Lodge had effective quality assurance and quality monitoring systems in place, which were based upon seeking the views of the people that used the service, in order to measure achievement, aims and objectives. What the care home could do better: Staff employment histories, that were recorded on staff application forms only requested the last ten years employment history and not a full employment history as required by law. Without a full employment history the employers are unable to ascertain each employees or potential employees work history or the reasons for any gaps in employment. This means that they are unable to ascertain if the individual has worked in any previous roles with vulnerable adults or children prior to the last ten years and ascertain the reasons why they left those positions. All of this information is required to ensure the staff employed are suitable to work with the people using the service. A training matrix should be in place to demonstrate that staff have undertaken the required training and enable the manager to ensure that staff training is kept up to date. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Derwent Lodge Derwent Lodge 11 Beaufort Street Chaddesden Derby DE21 6AX     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Angela Kennedy     Date: 2 6 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Derwent Lodge Derwent Lodge 11 Beaufort Street Chaddesden Derby DE21 6AX 01332347597 F/P01332347597 derwentlodge@rethink.org www.rethink.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Rethink Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Derwent Lodge care home provides nursing and personal care for up to sixteen people, eight males and eight females, aged 18 to 65 years, with mental health needs. Residents are supported to take part in daily living and social activities, and lead a more independent lifestyle. The home is a purpose built detached bungalow in Chaddesden, close to local shops, facilities and a bus route, and is a short distance from Derby city centre. All bedrooms are single rooms with en-suite facilities. The home has male and female facilities, with separate lounges (smoking and non16 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home smoking) dining room and kitchen. The home has a large garden. The local Primary Care Trust funds the individuals currently using the service. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was unannounced and took place over one day. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The focus of inspections undertaken is upon outcomes for people using the service and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. An Annual Quality Assurance Assessment (AQAA) had been completed by the service. This is a self-assessment for providers which is a legal requirement. This assessment Care Homes for Adults (18-65 years) Page 6 of 29 gives the provider an opportunity to let us know about their service and how well they think they are performing. The information provided in the AQAA is reflected within this report. At this inspection visit two people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. One of the people case tracked was able to express their views of the service and the support it provided. Other people living at the home that were not case tracked were also spoken with. Their views of the service and the care and support provided are included within this report. Several members of staff were spoken with and their views and opinions of the care provided, the support and training given to them is included within this report. The comments provided within four surveys received from the people living at the home, one relatives survey and four staff surveys are also reflected throughout this report. What the care home does well: 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 set out 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. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To establish if individuals needs can be met by the service, detailed assessments are undertaken before admission is agreed. Evidence: Information regarding the service, such as the service user guide was seen and contained all relevant details to support people to make a choice about the service. Information regarding the registration body in the service user guide needed amending as it referred to the National Care Standards Commission. Most of the people using the service had moved to Derwent Lodge when it opened in 2002. Therefore their needs assessments were reviewed and updated every 2 years to ensure they remained valid. Evidence was also seen to demonstrate that annual reviews of care were undertaken to ensure needs were met and any changing needs were identified. People spoken with and the surveys completed indicated that individuals using the Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: service had felt that they had been well supported in the assessment / admission process. The information within the providers self assessment stated that any new admissions to the service were undertaken on a gradual basis to ensure each person could be appropriately supported and consider their own needs in a relaxed and informal setting. This included a series of trial visits to the service for lunch or dinner, leading to an overnight stay. If the individual and the multi disciplinary team were happy following this, then a trial period of four weeks began. During this trial period the staff then monitor the individual and actively seek their views through the services quality assurance processes. If at the end of the trial placement the individual decides to move into Derwent Lodge a further meeting is held under the Care Programme Approach. This is to ensure the needs and aspirations of the person form an integral part of their recovery approach. Licence agreements were seen in the two files that were looked at, these had been signed and date by the individuals. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recovery plans,risk assessments and review systems in place ensured that individuals needs and choices were met. Evidence: The files of the two people case tracked were looked at and were organised and clear to understand. Individual plans were in place in the files of the two people case tracked. These plans were called recovery plans, as this is the personal process that is used for the people living at Derwent Lodge. This process offered a structured multi disciplinary approach to enable and support individuals to manage their mental health and take control of their own lives. The recovery plans seen identified and addressed individuals preferred lifestyle preferences and choices. All of the recovery plans seen had been signed by the individuals to confirm their agreement to them. Within both of the files seen there was written consent to demonstrate each persons agreement as to who information regarding them could be shared with and information regarding the individuals Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: capacity and a crisis plan. This demonstrated that the individuals wishes and preferences had been sought to ensure they could be followed if needed. As stated in the providers self assessment the staff supported each person to make decisions about their own lives by respecting them as individuals and ensuring that their rights to make choices and decisions was upheld. From the records seen,observations on the day of this visit and discussions with people using the service and the staff team, it was evident that individuals were supported to make decisions regarding their daily lives. Such as how they preferred to spend their day, their interests and hobbies, what they preferred to eat and decisions regarding holiday destinations. Minutes were seen of meetings undertaken by the people using the service, these records also confirmed that they were able to express their views. As stated in the providers self assessment a key worker system was in place and there was clearly defined roles for both key workers and co workers. The individual and the key worker meet on a two monthly basis or more often as required to review and implement recovery plans as needs are achieved. One of the people living at Derwent Lodge was asked about their key worker and they said, my key worker is a beautiful person, she is so thoughtful and very helpful, Im very happy with her Risk assessments linked with the recovery plans and included the actions that were to be taken by staff. These assessments were updated and reviewed regularly in line with the recovery plans. As stated in the providers self assessment these risk assessments enabled individuals to conduct their lives as they chose to, by supporting and encouraging them to take and manage risks as part of their care and recovery plan. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals were supported in their daily lives to maintain friendships and relationships and were actively encouraged to participate in the life of the home and the local community. Evidence: Records, discussions and observations demonstrated that people were supported in activities of daily living, such as planning, purchasing, preparing and cooking a meal, as well as preparing light snacks and drinks and doing their own laundry if they wished to. Domestic style kitchens were available for this purpose. Individuals spoken with confirmed that they were able to spend their day doing as they wished. The providers self assessment confirmed that all of the people using the service were placed on the electoral role as they wish for either local voting or postal voting. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: Individuals cultural and spiritual needs were identified and they were supported to maintain them, this was seen in the files of the people case tracked. Access to the local community was available to the people living at Derwent Lodge using a risk approach framework. Some people were able and chose to access the community independently and others were supported by members of the staff team. As stated in the providers self assessment a variety of community facilities were accessed, such as cinemas, pubs, local places of interest, banks and public transport. It was confirmed by the deputy manager that activities were generally based within the local community as this represented a normal lifestyle. Discussions took place with some of the people living at Derwent Lodge regarding holidays that had been undertaken or that were planned for the near future. It was confirmed that individuals were supported to make choices about their preferred holiday destinations. The deputy manager confirmed that staff had supported two groups of people to take a holiday in Wales and Skegness this year and that another group were going to Butlins in the near future. People were supported to maintain relations his with family and friends. It was confirmed that were visitors were able to call at any time. Some of the people living at Derwent Lodge visited their family on a regular basis. A chef was employed at the home and prepared meals for those who do not wish to cook for themselves. It was confirmed that everyone was supported to plan, purchase, prepare and cook a meal at least once a week as part of their activities of daily living programme. Records were seen to demonstrate that choices were available and that each person chose their preferred meal. As part of the activities of daily living people were encouraged to take an active role at meal times. This was done to promote a sense of inclusion and responsibility. A rota was in place for duties such as setting the table or clearing up after meals. People spoken with said that the meals provided were to a high standard and they confirmed that they enjoyed them. They also confirmed that they were able to prepare their own snacks and meals if they preferred to. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals were supported in meeting their health and personal care needs in accordance with their preferences and in a way that promoted their independence and autonomy. Evidence: The recovery pans seen demonstrated that any support that was required with personal care was provided in a sensitive way in accordance with the individuals preferences and choices. As stated in the providers self assessment all personal support given was given in a way that supported and promoted each person in developing their independence. Individuals were supported to undertake their own personal care and daily domestic tasks, and the majority of people did not require any physical help in this area. As stated earlier in this report, domestic washing machines were available for those who wanted to wash their own laundry. There was also a main laundry room were staff washed individuals clothes and to ensure individuals laundry was washed separately, everyone was allocated a specific laundry day. The key worker and co worker system in place ensured that there was consistency and continuity of support for individuals. Clearly defined roles were in place for key and co Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: workers which ensured that staff were aware of their responsibilities. Records were seen in the files of the two people case tracked that demonstrated that healthcare needs were met. As stated in the providers self assessment individuals were supported to ensure annual health checks, regular G.P./medication reviews, regular multi disciplinary reviews and any other relevant specialist input was provided to ensure individuals needs continued to be met.People living at Derwent Lodge accessed health care services within their local community. Records showed that any concerns regarding health care were followed up promptly. Since the last key inspection of this service there have been two medication administration errors at the home. The service responded to the errors promptly and took the appropriate action to maintain the safety of the individuals involved. They informed us immediately of these errors and addressed any training issues that were identified. Neither of these drug errors had resulted in any adverse effects to the individuals involved. The medication practices were looked at during this visit and were found to be satisfactory. There were clear records in place for receipt, storage, administration and disposal of medications held, this included the recording procedures for the use of none prescribed medication when administered. However there was no audit kept of the balance, receipt or disposal of none prescribed medication. The manager stated that this practice would be implemented. None of the people living at Derwent Lodge administered or stored their own medication and discussions with the deputy manager confirmed that if this was the case a thorough risk assessment would be undertaken to determine an individuals ability to do so safely. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals were confident that any concerns they had would be listened to and acted upon. The safeguarding practices in place ensured people were protected from abuse. Evidence: As stated in the providers self assessment there was a complaint policy on display in the entrance to the home. The contact details for the Care Quality Commission were not up to date on the policy displayed in the entrance hall and gave the former Derby address. This information was passed onto the manager for amendment. The complaints policy includes Rethinks national complaints procedure with the home having a local policy. People using the service were provided with a copy of the complaints procedure with their licence agreement. Reference was also made to the registration body in the handbook that was provided on admission, however this referred to the National Care Standards Commission rather than the present registration body, The Care Quality Commission. People spoken with stated that if they had any concerns they would inform the manager of the service. They appeared confident that any concerns they had would be addressed. Information in the providers self assessment stated that all individuals were able to make a complaint on a one to one basis with a staff member of their choice and are helped to access local independent advocacy services as required. Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: Monthly meetings were held for the people using the service and this gave individuals an opportunity to express any concerns they had and express their general views. The manager confirmed within the providers self assessment information that the service had received no complaints in the last twelve months, this was also confirmed at this inspection visit. The service had a safeguarding and whistleblowing policy in place. A copy of the Local Authorities policy was also available at the home, this ensured that the staff had up to date current procedures to follow, which enables them to clearly follow the local authority procedure, as they are the lead investigators in all Safeguarding referrals and investigations. Staff training certificates demonstrated that staff had undertaken safeguarding training and staff spoken with demonstrated a clear understanding of the safeguarding policy. Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment for the people living at Derwent Lodge is safe, comfortable and clean and promotes independence. Evidence: A partial tour of the building was undertaken to look at the communal areas of the home and the laundry facilities provided. As stated in the providers self assessment the premises was purpose built and is ideally situated in the community with local amenities easily accessible. Although bedrooms were not viewed during this visit it was confirmed that all bedrooms had an ensuite shower room. In addition to this there were two communal bathrooms that could be used if preferred. The home has two domestic style kitchens within each section of the house both with domestic washing machines and facilities where individuals can make drinks, meals or do their personal laundry. In addition to this the home has a main kitchen and laundry. There were two conservatories, one in each section of the house and these were the designated smoking areas for the people using the service. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: The garden area was spacious and included vegetable plots that had been produced by individuals that used the service that had an interest in gardening. Some of the people living at the Derwent Lodge talked about the vegetables that had been grown. The garden was fenced and gated to ensure privacy for the people living at Derwent Lodge. The home has a dedicated maintenance person to deal with all maintenance issues within the home. The general decor of the building was satisfactory. The manager confirmed that some areas of the building required some redecoration and that plans were in place regarding this. A housekeeper and domestic were employed and they shared the cleaning duties. Discussions with the house keeper took place and it was confirmed that the people using the service were supported to undertake domestic duties for their own personal environment as much as they were able. Satisfactory hygiene procedures were in place and the deputy manager confirmed that all staff had undertaken infection control training. Individuals that were spoken with confirmed that their home was kept clean and tidy. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment practices in place did not fully protect the people using the service. Evidence: People using the service have benefited from a stable staff team with the majority of the staff having worked at the home for some considerable time. Surveys returned from people using the service and those that were spoken with felt that there was sufficient staff available to meet their needs. Staff recruitment records were looked at for two staff. At the last inspection a requirement was made regarding staff recruitment records, as the records held at the home did not provide proof of identity, Criminal Records Bureau details, medical declaration and a record of interview and a full employment history. At this vist all of this information was in place, except for one area, this was regarding the recording of staff employment histories, that were recorded on staff application forms. The application forms only requested the last ten years employment history and not a full employment history as required by law. Without a full employment history the employers are unable to ascertain each employees or potential employees work history or the reasons for any gaps in employment. This means that they are unable to ascertain if the individual has worked in any previous roles with vulnerable adults or children prior to the last ten years and ascertain the reasons why they left those Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: positions. All of this information is required to ensure the staff employed are suitable to work with the people using the service. An urgent action letter was sent to the service following this inspection to address this issue. The providers self assessment stated that Rethink had developed a process to include people using the service to be actively involved in staff selection. It was stated that Derwent Lodge plan to adopt this practice for the people using the service. The home is staffed by six registered nurses who are supported in their role by care staff. It was confirmed in the providers self assessment and by the deputy manager that all but one member of the care staff team have a National Vocational Qualification at level 3, the one member of staff who did not have this qualification was working towards it. The manager stated that he was in the process of developing a training matrix to demonstrate the training that had been undertaken and any training that was due. Training certificates were in place in the staff files seen that demonstrated that training had been undertaken, such as fire safety, infection control, safeguarding adults, first aid and LILY nursing for the qualified staff. This is an initiative that has been endorsed by rethink and sponsored by LILY pharmaceutical company to support the improvement of physical health and well-being of individuals with mental health illness.The aim of this training was to ensure that each persons physical health was promoted and monitored and any identified issues acted upon. Staff spoken with also confirmed that they were provided with regular training. However as not all staff files were looked at and no training matrix was available it is not possible to ascertain if all staff were up to date with both mandatory training and training that was specific to the needs of the people using the service. Records were seen in staff files to demonstrate that staff supervision was taking place on a regular basis to ensure staff were supported and appropriately supervised within their role. Records seen also confirmed that annual staff appraisal had been undertaken. Care Homes for Adults (18-65 years) Page 23 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The practices in place ensured that people were consulted about the running of their home and demonstrated that their views and opinions were listened to and acted upon. The health and safety practices in place ensured that the people living at the home, staff and visitors to the home were kept safe. Evidence: The manager of the service has been in post since October 2008. He confirmed in the providers self assessment that he was undertaking a National Vocational Qualification at level 4 in management. The manager was able to demonstrate that he has applied for registration with the Care Quality Commission. Positive comments were made by the staff team regarding the management support provided to them. Regular staff meetings were undertaken and the minutes of these meetings were seen. Staff spoken with were positive about the team work at the service and they felt that they all worked well together. Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: As stated in the providers self assessment Derwent Lodge had effective quality assurance and quality monitoring systems in place, which were based upon seeking the views of the people that used the service, in order to measure achievement, aims and objectives. Annual quality assurance questionnaires were sent out to the people using the service and information regarding this was seen in files of the people case tracked. As stated in the providers self assessment the results of these questionnaires were audited to enable the service to review the satisfaction outcomes and further develop areas of support. The results from the surveys undertaken were printed and and placed on the notice board within the home, in the visitors folder and fed back at the meetings held for the people using the service. External audits were undertaken annually by Rethink and monthly Provider visits were also undertaken by the Area Service Manager of the home. This ensures that the service is quality monitored to enable its development and improvement. People spoken with felt their views were listened to and acted upon. Health and Safety checks were undertaken. Records of fire safety tests were seen, such as weekly fire alarm checks, evacuation records, emergency lighting checks, fire risk assessment, the servicing of Fire Fighting Equipment and the fire panel. The providers self assessment also stated that all service certificates, such as for electric, gas and appliances were up to date. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 34 19 To ensure you comply with 25/09/2009 the regulations and safeguard people who use your service a full employment history must be in place for all staff employed at Derwent Lodge together with a satisfactory explanation of any gaps in employment. Where a person has previously worked in a position which involved contact with children or vulnerable adults written verification of the reason why they ceased to work in that position must be obtained unless it is not reasonably practicable to obtain such verification. This is to ensure the staff employed are safe to work with the people using the service. Care Homes for Adults (18-65 years) Page 27 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action URGENT ACTION LETTER SENT Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 20 A record should be kept of the balance, receipt and disposal of none prescribed medication, this will ensure that all medications administered at the home are clearly audited to ensure safe practices are maintained. The name and address of the current regulation body should be recorded on the complaints procedures and policies within the service. This will ensure that individuals have the correct contact information. A training matrix should be in place to ascertain training undertaken and training due. This will clearly demonstrate that staff have undertaken the required training and ensure staff training is kept up to date. 2 22 3 35 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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