Inspection on 11/12/07 for Madeira Lodge

This inspection was carried out on 11th December 2007.

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

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

Other inspections for this house

Madeira Lodge 11/11/09

Madeira Lodge 05/07/06

Madeira Lodge 30/11/05

Madeira Lodge 20/09/05

Madeira Lodge 13/01/05

Madeira Lodge 07/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Madeira Lodge 38/40 Birnbeck Road Weston Super Mare North Somerset BS23 2BX Lead Inspector Odette Coveney Unannounced Inspection 09:30 11 December 2007 th X10015.doc Version 1.40 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 Madeira Lodge DS0000008049.V348646.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 Older People. 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. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madeira Lodge Address 38/40 Birnbeck Road Weston Super Mare North Somerset BS23 2BX 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) 01934 621846 01934 414668 Mr Derek Herbert Butler Mrs Christine Anne Rich Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named service user aged less than 65 years for respite care. 5th July 2006 Date of last inspection Brief Description of the Service: Madeira Lodge is registered to accommodate up to 40 people who are in the category Older People over 65 years. The home comprises of two adjacent properties overlooking Weston Bay, there are panoramic views across the bay from the communal areas at the front of the houses. All rooms have en-suite facilities and a number have attractive sea views. There is limited parking on a short sloping driveway. Madeira Lodge is owned by Mr and Mrs Butler, Mrs Butler has some minimal management input into the overall running of the business. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standard inspection, it was carried out in two days over a 9 hour period by one inspector for the Commission. This inspection was very positive and overall a judgement of good was made. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for individuals were reviewed. The registration certificate for the home was reviewed at this inspection and the information contained within it was found to be accurate. Eight comment cards were received prior to the inspection, four of these were from relatives of those who live at the home, four were from individual’s who live at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. What the service does well: The staff team at Madeira Lodge are caring and have developed good relationships with individuals at the home; they have a sound understanding of the needs of those living at the home. There is a low staff turnover and individual’s can be confident that they will receive support from people they know. It was clearly evident that the management and staff team are committed to ensuring that all of the needs of individual’s at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individual’s. When speaking with those who live at the home they all indicated that they were happy with the home, comments from residents included; ‘The staff here are wonderful, kindness itself!’, ‘Nothing is too much trouble’. Written feedback from relatives of individuals who live at the home included; ‘The staff at Madeira Lodge are golden, always willing to help out in any way and are very very good’, The home has a friendly and caring atmosphere, staff are attentive to my relatives needs’. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: In order that the correct protocols are undertaken in line with the local authority policy in order to protect residents is has been required that protection of vulnerable adults training is provided for staff. The home has a safe for storing valuables however it was found that individuals money were kept in a filing cabinet with no lock and although the main door to the office can be locked security of residents money must be better managed. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 7 In order to ensure that residents and staff do not trip and to also reduce the risk of cross infection it is required that the identified flooring in a toilet area is repaired, if unable to be repaired this must be replaced. It is also recommended that the lime scale staining on two baths be removed. In order that individuals are safely supported in areas of manual handling it is required that risk assessments contain further detail in order to ensure that if individuals fall they are supported safely inline with their assessed needs. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is in place about the facilities and services provided at Madeira Lodge and individuals can be confident that their needs will be met. Clear contractual arrangements are in place outlining individuals right and responsibilities. EVIDENCE: A requirement was made during the last site visit to the service that the Statement of Purpose must be updated. This document was reviewed at this visit and it was found that the Home’s Statement of Purpose has detailed information about services and facilities provided at the Home. The information within this document was comprehensive and contain clear information for residents and their relatives about the services and facilities provided at the home and furthermore contained information about the staff arrangements at the home, information about the admissions process into the home and how to raise issues of concern and how these would be responded to. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 10 There is a clear process to ensure that the service is able to meet the assessed care needs of prospective people moving to the home. There is an admission procedure, which is included in the statement of purpose and full assessments of needs were undertaken. Care files reviewed contained a ‘resident’ contract’ detailing the terms and conditions of stay at the Home and provided clear guidance on the rights and responsibilities of both the resident and the registered provider. Information within this document also includes information about fees and services to be provided. Intermediate care is not provided at this home. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s personal and health care needs are being met. Individuals are protected by the home’s medication practices and procedures EVIDENCE: The care files reviewed during this site visit showed evidence of pre-admission assessments to enable staff to develop personalised care plans of residents and to record how the needs were to be met. The care plans seen were detailed and explicit and the daily reports contained entries of what, when and how care was provided. Information recorded on care documentation corresponded with information given from residents, staff and relatives about the level and individualised levels of support that residents received. It was clear that support provided was flexible and tailored to individuals identified and requested support needs. A joint requirement was made during the last visit to the service, these were that where there is a history of falls a risk assessment must be undertaken and also where a nutritional risk has been identified any changes to that condition must be documented. It was found that nutritional risks and any associated Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 12 changes in individuals condition were well recorded and individuals needs are responded to appropriately with specialist services being accessed where required, furthermore the home have completed risk assessments in respect of individuals likihood of having a fall, however further information is required to ensure that information on how individuals would be assisted if they fell should also be included in order to ensure the safety of both residents and staff with manual handling techniques. Residents spoken with stated that staff supported and assisted them with personal care and that they were treated with dignity and respect and kindness. It was very evident from talking with staff and the individuals living in the home that people receiving a care service can choose when to get up and retire to bed. Care documentation provided clear information to staff to inform and guide their practice, the records provide information to show that individual’s are supported in their life in the manner they require and prefer. Individuals confirmed that they were supported to purchase their clothes and toiletries and personal shopping. Thorough examination of care documentation it showed that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. Procedure for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. The pharmacy supply printed medicines administration record sheets each month. Records of administration of medicines were clear. Records are kept of medicines received into the home. Waste medication is recorded and disposed of via the supplying pharmacy. A requirement was made during the last visit to the service that staff must be aware of how to use the medications fridge thermometer accurately. Staff spoken with were clear about this items use and records were in place to show that this was being used correctly. Staff members spoken with had full understanding of the needs of the residents living at the home. Staff clearly identified the values that the home promotes and to be afforded to the individuals living at the home: Dignity, Right and Privacy. All the care documentation and related information seen promoted good care based on the above values. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 13 All of the residents are allocated a key worker; staff spoken with had a clear understanding of their role and responsibilities. It was noted that information was in place to demonstrate that resident’s wishes concerning terminal care and arrangements after death have been discussed. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. . Residents can keep close contact with relatives,friends and the community. Residents are offered a varied and nutritious diet, and are able to take part in a range of social activities. EVIDENCE: Information seen evidenced that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. On the day of the visit residents and staff spoke with enthusiasm about the Christmas party held the night before with a raffle and entertainment. Residents told the inspector they enjoyed the entertainment provided at the home and in particular enjoyed it when the piano was played and ‘sing-alongs’ that were held. Residents confirmed they are able to participate, or not, in activities as per their choice. Residents were seen enjoying a daily newspaper, local news and magazines had obtained for them by staff. Residents were seen listening to music of their choice, watching television, reading and enjoying conversations with each other. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 15 Discussion with the manager, staff members and evidence from the visitors’ book showed that the residents maintain good contact with families and representatives. The level of contact varies for each resident living at the home, some receive regular visitors and go out with family, and others do not. Discussion with residents and staff evidenced that the home supports residents to maintain contact with friends and family and the local community. One resident spoken with stated, “My daughter visits when she can and my family comes to see me regularly and are always made welcome by the staff”. The home would contact individual’s next of kin should they need to be they need to be informed of issues, which affect the well being of an individual living at the home. This was confirmed in written feedback received from relatives prior to the visit to the home. At a brief walk around the building residents were seen spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. The inspector observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made after consultation on the meals available to them. Of the comment cards received from residents prior to the inspection no negative comments were made about meals at the home; an additional comment was ‘The food is lovely, plenty of it and all home cooked’. Written feedback received from relatives prior to the site visit included; ‘ They really care for the people living at the home, they motivate and provide different activities and outings an encourage them to take part’ ‘I know my relative is very well cared for and happy’. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of residents from harm and abuse, however security for monies held for safekeeping of residents must be improved. EVIDENCE: The Home has appropriate procedures in place for management of complaints. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the home. Resident’s responses noted on the comment cards evidenced that residents are aware of whom to complain to. One resident stated, “I have never had to make a complaint, if I had any concerns I would speak to a member of staff’. There is a copy of the local authority council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidences of abuse occur. Records of recently employed staff members were viewed and contained personal information and record of identity. Other information seen included two satisfactory references, record of previous employment, and satisfactory Criminal Record Bureau disclosures. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 17 The home maintains a record of complaints and the last recorded complaint was dealt with effectively and the parties involved were satisfied with the response from the home. A random check of monies held at the home for the safe keeping for residents was undertaken and all records reviewed were correct and corresponded with monies held. The administrator was clear about her role and responsibilities in this area and confirmed that an external audit of financial accounts is undertaken on an annual basis at the home. The home has a safe for storing valuables however it was found that individuals money were kept in a filing cabinet with no lock and although the main door to the office can be locked security of residents money must be better managed. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home is well furnished and comfortable, however attention must be given to the flooring in order that it is safe. EVIDENCE: There are adaptations in place throughout the Home and specialist equipment including mobility aids, sensory aids, a passenger lift and bathing aids. There is a spacious dining area and two comfortable lounge areas with a sun lounge. The home has recently benefited from two new decking areas to the front of the home for residents to enjoy in the warmer weather. Also to the rear of the home a small enclosed garden areas was being enhanced with raised flower beds Individuals were observed sitting in the lounge, the small sun lounge and going into their rooms, looking very relaxed and comfortable in their environment. The whole home is extremely ‘homely’ with lots of soft furnishings such as Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 19 plants, ornaments, footstalls and pictures and photographs all enhancing the areas within the home. The home has sufficient bathroom areas for individuals with both shower and bathing facilities in place. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. It was noted in a ground floor bathroom that there was a sizable hole in the vinyl flooring in the centre of the room and was a potential danger and a trip hazard, due to these concerns an immediate requirement was issued instructing the home replace the flooring. The manager confirmed to the Commission on that this flooring had been replaced and this was later followed up with written confirmation. It was also noted in a toilet area on the ground floor that the edging of the flooring had lifted, In order to ensure that residents and staff do not trip and to also reduce the risk of cross infection it is required that the identified flooring in a toilet area is repaired, if unable to be repaired this must be replaced. It was noted that two baths were heavily stained through lime scale damage it is recommended that this be removed in order to reduce the risk of contamination. Action must be taken to eliminate the Health and Safety Hazards as identified by the EHO and as stated in letter dated 08/09/05. This requirement was carried forward from the last inspection 09/09/05. The manager said that these issues had been dealt with. The inspector viewed the most recent environmental health visit report which took place at the home on, no areas of significant concern were raised and minor issues recorded had been addressed. It was evident from interactions between staff and residents during the inspection that staff have developed positive relationships with the residents. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from clarity of staff roles and staff who are trained and recruited in line with the home’s policies and procedures. EVIDENCE: There is a well- established staff team at Madeira Lodge. During the visit staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. On the day of the site visit there were sufficient numbers of staff on duty with flexible working by staff in order to meet individual’s needs and aspirations. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. Morale is high within this home and staff spoke positively about their role and the work they do and were able to give a number of examples of areas within their role which gave them job satisfaction such as one to one time with individuals, supporting residents in they way they prefer and building relationships based on trust. The manager said that she valued her staff and that they were an asset to the home. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 21 During the last site visit to the service a requirement was made that all staff must have a criminal records bureau and a protection of vulnerable adults check before commencing work at the home. A number of staff files were viewed at this visit and all of the required documentation was in place in respect of recruitment and selection practices and it was found that these were robust. Records of formalised one to one supervision support sessions were seen, these evidence that staff are given appropriate information and advise and are supported by the manager within their role. The home has a structured induction programme. This is to ensure that any new staff member is competent and confident to work with residents to meet their needs. Staff spoken with and certificates seen in individuals files provided confirmation that the training had been undertaken and staff that were spoke with were positive about how the training they had undertaken, including National Vocational Qualification, manual handling and first aid, however it was noted that a number of staff had not completed protection of vulnerable adults training and although staff spoken with were fully aware of their role and responsibility in this area and no concerns were raised during this visit it is required that staff training in undertaken. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home benefits from good leadership and management, its practices have offered protection to the health and safety of residents. However some improvments are needed to manaual handling assessments. The home is run in the best interests of the residents. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a committed staff team. EVIDENCE: Madeira Lodge is privately owned and is the sole care home of the proprietor. Mrs Christine Rich is the registered manager of the home. Mrs Rich has a wealth of knowledge and experience in working with and supporting the care of older people and has management experience in developing and supporting a Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 23 staff team. During the inspection Mrs Rich was able to demonstrate a clear understanding of the aims and objectives of the home and of her role and responsibilities for both residents and the staff team. The home has good systems for monitoring the quality of the care provided to the individuals living at Madera Lodge these included regular reviews of care plans, review meetings where the individual was involved, supervisions, staff meetings and a quality assurance tool, which encompasses the Care Homes National Minimum Standards. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment. The annual quality assurance assessment (AQAA), this is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the Registered Manager was fully completed and detailed and information contained within this was verified during the site visit. It was clear that staff are well supported by the management of the home with sound systems in place to support and guide staff practice in order to ensure that all staff are providing a good quality service to those who live at Madeira Lodge, these include appropriate training, regular staff meetings and supervision sessions. Staff spoken with said that they are positive that the manager and providers are committed to ensuring the needs of residents are met, that ideas and suggestion are listened to with regular individual supervision being held for continuity of care and effective communication. There was evidence that the home ensures so far as is reasonably practicable. The health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. It was noted that assessments are in place which identifies individuals who may be at risk of falling, however further information is required ensure that if individuals fall they are supported safely inline with their assessed needs. The home have manual handling assessments in place and these outline information about the support needed by residents and gave an indication of their level of risk in this area however in order that residents can feel confident that staff have clear information to support them safely it is required that manual handling assessments must contain full information of staff action/support. The home displays a current certificate of Employer’s Liability Insurance. The home has in place clear policies and procedures in areas of staff employment, individual’s finances and health and safety, all of which have Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 24 been reviewed and updated. This guidance provides clear information to staff to inform and guide their practice. A review of the fire logbook found that staff are receiving sufficent fire instruction and drills, maintence and equipment checks are undertaken on a regualr basis. A reccomendation was made during the last site visit to the service that it would be good practice to review the homes fire risk assessment to ensure it remains current. Since the last visit the home have employed the services of a contractor who has undertaken a detailed and robust fire risk assessment with minor areas of attention identified being addressed. The manager confirmed that this assessment would be reviewed by the contractor on an annual basis in order to ensure it is sufficient. Madeira Lodge DS0000008049.V348646.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP30 Regulation 13 (6) 16 (2) c 13 (5) Requirement Protection of vulnerable adults training must be undertaken for staff. Flooring in the ground floor bathroom must be made safe. Falls risk assessments must contain clear manual handling guidance to ensure the safety of both residents and staff. Resident’s money stored for safekeeping must be stored securely. Timescale for action 11/03/08 11/01/08 11/02/08 OP19 OP38 4. OP18 16 (4) 11/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP33 OP21 Good Practice Recommendations Residents meetings should be held. This was not checked at this inspection. Lime scale staining to be removed from two baths. Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Madeira Lodge DS0000008049.V348646.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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