Inspection on 20/09/05 for Madeira Lodge

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/12/07

Madeira Lodge 05/07/06

Madeira Lodge 30/11/05

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 Barbara Ludlow Unannounced Inspection 20th September 2005 11.20 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.V258958.R01.S.doc Version 5.0 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.V258958.R01.S.doc Version 5.0 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 414688 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.V258958.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th and 18th January 2005 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. It is owned by Mr and Mrs Butler, who have appointed Care Home Management Ltd to manage it on their behalf and act as their representatives of the persons in control. There is limited parking on a short sloping driveway. The home has communal sitting rooms at the front of the properties with expansive sea views. All rooms have en-suite facilities and a number have attractive sea views. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by B Ludlow for CSCI. The homes manager was on duty and was available throughout the inspection day. There were 33 service users in residence; one service user was booked to come in. All were seen and a number were spoken with either in their bedrooms or in the communal areas of the home. A tour of the premises was made; service users were seen and spoken with in their bedrooms others were seen in the communal rooms. Records were sampled for maintenance, servicing, personnel and medication administration. Care plans were sampled. Mealtimes were observed, both lunch and teatime. Feedback was given to Mrs Rich at the conclusion of the inspection. What the service does well: What has improved since the last inspection? Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 6 The inspector was visiting this home for the first time and was unable to judge or measure for service improvements. It was evident that refurbishment was in progress for some of the bedrooms, flat-lets and bathroom accommodation. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 7 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.V258958.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,NMS 6 does not apply. Service users have access to information and are welcome to visit the home to enable an informed choice of care home. EVIDENCE: The home has an A to Z of services that is used as the Service User Guide. Copies of this document are available at the home and were seen in the file available in the service user rooms. One file was examined; it contained a copy of the terms and conditions of residence, complaints procedure and an inventory of personal furniture items brought into the home. The homes manager makes pre-admission assessments and the first month of residence is treated as a trial period. One such assessment was seen held with the care plan and the community care assessment CM7. The inspector was informed that contracts are issued once a permanent place has been accepted. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 9 Care plans are compiled by the manager. One recent admission’s care plan detail was discussed with the manager. It was evident that the service users requirements for care such as adaptations in the en-suite to maintain their independence had been recognised and catered for. This was good practice. The home does not offer intermediate care. Respite care can be offered when there is a vacant room. Two respite care service users were seen at this inspection. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Care plans contained a good level of care planning, a recommendation is made. Service users are treated respectfully; this was confirmed by observation and by service users during the inspection. EVIDENCE: All service users were seen during the inspection day. All were well attired and looked well cared for. The feedback given indicated that care needs are met. Care plans were sampled and these indicated a good level of record keeping. Care plans carry photographic identification, relevant contact information. Weights are recorded, falls are risk assessed and care plans are reviewed each month and are fully reviewed every six or twelve months. Input from visiting community professionals was seen including the GP and District Nurse. The District Nurses attend to deliver nursing care tasks such as re-catheterisation, blood monitoring for diabetes and warfarin therapy and other care requirements. One service user told the inspector they had seen their GP recently for their cough. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 11 A recommendation is made for improvement, one care plan was seen where foot problems were noted and the chiropodists record had also indicated a problem, yet there was no clear follow up plan documented for care or management of this problem. Another record indicated one person was selfmedicating when in fact they were no longer able to manage this. Care records should reflect current care needs. The homes staff have received medication training from Protocol Training Days, undertaking an ‘Administration Awareness’ course that was reported by the manager to be good. Medication Administration Records (MAR) were examined. Two signatures must be recorded for all hand transcribed entries onto the MAR charts; some entries seen had one or no signatures. It was noted that controlled drugs are only recorded in the controlled record book and not on the MAR chart. A CSCI Pharmacist Inspector was consulted after this inspection. As there is no obligation to keep the controlled record book longer than two years from the date of the last entry, a change to the method of record keeping is required following this inspection. It is required that medications are recorded on the MAR chart, This chart then provides the individuals care administration record which will remain with their care planning record. Prescribed creams were seen in use that had not been labelled with ‘opened on’ or ‘discard by’ dates; this is required as good practice to ensure freshness and efficacy of cream products. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users expressed their satisfaction with the care and service provided at the home. One commented that ‘they are very, very good to you here’. Service users were observed to spend their time as they wished, activities are offered and are enjoyed. There has not been a residents meeting ‘for a while’, it was judged that these valuable opportunities for both the service user group and management to meet should be taken. EVIDENCE: The service users seen and spoken with at this inspection confirmed that they are able to spend their time as they wish. Painting was a particular hobby of one service user, this was encouraged and the paintings were displayed in the conservatory. There are large communal rooms for activities, bingo is popular and is held each Thursday. Service users commented that they enjoy the monthly trips out. Staff and service users informed the inspector that the public garden Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 13 opposite the care home is used for both supervised and unsupervised walks/ wheelchair trips, in nice weather to enjoy the views and have an ice cream. The home has a small shop facility for purchasing essentials such as toiletries. The hairdresser visits once per week on a Monday and there is a designated hairdressing room. One service user suggested that an exercise programme would be helpful to encourage people to keep their muscle strength and decrease the risk of falling. This may be an area the homes manager could explore with her knowledge of her service user group and at a residents meeting. The Manager informed the inspector that a residents meeting had not been held for a while. The home allows smoking but only in the designated area, the conservatory. Visitors are welcome at any reasonable time. Meals were served in attractively presented dining rooms. Service users commented positively on the meals served at the home. Breakfast was reported to be occasionally late being served on Saturdays, this was not confirmed. Tea was served a little later than scheduled on the day of this unannounced inspection, which may have been in part due to the inspection impacting on the managers busy work schedule. The menus are on a four-week cycle; no complaints were heard about the catering service. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a complaints procedure and maintains a log of any complaints. Recruitment practice evidence could not confirm that service users were afforded the best protection by current practice. EVIDENCE: There have been no complaints made to the manager since the last inspection. The last reported complaint was recorded in November 2004. Staff recruitment files were examined and revealed a shortfall in recruitment practice whereby CRB, POVA First checks had not been carried out before new members of staff were allowed to commence working at the home. It was noted that the home is well managed and service users confirmed that they are treated with respect and dignity. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The home is in a mixed state of repair and refurbishment. The premises are positioned to provide outstanding views across Weston Bay but were not purpose built for care. The only disadvantage being that not all accommodation has level access; there are small three stair flights to sixteen bedrooms. Service users in residence were very satisfied with their home and have personalised their own rooms to suit themselves and make them homely. EVIDENCE: The home consists of two premises joined by a conservatory/sitting area. Part of the home that was formerly a hotel is referred to by staff as the Cove and is on four floors, accessible by lift but with 3 steps to reach six bedrooms on the second and third floors. There are two lifts at the home to give access to all floors. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 16 The home is in a mixed state of repair and refurbishment of bedrooms and bathrooms. Bathrooms and toilets were seen that were unlocked as work was in progress, the inspector was informed that the doors to these areas are normally locked if unattended. The inspector was informed that windows are to be replaced in some areas as part of the refurbishment programme. All rooms have en-suite facilities of a wash hand basin and a toilet; some have either a bath or shower. Where personal care is delivered in a service users room there should be liquid soap, paper towels and an appropriate waste bin for staff hand wash waste. There should also be such hand washing facilities available to staff in communal toilets and bathrooms for good infection control management practice. The double rooms are provided as self-contained flat-lets with a lounge, bedroom and separate bathroom. This was seen to allow a more independent living style for the married couples in residence. A pleasant lounge, overlooking the sea, is available in each area of the home; these are both well used by residents. The Cove is used for activities and has a piano and an organ, there is a pool table and plenty space to comfortably accommodate the service users. Some of the seating was quite low. A large conservatory at the front of the building offers further communal space and is a designated area for those wishing to smoke. A large central dining room is situated next to the kitchen. The home was clean and comfortable. The kitchen area was clean and tidy, there had recently been an inspection by the Environmental Health Officer and this was reported to be satisfactory. A number of health and safety deficits had been brought to the attention of the homes management for action under the remit of the EHO. A letter dated 08.09.05 detailing twelve requirements had been sent to the homes manager. The action taken by the home to address these deficits will be monitored by CSCI. The laundry service received praise and the staff member responsible was described as ‘a wonder’. The floor covering in the laundry was damaged and did not provided an easily cleaned impermeable surface finish; this should be repaired or replaced. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home had a sufficient staff number on duty on the day of the inspection. Staff receive induction and training to undertake their duties at the home. Very positive feedback was made about the care that the staff give to service users and the very pleasant and kind way they are treated by staff. EVIDENCE: The duty rotas were seen these demonstrated sufficient staff numbers to deliver care. The nights are covered by two staff and when the resident number exceeds 30 a third member of staff sleeps on the premises and is available to help in the evening and early morning and in an emergency during the night if required. Staff and the Manager confirmed that training is available for staff. Records demonstrated attention to fire training and manual handling training. Medications training had also been available. Three new staff recruitment files were seen. References had been acquired for these recruits before they commenced working at the home. The home uses an umbrella body to acquire CRB checks for staff. There was no evidence of POVA First having been received by the home for staff required to commence work as quickly as possible. It is essential that staff that have commenced working without a CRB/POVA First have a fully documented risk assessment on file and work under supervision until satisfactory clearance is obtained. This Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 18 situation was clarified to the Registered Manager at the time of the inspection to allow her to amend the current practice. Interview records should be made and signed and dated with copies keep on file, this is good practice. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 The home has an experienced manager. Although the inspector heard of regular visits from the management company, their Regulation 26 notices, the last being for May and the company’s impact on the more recent management of the home was not in evidence. Health and Safety issues raised at a recent Environmental Health Inspection must be addressed. The home manages the storage of all records and the administration of financial records well. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 20 EVIDENCE: The registered manager has many years of experience in managing a care home and has completed level 4 NVQ in management and also is a qualified NVQ assessor. The Manager is supported by Care Home Management Ltd who are appointed by the registered providers to manage the home on their behalf. The inspector was informed that the management company visit every two weeks, however, Regulation 26 visit records that should be made on a monthly basis were not available for inspection at the home. CSCI last received a Regulation 26 notification in June 2005 this was for May 2005. Maintenance of these extensive premises was described by the manager as ‘massive’, there is a maintenance person employed at the home. The Fire Authority conducted a routine fire risk premises inspection in June 2005 and was satisfied with their findings. (Letter to CSCI 24/9/05). Fire log records: Fire drills were held in April and May 05. Fire training for 18 staff was given on 06/09/05, 15 staff still require updating. Fire extinguishers had been annually serviced on 02/03/05. The emergency lights are checked at six monthly intervals by an electrical company and were last tested in June 2005; these were scheduled for in house checking the day after the inspection. The annual fire alarm test was confirmed as done in December 2004. The weekly in house fire alarm test was recorded as 08/08/05 and was overdue. The inspector was informed by the Manager that this was due to be tested the next day, this must be confirmed with the inspection response. Risk assessments were in place for hot surfaces dated 06/04/00, this should be reviewed. Complaints Log: their had been no complaints made to the home or CSCI. Accident records were seen, there had been one accident reported appropriately under RIDDOR and CSCI had received a Regulation 26 notification also. The manager confirmed that staff have received first aid training and that all night staff have been trained in first aid. One corridor carpet in The Cove was identified as a trip hazard; this requires attention to its repair. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 21 The CSCI registration certificate was displayed and the Employers Liability Insurance, which was current and valid until 09.01.06. Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 22 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 x 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 1 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 3 3 1 Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 26 Requirement Regulation 26 visit reports must be carried out monthly and be available for inspection by CSCI. All staff must have a CRB/ POVA First check before commencing work at the home. 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 The weekly fire alarm test for 21/09/05 must be confirmed as undertaken with the inspection response. A regular weekly fire alarm test must be carried out thereafter. One corridor carpet identified as a trip hazard requires to be repaired. • Controlled drugs must be recorded on the MAR charts as well as logging in the controlled drug record book. Timescale for action 12/11/05 2 OP29 19 (1)(b)(i) Sch 2 13(4)(c) 21/09/05 3 OP19 09/09/05 4 OP19 23(4)(c) (v) 21/09/05 5 6 OP38 OP9 13(4)(c) 13(2) 12/11/05 12/11/05 Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 24 • Creams must be labelled with an opened on and discard by date. All hand transcribed entries on the MAR chart must have two signatures to demonstrate the checking of the entry. • RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP29 OP33 OP26 Good Practice Recommendations Interview records are good practice and should made and signed and dated. Residents meetings should be held. A review of staff hand washing facilities should be made to ensure that good practice is supported by the availability of liquid soap, paper towels and appropriate waste bin. Especially where assistance with personal care is given or where visiting professionals need to wash their hands. Care records should reflect current care needs. 4 OP8 Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Madeira Lodge DS0000008049.V258958.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!