Inspection on 28/06/05 for Madeira Lodge

This inspection was carried out on 28th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Madeira Lodge 13/07/06

Madeira Lodge 17/01/06

Madeira Lodge 27/10/04

Madeira Lodge 17/06/04

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

CARE HOMES FOR OLDER PEOPLE Madeira Lodge Madeira Road Littlestone New Romney, Kent TN28 8QT Lead Inspector Wendy Mills Announced 28 June 2005 09:00 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 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 H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Madeira Lodge Address Madeira Road, Littlestone, New Romney, Kent, TN28 8QT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01797 363242 Belmont Sandbanks Ltd Ms Penelope Jane Selby Care Home only 28 Category(ies) of Dementia (over 65) x 27; Dementia x 1 registration, with number of places Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There is a variation order for one person under the age of sixty-five, with failing mental capacity. Date of last inspection 27th October 2005 Brief Description of the Service: Madeira Lodge is a residential home providing care for up to twenty-eight older people with failing mental capacity. Belmont Sandbanks, the registered providers, own another residential care Home nearby. Mrs Selby is the registered manager of both Homes. The Home is located a mile from the small town of New Romney and within easy walking distance of sea. Accommodation is provided on two floors with a shaft lift connecting the two floors. There are twenty six single rooms, three of which have ensuite facilities and one shared room. There is a choice of sitting areas on the ground floor and residents have access to a well-established garden with seating to the rear of the premises. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection began at 09.00 and lasted seven and a half hours. The registered manager, Mrs Penny Selby and the registered provider, Mr Keith Hutchinson, were present throughout the inspection. The head of care, Ms Jackie Faulkner also assisted with the inspection. The inspector was able to speak in private to three residents, six relatives and six members of staff during the course of the inspection. In addition, she had contact with two other relatives prior to the inspection. She also spoke to several other residents in the main communual areas on the day of inspection. Key documentation, including care plans, was examined, a tour of the home undertaken and the responses to pre-inspection questionnaires were considered. Both indirect and direct observations were made throughout the inspection. The registered provider, the registered manager, the staff, the residents and their relatives are thanked for their assistance during this inspection. What the service does well: What has improved since the last inspection? The registered provider and the registered manager have worked hard to instigate appropriate organisational structures in the home. There are more staff meetings. Staff now feel their input into the home and their care of the residents is valued by the management team. Since the last inspection the home has accessed a staff advisory service to ensure that the management of the home complies with legislation and current good practice. The activities in the home are now better tailored to suit the needs of the residents. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 6 Some policies and procedures have been reviewed. Some new policies and procedures have been introduced and include one that covers violent incidents. The home has ensured that there are additional risk assessments in place. 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 H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4&5 The statement of purpose and the service user guide are good. They provide the residents and prospective residents and their supporters with the information they need to make a decision about moving into the home. The assessment and admissions procedures are sound. EVIDENCE: The statement of purpose has recently been reviewed and organisational structures have been changed. Discussion with the registered provider and the registered manager confirmed that the home is clear about its direction. There are sound policies and procedures for assessment and admission to the home that include pre-admission assessment and trial periods. Relatives told the inspector that they had been well supported by the home prior to the admission of their relatives. They said that they had been given good information and that they were able to make appropriate visits prior to making a decision about the choice of home. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,10&11 There is a consistent care planning process that provides the staff with the information they need to care for the residents. The home safeguards the privacy and dignity of the residents very well. The home deals with end of life issues well. EVIDENCE: Care plans are up-to-date and in good order. The specific needs of the residents are recorded. Health care professionals are contacted appropriately and their advice sought. The home has a series of checklists to ensure that residents’ needs are met throughout the day. All the residents were in good health on the day of inspection. Conversation with care staff confirmed that they are able to meet the needs of the residents. Staff were observed to treat the residents with great kindness and respect. Personal care was offered gently, discretely, and with great patience. One resident said that the staff are very kind. Relatives said that they can always talk to the staff if they are concerned about the health of a resident. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 10 Responses to the relatives’ questionnaire were mostly positive about the care given in the home. Indirect observation of the way in which staff offered care on the day of inspection, and conversation with them, confirmed that they are very well aware of individual needs. They are clear about the way in which they meet individual needs and demonstrate a high level of dedication to the residents. They hope to care for the residents for as long as they can meet their needs and, where possible, support them through terminal illness. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14&15 The home makes every effort to ensure that the residents are able to enjoy an interesting and fulfilling lifestyle. It helps the residents make appropriate choices when indicated. The home fosters good relationships with the families and friends of the residents. The home recognises the importance of good nutritional management and caters for special diets. EVIDENCE: The home employs an activities organiser and has recently purchased several appropriate games. She works both directly with the residents and with staff members to encourage the residents to get involved in interesting activities. On the day of inspection some of the residents were enjoying a game of indoor skittles and another was playing draughts with a staff member. Life histories and likes and dislikes are recorded in the care plans. Staff were observed to offer choice in a way that was appropriate to each resident’s understanding. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 12 There is a choice of menu and the food and there are plentiful supplies of nutritious produce. Both fresh meat and fresh fruit and vegetables are purchased locally. Most residents said that they enjoyed their meals. Residents are weighed regularly and food charts are set up when there is any concern about nutrition. Conversation with the cook and inspection of the kitchen and kitchen stores confirmed that food hygiene is maintained. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16&18 The home has a satisfactory complaints procedure with evidence that the views of the residents and/or their relatives are taken into account and acted upon. The staff have a very good awareness of Adult Protection issues. This protects the residents from abuse. EVIDENCE: Inspection of relevant documentation confirmed that there is a satisfactory written complaints procedure. Staff are clearly aware of their responsibilities to complain on behalf of residents who are unable to speak for themselves. Regular staff meetings and increased effort from the registered provider has improved communication in the home. Documentation shows that concerns are acted upon in a timely manner. Discussion with the registered manager about the way formal complaints have been handled confirmed that they are dealt with in a timely way. Staff have received adult protection training. Conversation with them showed that they have a good awareness of the whistle-blowing procedures. Staff said that they would be prepared to use the whistle-blowing procedure should the need ever arise. The registered persons demonstrate a willingness to address any concerns that staff may express. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,21,22,23,24,25&26 The standard of décor is good and recent investment has improved the environment of the home, however, further investment is needed. Overall there is a comfortable and homely environment for the residents and their visitors. Health and safety measures in the home are generally good although more attention is needed to ensure equipment in the home is in good order. The home is clean and pleasant but hygiene measures could be more stringent in respect of equipment such as commodes. EVIDENCE: The home was clean and mostly free from offensive odours on the day of inspection. During a tour of the home some moderate offensive odours were noted and some carpets are now looking tired. The standard of décor throughout is good. The registered manager said that rooms are re-decorated Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 15 as they become vacant. Some rooms, particularly those that have been occupied for some time, would benefit from a review of floor coverings and furniture. Bedrooms are comfortably furnished and homely. Several residents have chosen to bring items of furniture from their own homes. The bedrooms reflect the individuality of each resident. There is an adequate number of bathrooms and accessible toilets. Some bathrooms are fitted with equipment to assist residents to enter the baths. Whilst the standard of cleaning in the home is good, one bathroom now requires attention to ensure cleaning can take place effectively. For example, a bath panel is loose, tile grouting is missing and the floor is carpeted. The carpet is old and stained and does not fully cover the floor. This bathroom requires upgrading to allow for proper infection control measures to be taken. There are sound health and safety policies and procedures, including several checklists to ensure the safety of the residents is monitored on a very regular basis. A few health and safety hazards were noted during the inspection. The registered manager dealt with most of these as they were pointed out. However, there are a number of wheelchairs stored around the home. Some of these are in a poor state of repair. The wheelchairs must receive attention in accordance with the MDA notice of January 2005. Some commodes require replacement or refurbishment. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29&30 The staff have a good understanding of the needs of the residents. This is evident from the positive relationships between staff and residents and the good level of staff morale. Recruitment practices are sound and there is a good level of staff training. EVIDENCE: There is a good level of staff training and there are regular staff meetings. Staff were very positive about the recent changes in the communication structures in the home. They said that their morale is good and that they are looking forward to the opening of the new day centre that is being built on a plot in front of the home. They said that they fell they work well as a team and believe that their views are valued. Staffing structures, as laid out in the statement of purpose, allow for clarity of roles and lines of responsibility. There are clear job descriptions and inspection of staff files showed that all appropriate checks have been made before offering employment to new staff. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36&38 There is clear leadership throughout the home. However, sensitivity is required in the approach to managing change in the home. Communication in the home is good and the staff advocate well on behalf of the residents The views of the residents and their supporters are taken into consideration. EVIDENCE: There is a good level of staff training and there are regular staff meetings. Staff said that they can talk easily to the registered manager and the registered provider. There is regular staff appraisal and supervision. Staff all said that they are pleased with the amount of training on offer. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 18 Jackie Faulkner, the head of care, demonstrates a clear understanding of the care needs of the residents and the support needs of the staff. She has a good working relationship with the registered manager, the registered provider and the care staff. There are weekly management meetings. Staff say that these meetings have improved communications. Relatives said that they can talk to the staff about any concerns they may have and that these concerns are acted upon. Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 2 2 2 2 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 Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 3 3 2 Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 19,,21,22, 24&25 26 Regulation 23 23 Requirement An action plan for maintence of home, over coming year, to be supplied to CSCI Home to be free from all offensive odours Timescale for action 30th September 2005 outstandin g from last inspection 31st July 2005 outstandin g from last inspection 31st July 2005 31st August 2005 3. 26 23 Unhygienic commodes to be refurbished or replaced 4. 38 23(2c) All equipment in home to be adequately maintained. In particular, all wheelchairs should be check for condition and safety 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. Refer to Standard Good Practice Recommendations Madeira Lodge H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU 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 H56-H05 S23467 Madeira Lodge V225805 280605 Stage 4.doc Version 1.30 Page 22 - 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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