Inspection on 30/11/05 for Madeira Lodge

This inspection was carried out on 30th November 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 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 11/11/09

Madeira Lodge 11/12/07

Madeira Lodge 05/07/06

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 Barbara Ludlow Announced Inspection 30th November 2005 09:50 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.V257003.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.V257003.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.V257003.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Madeira Lodge is registered to accommodate up to 40 people who in the category Older People over 65 years. The home comprises 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 to act as representatives for the persons in control. There is car parking space on the sloping driveways adjacent to the properties. 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 sea views. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by B Ludlow for CSCI. Mrs Rich Registered Manager, and Mr Kimberley representing the management company Care Home Management Ltd. were both available throughout the inspection day. This was a very positive inspection; service users were complimentary about the care and service they receive at Madeira Lodge. The inspector discussed the previous inspection and was updated on the work that had been undertaken following an environmental health officer’s health and safety inspection. Good progress had been made. A tour of the premises was made with the homes deputy manager who is currently studying the Registered Managers Award, NVQ Level 4. There were twenty-five service users in residence and one person in hospital who was due to return. Service users were seen in the communal areas and in private in their rooms. Staff were spoken with during the day. Lunch and tea were seen served in the homes two dining rooms. Records were sampled, these included care plans and contracts, maintenance and servicing, recruitment and staff training. Feedback was given to the Manager and Mr Kimberley at the conclusion of the inspection. Pre inspection information supplied by the Manager and written responses to CSCI service user and relative/visitor feedback forms is included in the report. What the service does well: The home overlooks Weston Bay, with panoramic views from the communal areas at the front of the houses. All communal areas are spacious yet there is a homely atmosphere. The accommodation in use is pleasant and the home offers a good standard of accommodation for couples. Staff had a friendly and caring approach to the service users. Service users confirmed that they were happy with the care and service they receive at the home. Comment included ‘very friendly’. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 6 The home allows service users to spend their time as they wish and encourages hobbies such as painting. Service users go out if they can one referred to catching the bus that stops outside the home to go into town to shop. Another takes independent holidays. Communal activities are held and are popular amongst the service users spoken with, the large Cove lounge is generally used for these events, which includes Bingo. The home has been established for some time and offers continuity of care for the clients who have lived here for a number of years. What has improved since the last inspection? 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.V257003.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.V257003.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 to be made. EVIDENCE: The home has an A to Z of services that is used as the Service User Guide. A copy of this document is kept in a file in each service users room. The files contain a copy of the terms and conditions of residence, complaints procedure and an inventory of any personal furniture items brought into the home. Pre admission assessments are made by the homes Manager and the first month of residence is treated as a trial period, to ensure that care needs can be met at the home. Contractual arrangements were seen and discussed for one service user. The homes fee is £350.00 per week in line with the North Somerset Social Services rate. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 9 Feed back from nine service users indicated that five enjoyed living at the home. Four said sometimes. Eight service users said that their privacy was respected, one said sometimes. Thirteen relatives/visitors responded in writing to CSCI, twelve said they felt welcomed at the home one said no. All said that they could visit their relative in private if they wish. One person said they never felt welcomed when coming into the home. Madeira Lodge DS0000008049.V257003.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 are in place for all service users. Care must be taken to record relevant information on the individuals plan. A review of blood sugar monitoring equipment and practice for staff is recommended. EVIDENCE: Service users all had care plans and information is recorded in a day / night handover diary, each day. Four care plans were sampled; Initial assessments and risk assessments were in place. Relevant personal information is recorded. Contacts with health care professionals and the GP were recorded. The District Nurses attend to deliver nursing care tasks such as re-catheterisation and warfarin therapy and other care requirements. One district nurse attended the home during the inspection. One care plan was found to have little information regarding a period of time the service user was away from the home. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 11 There was evidence of chronic disease management, but where service users are self-managing/administering their medication there were no records of self-testing of blood sugar levels. Care practices must be reviewed advice from the Diabetic Specialist Nurse/Community Nurse to ensure that staff are up to date with advice from the Medical Devices Agency and the Health Protection Agency and are working as safely as possible. Medication Administration Records were examined; there were a number of unsigned hand transcribed entries. The current prescribed doses for one insulin dependent diabetic had not been recorded. This was brought to the attention of the manager at the time of the inspection. Medications are stored and administered from a trolley and a medications fridge is available for cold storage. The medications fridge temperature should be recorded as a minimum/maximum on a daily basis. The MAR charts had medication labels attached this is not best practice and should be brought to the attention of the dispensing pharmacist. Controlled medication record keeping has been changed since the last inspection and was satisfactory at this inspection. All service users responding in writing said they felt well cared for. Relative’s feedback included that a relative is well cared for and is respected by staff. Madeira Lodge DS0000008049.V257003.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 were generally satisfied with the care and service provided at the home. EVIDENCE: Service users were spoken with during the inspection and the feedback was very positive. Written feedback was positive about being well cared with comment such, as ‘staff are golden’, others said that it is a ‘good home’ and that they ‘wouldn’t want to live anywhere else’. Service users were observed to spend their time as they choose. Activities are offered and comments heard suggested that they were enjoyed; the written feedback was split between enjoyed and sometimes/no, (4:2/2). One service user said they would like to have more therapy, at the last inspection a service user had suggested more organised physical activity to improve strength and balance to reduce the risk of falling. It was noted on the pre inspection information that staff are trained to deliver armchair exercises. This will be explored further at the next inspection. The home allows smoking but only in the designated area, the conservatory. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 13 Visitors are welcome at any reasonable time. 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. Lunch and tea were served; meals are generally social events with service users eating together in the dining rooms. The menu is posted on the board in the main dining room but not in the smaller dining room. The kitchen was clean and tidy and the records were completed. Fresh fruit and vegetable supplies were seen. Service users asked about the food confirmed that they enjoyed the food and were offered fresh fruit. Service user written feedback indicated that five of the nine respondents liked the food, four said sometimes. One visitor commented that their was no choice available at mealtimes and that the food was poor another said their relative didn’t like the food. It is recommended that the Manager explore this further to ensure service users are satisfied with the food and choice offered to them each day. Madeira Lodge DS0000008049.V257003.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 has improved. Written feedback confirmed that all service users felt safe at the home and would know who to speak to if unhappy. EVIDENCE: There had been one complaint since the last inspection, this had been dealt with within 28 days and closed, and this complaint was substantiated. Four staff recruitment files were examined; CRB and POVA First checks and references were seen on file. Staff had received POVA training in January 2004; staff spoken with had a good understanding of abusive behaviour and how to report an incident should one occur. Refresher training is recommended for both new and existing staff on the local policy guidance ‘No secrets’ in North Somerset. Madeira Lodge DS0000008049.V257003.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 remains in a mixed state of repair and refurbishment but progress was evident. The premises are positioned to provide outstanding views across Weston Bay but were not purpose built for care. Not all accommodation has level access; there are small three stair flights to sixteen bedrooms. Service users in residence were 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. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 16 Two areas (four bedrooms) of the Lodge are accessed by two steps. Two lifts at the home to give access to all floors. There is one small lift that has been long out of use and this has been locked for safety. One person reported finding the stairs a disadvantage. Individuals occupying these rooms should be monitored for their ability to climb the stairs to ensure accommodation meets the service users need. The home is in a mixed state of repair and refurbishment of bedrooms and bathrooms, this work is progressing. Bathrooms and toilets were seen that were locked where work was in progress. Windows are due 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. 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 seating is 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, and had received a satisfactory Environmental Health Inspection in August 2005. 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 detailed twelve requirements. Action has been taken by the Proprietors/management company to address these deficits with the exception of the electrical requirement, which has not yet been completed. Progress will be monitored by CSCI. The laundry service is managed with towels and sheets being sent to a laundry service and clothing being managed in house. No concerns/comments were heard about the service. Personal clothing was well cared for and nicely ironed. Infection control measures were satisfactory. Madeira Lodge DS0000008049.V257003.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): 27,28,29,30 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. EVIDENCE: The duty rotas demonstrated sufficient staff numbers to deliver care and services as required. The night time is covered by two staff. When the resident number exceeds 30, a third member of staff sleeps on the premises and is available to help in the evening, early morning and in an emergency during the night if required. Written service user feedback forms from nine residents confirmed that service users felt the staff treated them well, eight felt that there privacy was respected, one said sometimes. Staff and the Manager confirmed the commitment to training for all staff. The pre inspection information identified fire training, seated exercise training, manual handling training, health and safety training, food hygiene and drug awareness. Also confirmed was NVQ Level 2 is held by five care staff, with 3 identified to study to Level 3 and one more carer to study to Level 2, the deputy manager is studying NVQ Level 4 management training. Future training plans include first aid and health and safety training. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 18 Four staff recruitment files were sampled, references had been taken up and the CRB/POVA First checks had been made. This was an improvement since the last inspection. It was confirmed that induction health and safety training encompasses fire training. Ten staff had received supervision in November 05. Madeira Lodge DS0000008049.V257003.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 and the Management Company demonstrated their support at this inspection. The outstanding requirement made at the Health and Safety Inspection must be completed. The home manages the storage of all records and the administration of financial records well. 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. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 20 The Manager is supported by Care Home Management Ltd who were present at this inspection and have submitted the Regulation 26 monthly visit copy report to CSCI. These extensive premises require a significant amount of ongoing maintenance and 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 alarm was serviced on 23.06.05 and weekly alarm checks had been recorded since 24.9.05. • The last emergency lighting check had been made on 27.11.05. • Fire drills were held in November 2005. Fire training for 18 staff was given on 06.09.05, 12 staff had not signed to say they had attended the training. The drills had included night staff. • Fire extinguishers had been annually serviced on 02/03/05. The bath hoist was confirmed as serviced on 19.10.05. Accidents are recorded and the information is stored on the service users or staff file. The CSCI registration certificate was displayed and the Employers Liability Insurance, which was current and valid until 09.01.06. Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 21 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 2 8 3 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 3 2 3 3 3 3 3 3 3 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 3 3 X X 3 3 3 2 Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13(2) Requirement All hand transcribed entries on the MAR chart must be signed by the person making the entry. It is good practice to have hand transcribed entries signed as validated by a competent other. Medication doses for those who are self-administering should be recorded in the care plan and on the MAR sheet. The medications min/max temperature must be recorded daily. 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.CSCI must be updated with an action plan. Care planning/records must contain relevant information for example detailing when service users are away from the home. Timescale for action 28/12/05 2 OP19 13(4)(c) 21/01/06 3 OP7 15(1)(2) (b) 21/01/06 Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 23 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 OP9 OP15 Good Practice Recommendations Blood sugar monitoring practice should be reviewed and advice and guidance be taken about current safe best practice. The Manager should ensure that all service users are satisfied with the food and choice offered to them each day. This may need to be incorporated into the homes Quality Assurance monitoring. Ongoing and refresher POVA awareness training is recommended for both new and existing staff on the local policy guidance ‘No secrets’ in North Somerset. Care must be taken to ensure that service users occupying rooms that are accessed by stairs should be monitored for their ability to climb the stairs, to ensure accommodation meets the service users need. There should be a record of staff having attended fire training with their signature as confirmation of attendance and to highlight staff requiring fire training and updating. 3 4 OP18 OP19 5 OP38 Madeira Lodge DS0000008049.V257003.R01.S.doc Version 5.0 Page 24 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. 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