Inspection on 13/12/06 for Mar Lodge

This inspection was carried out on 13th December 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mar Lodge 03/12/08

Mar Lodge 03/11/05

Mar Lodge 26/07/05

Mar Lodge 16/02/05

Mar Lodge 28/06/04

Mar Lodge 23/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Mar Lodge 26 Nottingham Road Melton Mowbray Leicestershire LE13 0NP Lead Inspector Mr Toby Payne Unannounced Inspection 13th December 2006 08:30 Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 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 Mar Lodge DS0000031542.V320973.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 Adults 18-65. 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. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mar Lodge Address 26 Nottingham Road Melton Mowbray Leicestershire LE13 0NP 01664 560302 01664 560302 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) Craegmore.co.uk Park Care Homes (No 2) Ltd Cheryl Ann Palmer Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to admit 1 named service user of category SI as specified in Variation Number V000000874 3rd November 2005 Date of last inspection Brief Description of the Service: Mar Lodge is a residential home is situated in the town of Melton Mowbray on the main Nottingham Road, approximately 1 mile from the town centre. The home is within easy access to local shops and public transport. Mar Lodge is a detached old building, which has been modernised whilst retaining its original features. It is registered to provide personal care for up to seven people with learning disabilities. The emphasis is on homeliness, and there is no feel of an institutional setting. The home has seven single bedrooms one with en suite facilities. All rooms are decorated to an acceptable standard after consultation with residents regarding the décor. The home has one lounge and one dining area and a large kitchen. Outside the house is a paved seating area and a pleasant conservatory that provides additional space for residents to use when the weather is good. The fees at the inspection on the 13/12/2006 ranged from £350 to £756 each week. Extra costs were hairdressing £8 to £12 and chiropody £7. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and started at 8.30 am. It was undertaken using a review of all the information available to the inspector about Mar Lodge Care Home. It took place over 4½ hours. The inspector spoke to each of the 7 residents, 2 members of staff and the acting manager. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of their care What the service does well: What has improved since the last inspection? The acting manager has involved families more and improved the contact with families and the local community. The acting manager and staff have encouraged more choice regarding how residents wish to spend their free time and have involved them more in the running of the home. The acting manager has reviewed the care plans to make them more personal and relevant to the person’s needs. One bedroom had been redecorated and refurnished with the full involvement of the resident who chose the colour and type of furnishings. A conscious effort has been made to welcome new people coming into the home. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Mar Lodge met the needs of residents coming into the home. However residents living at the home did not receive sufficient up to date information to enable them or their relatives/advocates to make an informed choice as to whether or not they wish to live in this home EVIDENCE: A new person was admitted in March 2006. This person’s care records were examined. There were detailed records to show the person had been fully assessed before they came into Mar Lodge. The staff also ensured that new people coming to the home received a warm welcome by existing residents. There was a statement of purpose but it was not up to date and there was no service user’s guide for the home available. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. There was detailed care planning which included risk assessments. The health and welfare of the residents was therefore fully met. People were encouraged to make decisions for themselves and be independent with the support and guidance of staff. EVIDENCE: Each resident had a detailed care plan. The care plan had been produced wherever possible with the involvement of the resident, their family/advocate and other relevant people. Since the last inspection efforts had been made to make care more individual and person focussed. Choice and decision making was clearly referred to in the care plans. There were daily records of activities and the care plans were reviewed every month. There were also risk assessments included. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 10 Staff were seen to respond to residents in a positive manner. Choice and decision making was clearly shown in the care plans and staff were trained to enable these choices to take place. Residents were given choice concerning their interests and activities. Resident’s financial records were checked and clear records were being kept. There were weekly resident’s meetings, which were arranged by the residents and enabled them to discuss any issues regarding the running the home. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13, 15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were involved in meaningful and appropriate activities, which included educational and recreational activities. EVIDENCE: Each person had information in their care records about contact with family and friends and their preferred activities. There was evidence of individual activity programmes, which were split into leisure, education and home activity. The inspection took place before most of the residents were about to go out for the day to college. Each person had a programme and one service user did voluntary work in a local charity shop. There was also a varied programme of evening activities, which had been arranged following discussions with the residents. These took place Mondays Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 12 to Fridays as the residents spent the weekends with their families. The activities included swimming, arts and crafts, visits to local pubs, restaurants and the cinema as well as local sports clubs. The activity programme and details of the clubs was displayed on the notice board at the entrance to the home. There were 4 residents who were actively involved in a local self advocacy group where they met every month outside the home. This had been going for a year and had proved very successful and empowered the people involved. On the day of the inspection one resident was keen to talk about archery in the afternoon and a visit to the Hay Market Theatre in Leicester to see Star Light Express. The home was decorated with Christmas decorations, cards and a Christmas tree. The residents had involved themselves in this and their artwork was displayed in the activity room off from the dining area. The menu was displayed and records of food temperatures, fridge temperatures were examined. The kitchen was clean and tidy. There had been an EHO inspection in September 2006. There were no concerns. A residents meeting takes place every Tuesday, which is arranged and chaired by the residents. There is no staff involvement. Issues, which arise, are discussed with the acting manager. The meeting discuss the menu for the week, any complaints or issues of concern. Meals were taken in the dining area in the lounge on the ground floor. All staff were required to prepare meals and all had food hygiene training provided. Residents were involved in making cakes and biscuits as well as choosing the menu. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s health and emotional needs were met. Resident’s needs were monitored regularly. Staff gave support to the people living in this home EVIDENCE: The home operated a “key worker” system in order to give a specific member of staff responsibilities for a particular resident. Care records clearly showed that any health or emotional needs were being met either by the community nurse or GP. Staff also showed knowledge of the particular needs of the residents. There were no major healthcare issues. The home had a detailed medication policy and there were records of medication received and returned to Boots. All staff had received training on the system used from Boots and 2 staff had received safe handling medication training and a further 3 would start this training in April 2007. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 14 Four of the seven residents were on medication. The stock was well maintained. Medication administration was observed. Medication was safely administered. No resident was self medicating. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any complaints received were taken seriously and residents are protected from abuse. People feel that their views are listened to. EVIDENCE: There was a robust complaints procedure. The home had a complaints book and it showed the last complaint was recorded on the 29/6/2004. The home also had a comment book and the last record was on the 22/6/2006. The comment was very complimentary. The commission and the home had received no complaints since the last inspection. None of the residents expressed any concerns about the home during the inspection. The home had an adult protection policy and all staff as part of their induction received abuse training. The local adult protection policy was in a folder at the entrance to the home. They also received a refresher training programme in September 2006 and further in depth training from an outside company in November and December 2006. Staff confirmed this and knew what abuse was and what they should do if they suspected abuse. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People lived in a safe, clean and well decorated comfortable accommodation, which reflected their individuality. EVIDENCE: The home was clean, comfortable and odour free throughout. Since the last inspection one resident’s bedroom had been redecorated with the resident being involved in choosing the colours and type of furniture. The manager carried out regular health and safety audits. Water temperatures were monitored every month and were within safe limits. A Legionella check was carried out in October 2006. There were no major concerns. The company who did the check was carrying out remedial work. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There were safe levels of staff and staff knew how to meet the resident’s needs EVIDENCE: There were no vacancies. The home was staffed Monday to Fridays as each resident went home to their families every weekend. . There were 5 care staff and 2 had obtained qualifications in care (National Vocational Qualifications) and a further 2 staff were waiting to start NVQ level 2. Training had included safe guarding adults, equal opportunities, infection control, health and safety, food hygiene and fire prevention. Staff spoke of the support they received and of the supervision they received from the acting manager. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 18 All staff were responsible for care, catering, domestic and laundry duties. They were therefore responsible for all services in the home. Sleep in cover is provided in the home, as there are no wakeful staff on duty at night. Sleep in cover is from 22.00 to 07.00 hours. The acting manager said this had posed no problem. However, where required additional help could be provided. Care staff supported the residents to be as independent as possible with these tasks. The staff felt they could meet the needs of the residents and felt they had sufficient time. This was observed during the inspection by staff laughing and joking with the residents. Residents were seen to say goodbye to staff before they went out for the day and staff did the same. Staff also spoke of the support provided and how they all worked as one team Staff did not receive a copy of the General Social Care Council’s Codes of Practice. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were lead by an experienced, competent and committed manager who supported the staff and residents. EVIDENCE: The acting manager had been in post since March 2006. She had previously worked at another home. She was not registered yet with the commission. The manager must apply for registration. She had started to study for a management and care qualification. She had reviewed care plans to make them more individual, encouraged residents to have more choices and involvement in the running of the home. She has also tried with success to improve communications between to the home and families and the local community. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 20 This effort had proved successful and they held a Halloween party and were to hold a Christmas party in the future. Staff were very positive about the home and manager. There was a very relaxed and happy atmosphere in the home and staff showed knowledge about the needs of the residents. Staff had confidence in the acting manager. The home had comprehensive policies and procedures... The company had a quality assurance programme. This has included audits by the manager of health and safety and infection control. Creagmore also undertake monthly unannounced monitoring visits and detailed reports have been sent to the Commission. There was a policy on equality and diversity. This included a policy on empowerment. All staff had received equal opportunities training in September 2006. The training pack was very detailed and included learning outcomes, equality and law and human rights. Records examined on the day of the inspection were available, well maintained and up to date. The home had a comprehensive and detailed health and safety policy together with risk assessments covering all aspects of daily living activities. A detailed fire risk assessment had also been carried out. There were regular tests of the fire system as well as regular fire drills. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 22 No 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 Standard YA1 Regulation 4 and 5(1) Requirement The registered person must ensure that there is an up to date statement of purpose and service user’s guide available in the home and that a copy of the service user’s guide is given to each service user. The registered person must arrange for a completed application for the manager to be sent to the commission. Timescale for action 13/02/07 2 YA37 8 13/01/07 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 YA6 YA31 Good Practice Recommendations It is recommended that wherever possible the manager ensures that residents are involved in developing their care plans and at their reviews It is recommended that the manager ensures that each member of staff receives a copy of the General Social Care Council’s Codes of Practice and are made aware of its contents and of their role. Mar Lodge DS0000031542.V320973.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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