Inspection on 11/08/08 for Marifa Lodge

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Marifa Lodge 21/08/07

Marifa Lodge 02/05/06

Marifa Lodge 03/10/05

Marifa Lodge 13/04/05

Marifa Lodge 13/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Marifa Lodge Delph House Wisbech Road Welney Wisbech Norfolk PE14 9RQ Lead Inspector Alan Buttery Unannounced Inspection 11th August 2008 10:30 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 Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marifa Lodge Address Delph House Wisbech Road Welney Wisbech Norfolk PE14 9RQ 01354 610300 01354 610241 enquiries@delph-house.co.uk www.delph-house.co.uk Mr Graham Rainbird Mrs Teresa Rainbird Manager post vacant Care Home 22 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) Category(ies) of Old age, not falling within any other category registration, with number (22) of places Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to twenty-two (22) Older People, of either sex, not falling within any other category may be accommodated. 21st August 2007 Date of last inspection Brief Description of the Service: Marifa Lodge is a care home providing personal care and accommodation for twenty-two older people. Marifa Lodge is a converted 19th century rectory in the village of Welney, on the Norfolk/Cambridgeshire border. It is close to the local amenities and a public house with accommodation. The home was opened in 1988 and consists of a two-storey building with a more recently built extension. The home provides sixteen single bedrooms and three shared on the ground and first floors. Access to the first floor is by a staircase at each end of the building, or a passenger lift. The home has well-maintained, accessible grounds, providing an attractive view over the fenland, close by the well-known bird observatory. The fee range was confirmed as between £343:00 to £410:00 per week. Additional charges include hairdressing, private chiropody and newspapers. A copy of the last inspection report is available in the main hall, and copies on request. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection, and during the inspection we looked at the key minimum standards for older people. One of the proprietors, Mr Rainbird is currently managing the home, and was available throughout to answer questions and provide information and documentation. During our visit we spoke with some of the people living in the home and to two of the staff on duty. What the service does well: What has improved since the last inspection? Since last year, new documentation has been introduced, and is under further development, which should ensure that the needs of the people living in the home are more clearly identified. A senior carer in the home has taken responsibility for arranging activities and this needs to include everyone living in the home Evidence of continued refurbishment was also seen during our visit Marifa Lodge DS0000061476.V370045.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. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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 Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is provided to people in the home so that they know what to expect, and prior to anyone moving into the home a detailed assessment ensures that the home are aware of their needs and able to meet them. EVIDENCE: Since the last inspection, the information available to people living in the home or thinking of moving there has been revised, and a new Statement o0f Purpose and Service user guide are now available, copies of which were seen during our visit. The service provides care to People referred by both Norfolk County Council and Cambridgeshire County Council as well as a number of privately funded packages, and has a procedure in place to ensure that any prospective admission is handled in similar fashion. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 9 Wherever possible a copy of the local authorities assessment is obtained, and following this a visit arranged to see the individual, either in their home or in hospital. Either Mr or Mrs Rainbird carries out this visit. Occasionally, either because it is an emergency placement, or because it is not possible to visit, someone moves in prior to the assessment, but in this case all relevant information is obtained within the first 24hours. Wherever possible, the assessment involves close family members, and includes a visit to the home, spending a few hours there to make sure they are happy with the facilities, and this normally involves lunch. Once the assessment is complete, the home can confirm to the individual or their care manager that they are able to meet the identified needs and a move date can be arranged. Initial care plans are then prepared in readiness for the person to arrive. The service does not offer intermediate care Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual plans detail the support required and how the individual wants the support provided, although these should also show the planned outcomes, and medication procedures ensure that all staff who assist with medication have had suitable training and are competent. EVIDENCE: As described above, individual care plans are written based on the initial assessment, and they provide the basis for the support and care when the individual first moves into the home. The care plans have been revised since the last visit, and although they are still under development, showed a good level of information. For example the background information seen on the care plans we examined was extremely good. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 11 Further work is needed to include all aspects of health and social care within the plans, and to include the outcomes that the individuals want from their care, and some of the staff involved in writing the care plans needs some additional training to ensure that the plans are of a high standard. The service has a good relationship with the local health centre and feel that they are well supported by the local GP’s, district nurses and pharmacy. and equipment is available for them when required. One of the people living in the home looks after his own medication, and has done for several years, but the home does need to ensure up to date risk assessments are in place and that the practice remains safe. Facilities are provided in his room for the safe storage of his medication. During our visit, staff were seen to be treating people with dignity and respect, both in way they talked to the people and the way they helped and supported them, for example when assisting people to go to the dining room for lunch. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A range of activities are available to people living in the home to take part in should they choose. A choice of well prepared home cooked food is available, and special dietary preferences catered for. EVIDENCE: Since the last inspection, one of the senior carers has taken on responsibility for co-ordinating activities and a wide variety of activities are now available to people in the home. During the summer they try and take as many people as possible out at least once a week, using their own minibus and visiting local attractions where they can enjoy some fresh air and a cup of tea. Some of the places they have visited include a local wildlife centre, Butterfly Park, Shopping centre, Methodist church ‘tea afternoon’ and a local windmill. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 13 They also try and have a cinema day once a week with video’s or DVD’s, various games, entertainment and help the people in the home to spend time in the gardens, which are easily accessible and have some large trees to provide shade. Although the activities are co-ordinated by the senior carer, care staff are expected to spend time with the people in the home on activities or just spending time sitting and talking with them. During our visit we saw the carer who co-ordinated activities helping one person who wanted her nails done, and applying nail varnish. The service try and have a visiting vicar come to the house, but being in a remote rural area this is not always possible, but where someone expresses specific religious needs this would be addressed. Home cooked meals are served in a pleasant dining room, which has` recently been redecorated, and it was good to see that tablecloths and fresh flowers were on all the tables. A varied menu is available and people have a choice of meals available. One of the people living in the home is a vegetarian, and appropriate meals are provided for her. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that complaints or allegations are appropriately dealt with, and people know that any issues they raise will be listened to. However, more training is needed to ensure staff are aware of how to deal with such concerns. EVIDENCE: The service has a complaints procedure in place which is given to everyone living in the home and available in the main entrance hall and which gives details of how complaints are handled and the timescales involved. Although the service has received some complaints, mainly around the support they provide one particular resident, these have been dealt with in accordance with the procedure. The commission has received one complaint, which was referred to the provider for action. A procedure is in place to ensure that adult protection issues are dealt with in accordance with local authority guidelines, however it was unclear from the records available whether all staff have received the appropriate training. It is included within the induction training for new staff but all staff must receive updated training on a regular basis. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service operates from home that is clean and offers good facilities to those living there, with accessible gardens. EVIDENCE: The home is a former rectory, which has been extended and is set in attractive grounds, which provide seating and shaded areas for the people living in the home. It offers a good range of facilities and is in a good state of decoration. Evidence was seen during a tour of the building of re decoration and updating and of the people living in the home being able to bring in personal items and furniture. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 16 On the day of the inspection, the home was clean and tidy and there were no unpleasant odours. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Documentation in the home showed that recruitment and administration is poor and people living in the home are not protected by the recruitment practice, or by a well trained staff team. EVIDENCE: This was the main area of concern resulting from our inspection. The staff we saw and spoke to during the visit clearly placed the interests of the people living in the home at the forefront of everything they did, confirmed by the people we spoke with during our visit. However, the main problem was the poor records available and the absence of details on training either given or planned. The service has a recruitment process in place but this was clearly not being followed. We looked at three staff files and spoke with two of the staff concerned. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 18 There were no references for one of the people, and only one detailed on the application (although this person has worked in the service for 4 years, another had a clear start date prior to receipt of references, Crb check and Pova check. This file had no training information since 2006 although in discussion with the member of staff she was able to confirm that she had had some training in the last year including medication, moving and handling and safeguarding. A further staff member’s file had no information regarding induction training, or any moving and handling training, and no employment history detailed. In addition only one written reference was available. A clear recruitment procedure is needed, with a standard form of interview notes and a training plan for the coming year to ensure that the procedures are in line with the standards and regulations. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is currently no full time registered manager, and this is causing difficulties in administration, and staff supervision. Proposals to change this are being considered which need to be resolved quickly to ensure people live in a well run home, although clear emphasis on the people living there was seen. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 20 EVIDENCE: At the present time there is no registered manager for this home, and day-today management responsibility is taken by one of the owners. If this is to be the case, an application should be made to register Mr Rainbird. However, if this is to be the case then the administration within the home needs to improve and all necessary paperwork and procedures to be available within the home. There is little doubt that the owners and staff place the interests of the people living in the home first, and this was seen during our visit in the way that the owner spoke with all the people we saw when walking round the home. People that we spoke to who live in the home were very complimentary, for example ‘This is a first class home’ ‘Not too big, I know everyone’ Procedures are in place to ensure that where the service holds money on behalf of people who live in the home, this is kept in a safe, and a clear audit trail ensures they know who and when money is drawn. In line with earlier comments regarding the management and administration of the home this has also affected supervision, which is not currently happening. If the owner is to take on full time management of the home, this is another area that he needs to improve upon. Health and safety procedures are in place, although more training needs to be provided to the staff in the home to ensure that they are aware of the correct procedures. Marifa Lodge DS0000061476.V370045.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 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 X 3 X X N/a Health AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 2 X X Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(1) Requirement Individual plans must show the involvement of the person they relate to and evidence of review to ensure they are up to date. All staff must receive training in safeguarding adult procedures to ensure they are competent in dealing with any allegations made. The provider must ensure that all information required in schedule 2 of the Care Home Regulations is obtained before any new staff commence employment to make sure people in the home are not placed at risk. All staff must receive appropriate training to ensure they are competent and able to meet the needs of the people living in the home. An application for the registration of a manager for the home must be submitted to the CSCI. All staff must receive appropriate supervision to ensure they remain competent to carry out DS0000061476.V370045.R01.S.doc Timescale for action 31/10/08 2. OP18 18(c)(i) 30/11/08 3. OP29 19(1)(b)(i ) 31/10/08 4. OP30 18(c)(i) 30/11/08 5. OP31 18(1)(a) 30/11/08 6. OP36 18(2) 31/10/08 Marifa Lodge Version 5.2 Page 23 their duties. 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 OP30 Good Practice Recommendations A risk assessment should be in place to ensure that where anyone manages their own medication, this does not place them at risk. A plan of training should be produced for the coming year in order that necessary training be given to all staff at the appropriate time. Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marifa Lodge DS0000061476.V370045.R01.S.doc Version 5.2 Page 25 - 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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