Inspection on 13/04/05 for Marifa Lodge

This inspection was carried out on 13th April 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

Marifa Lodge 11/08/08

Marifa Lodge 21/08/07

Marifa Lodge 02/05/06

Marifa Lodge 03/10/05

Marifa Lodge 13/09/04

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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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marifa Lodge Wisbech Road Welney Wisbech PE14 9RQ Lead Inspector Jenny Rose Unannounced 13th April 2005 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. Marifa Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Marifa Lodge Address Wisbech Road Welney Wisbech Norfolk PE14 9RQ 01354 610 555 01354 610 241 admin@marifacare.wanadoo.co.uk Mr Graham Rainbird, Mrs Teresa Rainbird 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) Mrs Elizabeth Salter Care Home 22 Category(ies) of Older people (22) registration, with number of places Marifa Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Up to twenty-two (22) Older People, of either sex, not falling within any other category may be accomodated Date of last inspection 13/09/04 Brief Description of the Service: Marifa Lodge is a care home providing personal care and accommodation for twenty-two older people. Mr and Mrs Graham Rainbird have recently puchased Marifa Lodge. 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, including the village shop 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.. Marifa Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, taking place over 7 hours on a weekday. Mrs Elizabeth Salter was present during the inspection and meetings took place with Mr Graham Rainbird at the beginning and close. Preparation for the inspection had taken place in the CSCI office. On the day, many records were viewed and a tour of the building was undertaken. There were 20 service users, one shared room and one single room vacancy. Five service users were spoken to, two in private, together with a group of three members of the care staff and the maintenance person, also one visitor. What the service does well: What has improved since the last inspection? What they could do better: * * * * The paper system for seeking the views of the service users needs to be implemented to ensure a programme of continuous improvement. Care plans need further improvement; including risk assessments for the mobility of service users, together with the incidence of falls to properly meet the needs of the people living in the home Opportunities for stimulation through activities should be offered to service users to suit service users’ physical, emotional needs and capacities The system for staff training, development and supervision, needs more rigorous implementation to improve the quality of life for service users Marifa Lodge Version 1.10 Page 6 The number of care staff on duty could better reflect the needs of the group of service users in the Home. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marifa Lodge Version 1.10 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 Marifa Lodge Version 1.10 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) 2, 3, 4 There is an admission process and service users are given clear information regarding the service, upon which they can base their decision that the service will meet their needs. EVIDENCE: Every resident is now provided with a statement of terms and conditions. The home conducts an assessment prior to a resident’s admission and there is the opportunity for visiting the home with their family beforehand. One new resident commented that she was very happy that she was allowed the choice of taking her meals in the sitting room, as she was unused to taking them in company, when she was in her own home. This resident had visited with her relatives beforehand to assess the suitability of the home. She said she was pleased that her family, with their young children were welcomed to the home at any reasonable time. Marifa Lodge Version 1.10 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) 7,8,9 In order to fully meet residents’ health and personal care needs, further attention must be given to the regular revision and review of the care plans, together with risk assessments for falls and the service users who choose to self medicate. The quality of record keeping needs improvement. EVIDENCE: There have been improvements to the care plans, but photographs of the residents should appear on all care plans and on the MAR sheets, since there are several residents sharing the same first names. Some care plans contained a social history, and one resident preferred to keep her own record of this in her room, to share with whom she wishes, however there is a recommendation for further improvement. It was evident from the Accident Book that there were several residents who may be at risk of falls. It is therefore recommended that more rigorous risk assessments, with regular reviews, need to be undertaken, together with an assessment of service users’ psychological needs. Two service users were spoken to regarding their own medication, which was kept in a locked drawer in their rooms, for which there were risk assessments. One recorded her administration on a MAR sheet, another preferred to record her administration on a calendar, together with a record of her visitors. The Marifa Lodge Version 1.10 Page 10 risk assessments should be regularly reviewed and kept within the care plan. Arrangements were made for those service users who wished to smoke and it was observed that they did so in designated smoking areas. However, there was no risk assessments in the care plans examined regarding smoking, nor recorded that this was an activity of the service user’s choice. Marifa Lodge Version 1.10 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 has made limited progress to improve the provision of activities in conjunction with the service users. The dietary needs of service users are well catered for. EVIDENCE: Service users maintain contact with family and friends as they wish. The visitor, who visited the home several times a week, said that she was very satisfied with the care given to her mother, and she felt her mother was happy. There was no designated person for organising activities, and it was not clear that there was time for the staff to take on this role in addition to their personal caring tasks. Service users, who were able, were encouraged to retain autonomy and control over their lives in terms of choosing where to eat their meals, where to spend their time and choosing to smoke, or continue self medication. The cupboards and freezers are well stocked, the latter with much home-made produce, all of which several service users commented upon as being of “good quality”, well balanced and offering a wide variety of food. Marifa Lodge Version 1.10 Page 12 Marifa Lodge Version 1.10 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, 17, 18 Service users, staff and relatives have a knowledge and understanding of the channels through which to make complaints or concerns about Adult Protection issues to protect service users from abuse. EVIDENCE: There is a clear complaints procedure with no complaints received at the home. The service users spoken to were aware to whom to complain if they had any concerns. One service user has an advocate to handle her affairs. Postal votes have been arranged for the forthcoming election for service users. Staff spoken to were aware of the Adult Protection procedure and had undergone training in this area. Marifa Lodge Version 1.10 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, 24, 26 The standard of the environment is good, and there have been many improvements providing service users with an attractive and homely place in which to live. EVIDENCE: The kitchen has been completely refurbished since the last inspection, with the approval of the Environmental Health officer (seen). Replacement of furniture has also taken place. The accessible gardens are well maintained and provide a very pleasant outlook from the property, the maintenance records for this and routine services were up to date and efficiently kept. This is to be commended. The bathrooms are cleanly decorated, and there is a net curtain in one of them, providing a more homely touch. The home is hygienic, clean and pleasant. Marifa Lodge Version 1.10 Page 15 The service user’s bedrooms seen were light, attractive and comfortably furnished with new beds. In many instances the bedrooms were personalised and screening was provided in shared rooms to ensure privacy for personal care. Many had good views of the well-kept gardens. There is a resident cat and some visitors bring dogs to the home, which provides a homely touch for those service users who like animals. One service user commented: this is “a small, homely place, not like an institution”. Marifa Lodge Version 1.10 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, 30 Staff training has improved and service users are satisfied with their care. However, the ratios of care staff to service users must be determined according to the assessed needs of the service users and a system operated for calculating staff numbers, including domestic staff, required to deliver this. EVIDENCE: Service users spoken to said that the staff at the home are kind and caring, “You can’t fault them in here, they are kind and I never have to wait”. From a discussion with a staff group it was evident that the staff are conscientious and enthusiastic about their work and anxious to give good personal care to the service users, some of whom have high dependency needs. However, there was no evidence of a system for calculating staff numbers, including domestic staff, determined according to the assessed needs of the service users Four members of staff have at least NVQ level 2 training, 3 are undertaking level 2 and two members of staff starting NVQ 1 Domestic. The Manager, who has attended many courses, is about to complete the NVQ 4. All members of staff are about to start Dementia Mapping Training, which is to be commended. The training and staff development programme is in the process of being developed and the Manager advised that the outside agency, which had been contacted regarding the home’s training needs had been unable to proceed at the time and it would be necessary to contact them again. . Marifa Lodge Version 1.10 Page 17 Marifa Lodge Version 1.10 Page 18 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) 32, 33, 35, 38 The health, safety and welfare of service users and staff are promoted. The home must regularly review all aspects of its performance in order to improve the quality of the service as a whole in the best interests of the service users. EVIDENCE: There is a paper system in place for ascertaining the views of the service users, staff. relatives and other members of the community and acting upon them, but this has yet to be implemented. Joint receipts for individual service users’ personal monies are issued, and these are locked in a separate safe. There were randomly checked and found to be correct. The maintenance records regarding the health, safety and welfare of service users and staff were seen to be in good order. Marifa Lodge Version 1.10 Page 19 Marifa Lodge Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 1 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 x 2 2 x 3 2 x 3 Marifa Lodge Version 1.10 Page 21 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. Standard OP33 Regulation 24 Requirement The Registered Providers must ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users are implemented in order to measure the success of the home and meet the changing needs of service users, by fully implemented. (This requirement is outstanding from the last inspection). The Registered Person must ensure that a training and development plan is produced for each individual member of staff and a planned approach to meeting the homes training needs. (This requirement is outstanding from the last inspection). The Registered Person must ensure that staff records include documents as per Schedule two. (This requirement is outstanding from the last inspection) The Registered Person must ensure that the induction and foundation training meets the specification of the Training Organisation for the Personal Version 1.10 Timescale for action 31 July 2005 2. OP30 19 31 July 2005 3. OP30 19 31 July 2005 4. OP30 18 31 July 2005 Marifa Lodge Page 22 5. OP8 13 6. OP27 18 Social Serices. Evidence of training should demonstrate this.(This requirement is outstanding from the last inspection). The Registered Person must promote and maintain service users health and ensure access to health care services to meet assessed needs, including professional advice regarding continence and opportunities for exercise and physical activity for those at risk of falling. The Registered Person must introduce a system for calculating staff numbers to be determined according to the assessed needs of service users. 31 July 2005 Immediate and ongoing 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 OP7 Good Practice Recommendations It is recommended that care plans reflect the previous lifestyle, social interests and hobbies in addition to care requirements. (This recommendation is outstanding from the last inspection). It is recommended that the provision of activities be reviewed in conjunction with service users (This recommendation is outstanding from the last inspection). It is recommended that the risk assessment for service users who administer their own medication is kept with the care plan and regularly reviewed. Also risk assessments for those service users who choose to smoke. It is recommended that photographs of service users are used in the care plans and on the MAR sheets 2. 3. OP12 OP9 4. OP7 Marifa Lodge Version 1.10 Page 23 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 Marifa Lodge Version 1.10 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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