Inspection on 02/05/06 for Marifa Lodge

This inspection was carried out on 2nd May 2006.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marifa Lodge Wisbech Road Welney Wisbech Norfolk PE14 9RQ Lead Inspector Mrs Jacky Vugler Random Unannounced 2nd May 2006 09:30 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.V293176.R01.S.doc Version 5.1 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.V293176.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Marifa Lodge Address Wisbech Road Welney Wisbech Norfolk PE14 9RQ 01354 610300 01354610241 graham@marifacare.wanadoo.co.uk 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) Mr Graham Rainbird Mrs Teresa Rainbird Mrs Elizabeth Salter Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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. 3rd October 2005 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, 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. Information regarding the range of monthly fees charged and any additional charges is not available, as the pre-inspection questionnaire was not received prior to the inspection. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection taking place on a weekday. Mrs Elizabeth Salter, the Manager, was present throughout the inspection. Mrs Teresa Rainbird, Proprietor was present for a very short time. On the day several records were viewed and a tour of the premises was undertaken. There were twenty residents accommodated on the day. Six residents were spoken with privately and three members of staff. Six comment cards were received from residents, one from a visitor and one from a GP. The majority of these were satisfied with the care provided. The Inspector was disappointed not to have received the pre-inspection questionnaire from the home, prior to the inspection. This made the planning of the inspection unnecessarily difficult. What the service does well: What has improved since the last inspection? Staff said that the residents “standard of living is improving, for example, the food provided”. During the night there is one waking member of staff and a member of staff sleeping on the premises in case of emergency. A member of staff has been employed to organise activities and this is seen as good practice. She keeps very good records of activities undertaken by the residents. The care plans have improved; they contain more detail, which gives staff clearer guidance on how to meet the residents’ needs. They contain more detail of the resident’s previous lifestyle and are reviewed more regularly. The trees at the front of the property have been removed, which gives a good outlook for the residents. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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.V293176.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an admission process and residents are given clear information regarding the service, upon which they can base their decision that the service will meet their needs. EVIDENCE: Each resident is supplied with a statement of terms and conditions. The home conducts an assessment of needs prior to a resident’s admission. There is an opportunity for the prospective resident and their family to visit the home beforehand. The last three residents admitted came to look around the home with their families. A statement of purpose and service users guide were not given to them at that time as they are currently being updated and in draft form with the providers. It is required that the updated statement of purpose and service user guide are forwarded to the CSCI. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning has improved ensuring the residents’ needs are fully met. The residents are protected by the homes procedures for dealing with medications. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The Manager has worked hard to improve the care plans; they now give more guidance to staff. Residents’ life stories are included as well as their interests and hobbies. Residents have signed their care plan where possible. Reviews take place every two months and the care plan updated where necessary. Risk assessments are now in place for falls, for the resident wishing to smoke and for those resident wishing to administer their own medications. It was noted in some care plans that the use of bed rails is needed. It is required that a risk assessment is written for the use of bedrails. Visits by other healthcare professionals are recorded. A record is kept of personal possessions brought into the home by residents. Medications are appropriately stored and recorded. The controlled drugs were checked and correct. A record is kept of medicines returned and the Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 10 pharmacist signs this. Three residents currently administer their own medication and each has a risk assessment and lockable facility. All staff administering medications have completed training for this. Residents’ privacy and dignity were seen to be respected during the day of inspection. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle within the home meets the social and recreational needs of the residents since the employment of an activities organiser. Residents are able to maintain contact with family and friends. Residents are able to exercise choice and control over their lives. Residents receive a nutritious diet in pleasant surroundings with individual requirements catered for. EVIDENCE: The provision of activities has greatly improved at this home since December 2005 when they employed an activities organiser for fifteen hours a week. An activity folder is kept and in that is recorded all the different types of activities on offer. This is a very comprehensive file and is commended. At the time of the inspection this member of staff was on sick leave and the care staff have not had time to conduct activities. It is recommended that the activities undertaken be also recorded in the residents care plan. The home has an open visiting policy and one resident goes out with family or friends most days. Some choices are available to the resident, for example, bedtime for those able to make that decision. Those that can choose what to wear do, others, the carer gets the clothes out so they may choose. Residents are able to go into the large garden with a member of staff. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 12 Although a choice of meals is not printed on the menu, staff said that chicken is always cooked and available to those who do not want the main meal. They also said that staff know the residents likes and dislikes, it is recommended that these are recorded in their care plans. The tea is a choice of sandwiches, yoghurt and fruit. The menus seen were varied and nutritious. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents, staff and relatives have a knowledge and understanding of the channels through which to make complaints or concerns about adult protection issues to protect residents from abuse. However, the residents are not fully protected from abuse by the homes recruitment procedures and staff training. EVIDENCE: The complaints procedure is displayed in the entrance hall above a complaint, comments and suggestion box, with several blank forms available. No complaints have been received. Residents spoken with were aware to whom to complain if they had any concerns. The home has an abuse awareness policy and a whistle blowing policy. Staff spoken to are aware of abuse, however only not all staff have received training in this area. It is therefore required that staff are given training on understanding adult abuse, and procedures for protecting vulnerable adults. All staff have a Criminal Records Bureau disclosure returned, except for three new staff. However, no POVA first checks have been applied for. It is a requirement of this report that all staff have a POVA first check received before commencing employment. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 the following standard(s): 19, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing comfortable accommodation for the residents. The gardens are attractive and well maintained. In order to provide safer accommodation for the residents the hot water at hand basins must be regulated. EVIDENCE: This is a pleasant home which is very clean and tidy and well maintained. There are several small attractive sitting areas on the landing with table and chairs. There are two comfortable lounges and a spacious dining room with seating around small tables. The furnishings are of a good standard. The residents’ bedrooms are comfortable and personalised. Each bedroom has a Perspex box fitted on the wall and these contain ‘Who cares?’ leaflets and blank comment cards. This is good practice. Window restrictors and radiator guards have been fitted. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 15 Hot water regulators have been fitted to the baths. However, during the inspection it was noticed that the hot water at the hand washbasins was at temperatures far exceeding those recommended. It is therefore a requirement of this report that a risk assessment be written on the hot water temperatures and thermostatic control valves fitted where a risk is highlighted. Bedroom 16 had a noticeable odour and it is required that this carpet be cleaned or replaced. Otherwise, The home is clean, hygienic and free from unpleasant odours. The extensive gardens are attractive and well maintained, although one resident said, “the gardens are not quite as good as they used to be”. A member of staff also commented to this effect. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels have improved at this home. Staff recruitment files need improving and the residents would be better protected with more robust recruitment procedures in place. The training opportunities offered to staff are poor. EVIDENCE: This is a good staff group who are conscientious and enthusiastic about their work. Staff commented that “the team work is very strong”, but also that “staff morale is very low”. On the day of inspection there was the Manager, one senior care assistant, two care assistants, a cook, domestic, a laundry person and the maintenance man. These staffing levels are improved ensuring that the carers do not spend time doing other tasks. There is one carer working at night with another sleeping in on the premises, although, it is recommended that according to the dependency levels of the residents another waking night staff be available if required. 27.7 of staff have achieved the NVQ level 2, one these has nearly completed level 3, and another has level 3 and is waiting to commence level 4. Three other staff are currently undertaking the NVQ level 2. The staffing records do not contain all of the information required, for example, a photograph and a health questionnaire. There is therefore a repeated requirement that staff records contain the information required. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 17 As previously mentioned, although a criminal records bureau disclosure is routinely obtained for new staff, the POVA first check has not been applied for and a requirement has been made to this affect. The availability of staff training is currently poor and most statutory training is out of date. All of the staff spoken to commented on the lack of training available. Eight members of staff completed basic food hygiene 10.3.06. Fire training and moving and handling, including the use of a hoist, are undertaken on induction by using a video followed by questions. The Manager said that no further training has been undertaken. The Manager and a senior carer have completed the Moving and Handling Train the Trainers course, but this has now expired. Other videos with questionnaires have recently arrived at the home, but these are not yet in use. One senior carer on night duty has a current first aid certificate. Two staff have completed infection control training. One member of staff completed the Equal Value, Equal Care training in May 2005. It is required that staff receive training appropriate to the work they are to perform. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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 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, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general, this set of standards is improving. However, the Registered Manager will soon be leaving and this may affect the stability of the leadership within the home. A comprehensive quality assurance system is in the process of being implemented. The residents’ financial interests are safeguarded. The health and safety records are kept on the premises and available for inspection. However, staff training related to safe working practices is not up to date. EVIDENCE: The fire records were satisfactory and kept on the premises. The portable appliance testing was in date. Service certificates were seen for other equipment, for example, nurse call system, hoists and passenger lift. All the Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 19 recommendations from the environmental health officer’s inspection were complied with. General risk assessments are in place and current. Accident records are detailed, although it is recommended that a method be devised to make auditing these records easier. Staff have undertaken little statutory training and it is therefore a requirement of this report that all training relating to safe working practices is either undertaken or updated. The residents’ that are able, control their own finances and have a lockable facility in their room. The home keeps the money for other residents in a safe and the financial records are satisfactory. The money for five residents was randomly checked and correct. It is recommended that all receipts are kept and that the financial records are audited monthly. The home has recently acquired and started to implement a quality assurance system. This is a comprehensive system, but only partially completed; therefore the Inspector will need to re assess this at the next inspection. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 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. 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 2 3 3 3 3 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 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 21 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 OP1 Regulation 4, 5 Requirement The Registered Providers must ensure that the updated statement of purpose and service users guide is forwarded to the CSCI. The Registered Person must complete a risk assessment for each service user needing to use bed rails. The Registered Provider must ensure that appropriate systems are in place to ensure that hot water tap temperatures remain close to 43’C and that this is checked regularly (with records kept). The Registered Person must ensure that the carpet in room 16 is either cleaned or replaced. The Registered Person must ensure that staff records include documents as per schedule two. (This requirement is outstanding from the last three inspections and the previous timescale of 31.12.05 has not been met). The Registered Person must ensure that arrangements are made which prevent service DS0000061476.V293176.R01.S.doc Timescale for action 30/06/06 2. OP7 13 30/06/06 3. OP25 13 31/07/06 4. OP26 16(2)(k) 30/06/06 5. OP29 19 30/06/06 6. OP29OP18 13(6) 30/06/06 Marifa Lodge Version 5.1 Page 22 7. OP38OP30 18 users being harmed, suffering abuse or being at risk of abuse. The Registered Person must ensure that staff working at the home are provided with adequate training appropriate to the work they are to perform, and that training related to safe working practices is either undertaken or updated. 30/06/06 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. 3. 4. Refer to Standard OP7 OP15 OP35 OP38 Good Practice Recommendations It is recommended that activities undertaken be recorded in the residents care plan. It is recommended that the resident likes and dislikes regarding food are recorded in their care plan. It is recommended that receipts for residents, expenditure are kept and that residents’ financial records are audited monthly. It is recommended that a method for auditing accident records be devised. Marifa Lodge DS0000061476.V293176.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Norfolk Area Office 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. 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