Inspection on 21/08/07 for Marifa Lodge

This inspection was carried out on 21st August 2007.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marifa Lodge Delph House Wisbech Road Welney Wisbech Norfolk PE14 9RQ Lead Inspector Mrs Geraldine Allen Unannounced Inspection 21st August 2007 09:00 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.V349222.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.V349222.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 vacant post 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.V349222.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. 2nd May 2006 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 £395:00. Additional charges include hairdressing, private chiropody and newspapers. Mr Rainbird said that prospective residents are advised verbally of the fee payable at the time of initial enquiry. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 21st August 2007. The Annual Quality Assurance Assessment (AQAA) was completed by Mr Rainbird and returned to CSCI. This gave detailed information about the service and the plans in place to improve the care and facilities provided. The document is well completed and reflects the current service. The Commission sent out questionnaires at random to some people who live at the home and their next of kin. Only 1 resident and 1 relative responded. The views expressed in the questionnaires have been reflected within this report. Further information was obtained on the day of inspection by touring the premises, speaking with residents, staff and visitors and also observing practice and interaction. Generally, people felt they were well cared for by staff who were kind and responsive to their needs. There was less satisfaction about the social aspects of their lives. A total of 9 requirements and 7 recommendations that reflect good practice were made. What the service does well: People are cared for by staff who are kind and respectful. Interaction between people living at the home and staff was always appropriate and friendly. Staff were working hard to meet the needs of people in the way they preferred. People said they enjoyed the food provided at the home. They spoke about the range of choices available at each meal and said the food was tasty and plentiful. Although people said they would like more activity in the home, they also spoke positively about the home’s minibus and the places they had been able to visit recently. People said they felt comfortable about speaking to the care manager or another member of staff if they had any concerns or worries. They said their concerns were always taken seriously. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marifa Lodge DS0000061476.V349222.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.V349222.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): 1, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was no Statement of Purpose or Service User Guide available on the day of inspection. Admissions are not made to the home until a full needs assessment has been undertaken. EVIDENCE: Mr Rainbird said that the statement of purpose and service user guide are available on the home’s website and further hard copies will be made available shortly. A copy of these documents is provided to all enquirers, although there were none available on the day of inspection. A copy was subsequently printed off for inspection purposes. A copy of the service’s Aims and Objectives had been provided to CSCI. This document is described as a “guide” for staff and a statement that “sets the vision for an effective service”. It contains a range of statements under a set of core values. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 9 All prospective residents have an assessment of their needs completed before they move into the home. A contract containing the fee payable is provided when the new resident enters the home for their trial period. A final contract is provided once they become permanently placed. This home does not provide intermediate care. Marifa Lodge DS0000061476.V349222.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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have a care plan that is individual to them although there were some gaps in records about care delivery. The way information is stored within the care plans makes it difficult for staff to retrieve important information. Medication systems do not follow safe practice guidelines. Not all staff dispensing medicines are trained to do so. Staff treat people with respect and dignity when delivering personal care. Some records do not safeguard against breaches of confidentiality. EVIDENCE: The care planning documents and standard of recordings were discussed with Ms Thompson after looking in detail at 3 care plans. It is acknowledged that work has been done previously to improve the care plans at this service, however there is scope for them to be developed further. All residents had a care plan that reflected their specific needs. In order for the care plans to provide effective guidance to staff the following points need to be addressed. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 11 It was agreed that all care plans need to be looked at and the way information is stored reconsidered, so that they easier for staff to use. The information contained within them needs to be clear and up to date. Regular reviews are needed to ensure the care delivered is appropriate for the individual. The risk assessments need to be reviewed and updated. The daily records are task orientated and need to include more information about social and emotional matters on a daily basis. The accountability sheets must be completed daily so that there is evidence care is being delivered as per the care plan. One member of staff said she felt the care plans were alright and described them as “better than some”. Staff use a communication book that contains confidential information about named residents. As a result, some people had their right to confidentiality breached. Whilst it is acknowledged that staff need a way to communicate between shifts, the content and the way information is recorded in this book needs to be reconsidered. Two visitors were spoken to and both expressed dissatisfaction with the care provided to their relative. They provided specific examples of their concerns and confirmed these had been raised with the service. These concerns included matters relating to health care and included delays in obtaining medicines and failure to follow medical instructions. Both visitors felt there was still room for improvement in the care of their relatives. Both were keen to point out that staff do their best. The opportunity was taken to speak with a visiting District Nurse. She said the home had gone through “troubled times” but was better now. She said staff refer appropriately to health care teams and follow their instructions. She also said staff were always available when nurses visit and said visits take place about 2 times per week. The nurse said that arrangements were in place for doing diabetic and insulin training with staff. The arrangements for medication were looked at and the member of staff responsible at the time of inspection was spoken to. The service uses a monitored dosage system that is contained in sealed cassettes. The cassettes are kept in a carry case along with “as required” medicines. The carry case was described as awkward and, looking inside, it was untidy. The home has a medicine trolley but this is not used. However, subsequent to this inspection, the service provider has advised that the medicine trolley is now in use. The medicine administration records (MAR) were looked at and had significant gaps where it was not possible to confirm if a person had taken their medicine as the chart was not signed. The controlled medicines held for 1 resident were checked against the controlled drugs register and were correct. However, the register was not being kept properly as there was 1 entry where only 1 person had signed and the signature was not correct as it was their first name only. The temperature for the medicine fridge was not being checked and recorded. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 12 Ms Thompson said that the only 4 staff, including herself, had received training to administer medicines. At least 1 person was administering medicines who had not received any training. The training was described as “in-house” and did not therefore comply with minimum standards. One member of staff responsible for dispensing medicines said she has not received training since starting at this service although she had been shown how to dispense a couple of times but her competence has not been checked. Staff were seen protecting privacy and dignity through good practice. Personal care was provided behind closed doors. People were spoken to appropriately. People comfortable in their appearance and clothes were clean. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people were not always able to follow the lifestyle they preferred and did not have regular access to meaningful daytime activity. Visitors were welcomed at the home. The food in the home was of good quality and met the dietary needs of people using the service. EVIDENCE: Three people who use the service were spoken to. One person said they had not lived at the home for very long and found it quiet. They said there were not many people to talk to and they would like to get out more. Another resident said she was bored because there was nothing to do. This person also spoke about recent outings in the home’s minibus to Wells, a local wildfowl trust and also on a shopping trip. Another resident said she had not lived at the home for long but was very happy there and particularly enjoyed the food. She said she had a lovely room and was just waiting for someone to put her pictures on the walls for her. She said she felt comfortable about speaking to staff if she was unhappy or had any worries. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 14 The home does not employ a person to organise activities and care staff arrange any activity. People using the service said there was often very little happening at the home. Observations were made throughout the day but no social activity or meaningful occupation was seen. The television was left on in the main lounge and 2 residents enjoyed sitting in the quiet lounge during the afternoon. It was noted that many residents were disengaged and asleep during the day. When asked about activities, one carer said they had played bingo with some residents the other evening. Visitors were spoken to. One said there were “good” staff on duty on the day of inspection but referred to a recent incident when a carer had asked her the name of a resident in the main lounge, as she did not know it. On another occasion the visitor had been asked by a carer how to make macaroni cheese for tea as she did not know how to do it. Another visitor said that staff make her feel welcome. She said she visits every week and feels there are not enough staff about during the afternoon. She also said there was seldom any activity taking place. Lunch was observed. The home splits lunchtime into 2 sittings, with those people needing help receiving their meal on the 2nd sitting. Staff sat beside residents who needed to be fed and they provided verbal prompts for others so that they could eat independently. The food arrived ready plated. The cook was spoken with. She said choices and preferences were established and described the choices for the day. She said the choice for tea was either scrambled egg or sandwiches. The cook said the tea would be prepared for the afternoon staff so that would not have too much to do. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 15 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): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure but this was not displayed and was not available to visitors on the day of inspection. Policies and procedures for safeguarding people who use the service were in place. Some but not all staff had attended training about safeguarding adults EVIDENCE: Although the service has a suggestion box clearly displayed in the entrance hall, the complaints procedure was not displayed. Ms Thompson said the complaints procedure is currently being reviewed and updated. A copy of the current complaints procedure was later provided but this does not include timescales for responses to complaints nor a clear process to follow if the person is dissatisfied with the initial response. One visitor said she had made complaints about the care and had also completed the home’s satisfaction questionnaires but was not sure of the outcomes of her concerns. The home has a whistle blowing and protection of vulnerable adults policy and this is known to staff. Not all staff have received training about safeguarding adults but Ms Thompson provided information that this was currently being arranged. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 16 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): 19, 23 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the needs of the people who live there. The environment is well maintained. The home was well lit and was clean, tidy and free of unpleasant odours. EVIDENCE: A tour of the premises was conducted. All areas were clean but there was a musty smell in the main lounge that was possibly due to an old leak from the roof. The state of decoration was generally good and the dining room had recently been redecorated to good effect. Some bedrooms were seen and there was a varying degree of personalisation. The bedrooms were clean and in a good state of décor. Some beds were unmade until after lunch. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 17 It was noted that disinfectant was left in the bathrooms and this was pointed out to Ms Thompson as there was a risk of ingestion. The laundry contained 2 industrial washers and 2 industrial dryers. Separate smoking facilities were not available for staff and they were required to smoke outside. To facilitate this and to ensure they were contactable, staff take walkie-talkies with them when outside of the building. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For the most part, sufficient staff are employed to meet the needs of the people who use the service. The service has a good recruitment procedure that is followed in practice. The home has a training plan that reflects the needs of the people living there, although there are some gaps that need to be filled. EVIDENCE: A copy of the staff rota was obtained. This showed that only 2 care staff are on duty during the afternoon. In addition to providing personal care, the afternoon staff are also required to prepare and clear away tea. Some teas are cooked, for example scrambled eggs and it was established that not all staff preparing food have completed food hygiene training. Ms Thompson said she is responsible for putting the staff rota together and tries to ensure there is a skill and experience mix. Two staff files were looked at in detail. In 1 file there was a note stating that 2 telephone references had been obtained, however the content of the references was not recorded and there was no evidence these were followed up in writing. The other file contained the required 2 written references. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 19 Other elements of the recruitment process were good and there was evidence that appropriate checks were carried out. There was evidence within the staff files that new staff receive induction training. There was also evidence of training undertaken by the member of staff. Supervision records showed that this is not taking place in accordance with best practice. One member of staff had only received supervision on 2 occasions since 23/1/06, the last being 13/3/07 In addition to the cook, 3 staff were spoken to during the inspection. A senior carer said she had worked at the home for 2½ months. She described the care plans and also the guidance she had been given about medicines. She said she was aware of the home’s Protection Of Vulnerable Adults (POVA) procedures and whistle blowing policy. Another carer was spoken to. She had also only recently been recruited. She described the pattern for the afternoon shift and said she was aware she was doing scrambled eggs for tea. She said the tea would be prepared and taken to the dining room for serving so that those needing help could be assisted. She said that 5-6 people needed 2 staff to hoist them and when being put to bed. If call bells are heard then a member of staff goes and cancels and arranges to go back later unless the matter is urgent. Staff do not normally do baths at night unless the resident requests one. She said she had done all statutory training at her previous home. She was currently working through the induction training and confirmed she had watched the fire safety video during her 1st week of employment. Another carer was spoken to briefly. She said she feels 2 carers can cope with the care needs of residents during the afternoon but help is needed to prepare and clear away at teatime. A copy of the staff data base was provided. This shows that the home currently employs 12 day carers, 3 night carers, 1 cook, 5 domestics and 1 maintenance person. Six staff are currently doing NVQ2 and 5 NVQ3. Only 5 of the day care staff have completed food hygiene training although they are required to prepare light teas and handle food. Only 5 staff have completed moving and handling training (all 2006). Two staff have attended POVA training and only 8 have received fire safety training. Five have attended health & safety training. The record shows that only 2 staff have received medication training, although Ms Thompson stated that this should actually be 4 staff. Ms Thompson said she was arranging training about POVA, food hygiene, manual handling, risk assessment and infection control. The cook, who works part time, confirmed she has done food hygiene. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care manager is developing her management skills and knowledge although her role needs to be better defined with the service providers. The service seeks the views of people who live in the home and their visitors but this needs to inform an improvement plan and be made known to all stakeholders. Staff do not receive formal supervision in line with best practice. The home works to a clear health & safety policy. EVIDENCE: Ms Thompson said she is currently head of care and it is intended that she will eventually become the manager of the home. She is currently doing the Registered Managers Award. Mr Rainbird is the general manager and has Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 21 previous care experience. Mrs Rainbird is a qualified nurse and has some involvement in the day-to-day running of the home. Ms Thompson’s job description was discussed with her and it was agreed that it does not necessarily reflect what she does. Ms Thompson is going to review and rewrite her job description and a copy will be forwarded to the Commission. The home’s quality assurance was looked at. The last satisfaction survey was sent out in June 2007. The returned questionnaires had not yet been summarised and Ms Thompson was advised that an improvement plan needed to be developed from this and a copy of the summary and improvement plan made available to all people, including CSCI. Ms Thompson was also advised to expand the process to involve all stakeholders and not just residents and relatives. The arrangements for resident’s personal allowances were looked at. The monies were kept in separate containers for each person. The money held for 1 resident was checked against records and was correct. Good records are kept but staff need to ensure that full signatures are used when signing for transactions. Staff are not receiving formal supervision in line with best practice. This needs to take place at least 6 times per year and needs to be implemented without delay so that staff receive the guidance they need and feel supported. Health & safety records were looked at. The service has a contract for waste collection. The servicing for both the fire alarms and emergency lights were overdue and Mr Rainbird said these were being followed up. Fire fighting appliances were serviced on 15/8/07. Environmental Health had conducted a kitchen inspection on 24/7/07 and identified 2 minor matters that had been dealt with by the time of this inspection. The gas cooker had been serviced on 3/7/07. Mr Rainbird said that all sinks, baths and showers had hot water governors fitted. Accident records were looked at. There was evidence that a full analysis is taking place and that there is monitoring of incidents. This was discussed with Ms Thompson. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4&5 Requirement A copy of the Statement of Purpose & Service User Guide that complies with Schedule 1 of The Care Homes Regulations must be made available. This will ensure that people are able to make an informed choice about moving into the home. A copy of these documents must be forwarded to CSCI. Individual care plans need to contain information that is clear and up to date. This will ensure that care delivered accurately reflects the needs of the person. Accurate records must be kept about medicines administered by staff. This will ensure that there can be confidence people receive treatment as prescribed. Only staff who have received certificated training can administer medicines. This will ensure safe practice at all times. Records must not be kept in such a way that the privacy, dignity and confidentiality of people is breached. This will ensure that the basic rights of DS0000061476.V349222.R01.S.doc Timescale for action 16/10/07 2 OP7 15(2) 16/10/07 3 OP9 13(2) 18/09/07 4 OP9 13(2) 18/09/07 5 OP10 12(4)(a) 18/09/07 Marifa Lodge Version 5.2 Page 24 6 OP12 16(2)(n) 7 OP16 22 8 OP30 18(1)(a) 9 OP36 18(2) people are protected. People need to be consulted about an activity programme that reflects their preferences and lifestyle. The programme must then be put in place. This will help to ensure that people enjoy a quality of life that considers their social and emotional needs. The home’s complaint procedure needs to be updated, displayed in the home and made available to all people who live at or visit the home. This will ensure that people know how to bring any concerns or complaints to the attention of the service at an early date. Staff must receive training that is appropriate to their role and the tasks they are required to undertake. This will mean that staff are competent and safe practice will be followed. Staff must receive formal supervision at least 6 times per year. This will mean that staff receive the guidance they need and are well supported. 16/10/07 16/10/07 16/10/07 16/10/07 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. Refer to Standard OP7 Good Practice Recommendations Care plans need to consider the social and emotional needs of people in addition to their physical needs. These issues need to be recorded so that an holistic view of the person is seen and acted upon. The way documents are stored within the care plans needs DS0000061476.V349222.R01.S.doc Version 5.2 Page 25 2 OP7 Marifa Lodge 3 OP19 4 OP27 5 OP31 6 OP33 7 OP35 to be reconsidered so that all information is easily accessible for staff. Care needs to be taken that cleaning and disinfecting fluids are not left in bathrooms and other communal space. This will help to reduce the risk of accidental ingestion. Ideally, another member of staff should be employed to cover the teatime period. This will mean that better standards of hygiene are achieved because staff are not required to cover personal care and also prepare food at the same time. The service provider needs to put together a job description that accurately reflects the role of the manager and her responsibilities. This will provide clarity to areas of responsibility and accountability with the service providers. Once the results of the last satisfaction survey have been collated, the service should put together a summary and improvement plan that is made available to all residents and people who use the service. This will show that views are taken seriously and acted upon. Two full signatures should be recorded for all financial transactions carried out on behalf of people at the home. This will help to ensure non-abusive practice. Marifa Lodge DS0000061476.V349222.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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.V349222.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!