Inspection on 03/10/05 for Marifa Lodge

This inspection was carried out on 3rd October 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 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 11/08/08

Marifa Lodge 21/08/07

Marifa Lodge 02/05/06

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 Unannounced Inspection 3rd October 2005 10:15 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.V253282.R01.S.doc Version 5.0 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.V253282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marifa Lodge Address Wisbech Road Welney Wisbech Norfolk PE14 9RQ 01354 610300 01354610241 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.V253282.R01.S.doc Version 5.0 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. 13th April 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. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection by two inspectors, taking place over 7 hours on a weekday. Mrs Elizabeth Salter, the Manager, was present during the inspection. Preparation for the inspection had taken place at the CSCI office. On the day several records were viewed. There were eighteen service users in residence. Four residents and one visitor were spoken to privately and a member of staff was spoken to privately. One comment card has been received form a relative since the inspection, and this person is not happy with the level of care provided. What the service does well: What has improved since the last inspection? What they could do better: • • • • • There are a number of outstanding management issues, which are not in the remit of the registered manager, but are in the hands of the registered providers. There should be risk assessments, regularly reviewed in care plans for those people who self-medicate and for those who choose to smoke. There should be photographs of residents in care plans. Where service users choose to be called by other than their ‘given’ name, this should be clearly indicated on the front of the care plan. It is recommended that there is a Comments/Suggestion Box in the hall, accessible to visitors for any suggestions about the service. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 6 • • • • • It is recommended that existing care plans are re-organised and developed rather than changing to a new system in book form. The home need to monitor the arrangements for night staff carefully to ensure they are meeting need. All health and safety records must be kept on the premises. The completion of fire risk assessments would further improve the safety of residents. Some chairs could do with replacing. 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.V253282.R01.S.doc Version 5.0 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.V253282.R01.S.doc Version 5.0 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): 6 The home does not provide intermediate care. EVIDENCE: Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 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 & 10 In order to fully meet residents’ health and personal care needs, further attention must be given to the regular revision of the care plans, together with risk assessments. The quality of record keeping needs improvement and this is a repeated judgement from the last inspection. EVIDENCE: Several care plans were seen and there had been some improvements, but not all care plans had photographs. On the last inspection there were several residents with the same names and during this inspection, it appears there is at least one resident who chooses not to be called by her ‘given’ name and this is not clearly recorded on the front of her care plan and there is no photograph. There is therefore a repeated recommendation for this. The Manager showed an example of a new care plan in book form, but the format did not appear to be as comprehensive as the present care planning. There was no space for pre-admission assessments, on which the care plan should be based. Neither did there appear to be space for details of risk assessments and relatives’ involvement with signatures where appropriate. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 10 The new care plan books also were not so comprehensible for residents, since they contained a tick box system. It is recommended, therefore, that the present system for care planning is improved and developed by reorganising the information with dividers, which allow for expansion for information. Two residents spoken to were self-medicating and kept their medication in a locked box in a drawer in their room. One recorded the administration of the medication on a MAR sheet, which was also used for reordering purposes. However, for one resident there was no risk assessment for this included in the care plan, the other resident who also wished to smoke had risk assessments in place, but they were basic and needed updating. There is therefore a repeated recommendation for this. One resident spoken to was aware of her care plan and had signed it. The daily records are informative. Although reviews of the care plans have taken place regularly, it is recommended that these take place monthly. The advice of other healthcare professionals is sought when needed, for example the continence advisor, the District Nurse and the physiotherapist. There was evidence from one care plan that a resident’s changed needs were being reassessed by the GP and the Community Psychiatric Nurse, in order to ascertain whether the home was still able to meet her needs. The Manager advised that the residents have the opportunity to exercise twice weekly using movement to music. The residents spoken to say that they felt staff respected their privacy “staff knock on the door” and close the door when helping with personal care. One resident spoken to was satisfied with her care. One visitor commented that the home paid attention to the details of her relative’s needs, since she would need help with feeding on some days and not others. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 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 Some improvement has been made to the provision of activities at the home, however the home may benefit from a person employed to organise activities. EVIDENCE: One visitor spoken to felt that the home did “very well for her”, in looking after her relative. She also felt her relative’s wishes were respected, which was demonstrated by her being able to change to a ground floor room, rather than a first floor room, the day after she arrived in the home. She said that the home welcomes her relative’s frequent visitors. This visitor felt that her relative could benefit from more activities. The Manager said that activities took place in the mornings and gave evidence of those which have taken place since the last inspection. However, it would appear that activities could only take place when there are sufficient staff, which is covered elsewhere in this report. Another resident spoken to, said that he was not concerned about activities; he enjoyed visits from his relative, walking in the garden, reading and watching television. It is recommended that any activities provided be recorded with the names of those taking part and consideration be given to employing a person to organise activities. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 12 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 Residents, staff and relatives have an understanding of the channels through which to make complaints or concerns about adult protection issues to protect residents from abuse. EVIDENCE: Four residents and a visitor who were spoken to on the day felt they knew how to complain, should there be the necessity and that they would be able to express an opinion. However, following a discussion with the Manager, it is recommended that there be a Suggestions/Comments Box available in the hall for residents’ and visitors’ to use. The visitor commented that she was not aware of having seen the last inspection report and the Manager said that she would make sure that there was a copy available in the home. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 13 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): These standards were not assessed on this occasion. EVIDENCE: The Manager confirmed that a stand-lift had been ordered, in order to maximise residents’ independence and that ten new bed tables had arrived in the home. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 14 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 & 30 Service users needs are not always met by the number of staff on duty. Staff training continues and the records have improved. EVIDENCE: The four service users and the visitor spoken to all confirmed that the staff were attentive to their needs. One resident commented: “the staff are very good and patient”, another, that she had to sometimes wait for staff to answer her call bell, as she realised that they were busy elsewhere in the home. One visitor commented that she felt that during the afternoon, only two staff on duty often meant that there was a lack of staff on the ground floor, should a service user on the first floor need the attention of two staff. Since the last inspection the Manager has completed an assessment of the dependency needs of the residents to assist with calculating staffing numbers. This should be used in determining adequate staffing. It should also be reviewed regularly as there are a large number of highly dependent residents. Sometimes the sleep-in member of staff is not on the premises and delays occur for the waking night staff in getting assistance. Management of the home need to monitor the workload at night to see if an additional member of waking night staff is required. Also, given the dependency levels of residents and the layout of the building, it would seem that the employment of a person to organise activities would be of benefit. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 15 The induction programme for new staff was seen and this cross-references to the TOPSS standards. Since the last inspection the Manager has implemented a training record for staff, it is recommended that review dates be added. Training in food hygiene, moving and handling and fire are booked for this month. All staff administering medications have completed appropriate training, updated in September 2005. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 16 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): 33, 36 & 38 The health, safety and welfare of residents and staff are promoted. EVIDENCE: The supervision of staff takes place regularly, though not six times a year, and it needs to be recorded. The manager showed an analysis of a service users’ survey, which was positive. However, she said that it was often difficult to get the surveys completed and returned from relatives. She said that the home intended to send the satisfaction surveys to relatives and also to give them to the staff to complete. This is seen as good practice. There was also evidence of quality assurance audits in the kitchen cleaning rota and bedroom checks. The outcome of the surveys should be shared with the commission. The Maintenance Person is responsible for keeping the Fire Records and servicing checks, which were all seen to be in good order. However, not all the Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 17 complete records were on the premises and there is therefore a requirement regarding this. The fire office visited 28.02.05; the fire alarms are tested weekly; the emergency lighting monthly and fire appliances last tested 28.8.05. The maintenance man advised that the fire alarm system is checked by an outside company six monthly, although these records were not on the premises. The nurse call system, hoists and passenger lift were serviced regularly and these certificates were seen. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 18 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 1 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x 2 x 2 Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 OP27 Regulation 18 (1)(a) Requirement The Registered Person must ensure that staffing levels are monitored carefully to ensure they are meeting need (this includes day and night). The Registered Person must ensure that staff records include documents as per schedule two. (This requirement is outstanding from the last two inspections). The registered Person must ensure that the PAT testing on electrical appliances is updated. The registered person must ensure that a record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the care home is kept on the premises. Timescale for action 31/12/05 2 OP29 19 30/11/05 3 4 OP38 OP38 23 (2) 17 (2) 4 (14) 31/12/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 20 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 four inspections). It is recommended that the risk assessment for the service user wishing to smoke is kept with the care plan and regularly reviewed. (This recommendation is outstanding from the last inspection). It is recommended that care plans be reviewed monthly and any findings recorded. It is recommended that the risk assessment for the service users who administer their own medication is kept with the care plan and regularly reviewed. (This recommendation is outstanding from the last inspection. It is recommended that a record is kept of activities offered to residents and that consideration be given to employing a person to organise activities. It is recommended that staff supervision sessions be recorded 2 OP7 3 4 OP7 OP9 5 6 OP12 OP36 Marifa Lodge DS0000061476.V253282.R01.S.doc Version 5.0 Page 21 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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