Inspection on 15/03/07 for Martham Lodge

This inspection was carried out on 15th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Martham Lodge 17/10/05

Martham Lodge 30/11/04

Martham Lodge 31/08/04

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 Martham Lodge 34 The Green Martham Great Yarmouth Norfolk NR29 4PA Lead Inspector Hilda Stephenson Key Unannounced 15th March 2007 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 Martham Lodge DS0000027450.V333451.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. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martham Lodge Address 34 The Green Martham Great Yarmouth Norfolk NR29 4PA 01493 748740 01493 740794 susan.hollyman@virgin.net 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 Raymond John Hollyman Mrs Susan Fiona Hollyman Mrs Emma Phyllis Douglas Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Twenty (20) Older People may be accommodated. Twenty (20) people, over sixty-five (65) years of age, with dementia may be accommodated. The total number not to exceed twenty (20). Date of last inspection 17th October 2005 Brief Description of the Service: Martham Lodge is a care home offering personal care and accommodation to 20 service users with dementia. The home is privately owned and has been run by the current proprietor for approximately 4 years. It stands in the centre of the large Norfolk village of Martham. The service is located in an old house with newer extension. Accommodation is offered on 2 floors and the home has a shaft lift. There are 16 single and 2 double bedrooms, none of which are en-suite. There are attractive enclosed and secure gardens suited to the needs of people with dementia. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home was conducted as an unannounced key inspection during the day on 15th March 2007. The evidence was taken by speaking to seven of the twenty residents, three staff, three relatives and the manager, and by examining care records, staff files and the certificates and records required by regulation. The home is a small residential home catering for the needs specifically for residents suffering from dementia, and was found to be clean and tidy with the residents carrying on with their own daily routine. Due to the nature and limitations that short-term memory impairment can bring, most of the feedback was obtained through observation and feedback from relatives. What the service does well: What has improved since the last inspection? Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 6 The home was issued one requirement on the previous inspection visit to fit an appropriate lock to the toilet at the front entrance to allow privacy for residents. This has been completed. Care plans contain more detail and life histories of each resident enabling staff to care on a more personal level. Improvements to the premises have continued throughout the past year with two bedrooms being redecorated, carpets replaced and the adaptation of the powder room. The main lounge has also been repainted. 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. Martham Lodge DS0000027450.V333451.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 Martham Lodge DS0000027450.V333451.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are given clear information prior to admission to assist them to make a decision to move in. All Residents are visited prior to admission to ensure the home can meet their individual needs prior to them moving in. EVIDENCE: Three relatives were spoken with regarding the admission process. All three stated that they felt included by the manager in deciding whether the home would be suitable for their relative. They all received the written documents including the contract and had also read the last inspection report. The manager visited all three residents either at home or hospital to fully assess their needs and discuss further care needs with their relatives. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 9 The assessment details regarding the daily needs of newly admitted residents were included within the care plan. Two of the relatives explained how they helped compile a life story of their relative, to help staff relate better with them. The relatives felt included with the admission process, with the majority visiting the home in place of the prospective resident due to their frailty. Martham Lodge DS0000027450.V333451.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and/or their relatives are involved when the care plan is compiled and reviewed to ensure that the residents’ individual needs are met. Safe medication administration procedures are in place to help protect residents. EVIDENCE: Two care plans were chosen at random. Both residents and their relatives were spoken with to collect their opinions of the care and the home. One was a newly admitted resident and the second resident had lived at the home for several years. The newly admitted resident’s care plan contained the initial assessment details undertaken by the manager, an assessment from the resident’s social worker and a summary of care needs. The relatives confirmed they were compiling the life story to help staff gain a better understanding of the resident. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 11 The second care records included very detailed care needs including a comprehensive life history compiled by the relatives about relevant details of the resident’s background. A summary of care needs was reviewed on a three monthly basis and each review was signed by the relative due to the resident being unable to make their own decisions. The staff confirmed that not all relatives were involved as much as the two residents involved with case tracking. A sample of one further care record was seen and found to be suitably detailed. The medication was stored in a locked cupboard. The two Medication Administration Record sheets were checked and complete. The home has a safe procedure for administration of medication. Staff have recently undergone a medication training update. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can enjoy a varied and nutritional menu ensuring personal tastes are taken into account. Sociable activities are organised on a regular basis that take place during various times of day. Visitors are welcomed into the home by friendly polite staff. EVIDENCE: During the day the hairdresser and manicurist were visiting. Twelve of the residents were having their hair done, and the small quiet lounge was taken over as a salon. The care plans contain details of social history and hobbies and general interests and these are taken into account when the staff organise activities. Due to the majority of the residents having limited concentration levels activities are organised mainly on a one to one basis, or very small group sessions. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 13 It was observed that the staff adapt to residents needs; staff were spending small amounts of quality time with several of the residents during the day, some were listening to music, having their nails done, reading or discussing the past, and two residents were helping with small household duties. There are three lounge areas and one dining room with a clear walk through for those residents who enjoy the exercise. Several relatives were spoken to during the day and all confirmed that they were welcomed and were always offered to take tea with the resident. Due to the frailty of some residents to choose their own menu the cook has residents’ likes and dislikes to work to when compiling the menu. At present there is a choice for the majority of meals although one main meal at lunch time with alternatives in place for those who wish. The home has adapted cutlery and crockery for use by some residents. The staff ensures that residents’ weight does not fluctuate and that their nutritional needs are a high priority, which is good practice. Lunch was a relaxed busy, sociable occasion, with staff serving meals and assisting in a discreet manner. Some residents confirmed that meals were tasty and the amount of food was excellent and could not be improved. The kitchen was clean and tidy. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polite well-trained staff care for residents. Good procedures are in place to ensure all complaints are investigated adequately. The home trains staff to help protect residents from abuse. EVIDENCE: The manager confirmed that complaints were recorded and dealt with immediately, either by herself or the proprietor. During discussions with residents and relatives no complaints were received. Relatives were very positive about the care and attention that staff gave the residents. The manager explained the adult protection procedure. Senior staff confirmed that they were aware of the adult protection procedure and had attended training during the year. Staff records were seen and showed evidence that adult protection had been included in the induction and ongoing NVQ training. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable home. EVIDENCE: A partial tour of the home showed that some improvements had taken place since the last inspection. The manager had added colourful signs at eye level and below to enable residents to see where the toilet, bathroom, lounge and dining room was situated. The home had a slight odour although several of the carpets were being deep cleaned during this visit, which may have been the reason for this. No comments were received from visitors regarding any odour. The manager confirmed that two bedrooms had recently been decorated and carpets had been replaced; one lounge had been repainted with a softer colour than in previous years. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 16 Two bathrooms had been repainted; one was rather clinical but the second had been converted to a powder room for ‘pampering sessions’ for residents. Several bedrooms were seen and they contained a variety of personal possessions. Some relatives confirmed that they had been asked their opinion on the colour scheme. It was noted that the carpet up to the managers office was rather grubby, although no residents or relatives use the stairway, any contact is organised in the main care office on the ground floor. Access to the secluded garden is through the dining room. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by well-trained polite friendly staff. The home increases the numbers of staff according to arranged sociable activities. The manager employs new staff by following a good clear recruitment procedure to ensure the safety of residents. EVIDENCE: It was observed during this visit that staff carried on with their individual duties while others interacted with residents spending time organising short sociable sessions.Three staff were on duty caring for the residents in addition to a domestic, housekeeper, handyman, the manager, trainer and the proprietor. A copy of the duty roster was seen and showed that all areas of the day and night had adequate numbers of staff on duty. Three staff were spoken to and training records were seen. The home has an exceptional amount of training for the staff, with the trainer based at the home. All newly recruited staff undergoes the induction training supervised by the trainer or senior staff, with several courses and training sessions on a weekly basis. The home has a good clear recruitment procedure in place. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 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. 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. Management arrangements are meeting the needs of residents and their relatives. Safe procedures are in place to ensure the health and safety of residents. EVIDENCE: The manager has completed the Registered Managers Award. The manager does not hold any personal spending money for residents. There is a quality assurance system in place. Those residents that can make their own decisions are asked their opinion. The majority of feedback is Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 19 obtained from relatives from the questionnaires that the manager sends out. She compiles a quarterly newsletter to inform relatives of any changes and of any outcomes from the questionnaires. Currently a monthly coffee morning for relatives and residents is being organised to discuss future events and changes. The manager holds regular meetings with staff and involves senior staff with supervision sessions of the junior staff. Staff confirmed that the manager has an ‘open door’ and is open to good ideas and future planning. A random check of health and safety procedures was made, such as fire risk assessment, training and moving and handling. Risk assessments are in place for individual care and safety of staff and visitors. Records seen of the boiler, lift servicing and fire drills and electrical goods were satisfactory. The proprietor visits the home most days to provide ongoing support to residents, staff and the manager. Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x N/A 3 x 3 Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Martham Lodge DS0000027450.V333451.R01.S.doc Version 5.2 Page 22 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. 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