Inspection on 17/10/05 for Martham Lodge

This inspection was carried out on 17th 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

Martham Lodge 15/03/07

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 Mr Pearson Clarke Unannounced Inspection 17th October 2005 13:40 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.V256366.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. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Martham Lodge Address 34 The Green Martham Great Yarmouth Norfolk NR29 4PA 01493 748740 01493 740794 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.V256366.R01.S.doc Version 5.0 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 8th June 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.V256366.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the home was unannounced and took place during the afternoon. The inspector spent time with the manager and talked to the staff on duty. No visitors were present in the home and it is recognised that as a result of their advanced dementia service users are restricted in their ability to contribute to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The management need to continue their efforts to ensure that relatives are in agreement with the approach to care adopted by the homes staff. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 6 Redecoration should continue where needed and all bathrooms and toilets should be equipped to protect residents privacy. 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. Martham Lodge DS0000027450.V256366.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 Martham Lodge DS0000027450.V256366.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): These standards were not inspected on this visit EVIDENCE: Martham Lodge DS0000027450.V256366.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 EVIDENCE: Sample plans of care were inspected and these continue to offer generally comprehensive and well presented records. The last inspection of the home resulted in a recommendation that the service seek written agreement to the care given from relatives and whilst efforts have been made in this area there is still work to do. This was discussed with the homes manager and it is understood that many people are reluctant to engage with the process. Whilst the Inspector accepts that relatives cannot be compelled to do this it is important that the process continues, particularly as the homes service users are unlikely to be able to represent themselves. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 10 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 Service users enjoy a relaxed regime where their social care needs are appropriately met. EVIDENCE: The inspector noted that regular activity is provided and a schedule of planned visits to the home is displayed. The manager confirmed that a newly introduced percussion workshop had been very successful and it was hoped to make this a regular session. At the time of this visit some residents were relaxing in the lounges whilst others were moving around the home and gardens in a relaxed manner. Interactions between staff and service users were relaxed and the general atmosphere within the home was calm. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 11 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 The service has an appropriate complaints process in place and complaints are heard and acted on. Policies procedure and practice work to ensure service users are appropriately protected. EVIDENCE: The complaints record was inspected and this demonstrated that complaints received were fully investigated. There have been no complaints since the last inspection. This inspection took place shortly after a recent adult protection issue at the home. This incident served to demonstrate that the homes whistle blowing and protection process are in place and are followed. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 12 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): 19,21,26 The environment is generally safe and clean and is arranged to meet the needs of those cared for. EVIDENCE: The last inspection of the service resulted in a requirement to guard the remaining uncovered storage radiators in residents bedrooms. At the time of this visit work was underway to comply with this and the last cover was fitted whilst the inspector was in the home. A general tour of the home was undertaken although this did not include residents bedrooms. All areas seen were clean and no unwanted odour was experienced. There has been some recent redecoration and this needs to continue. It was noted that the ground floor toilet near to the front door did not have a privacy bolt fitted. This was discussed and it is important that service users have the opportunity for privacy whilst using these services. The appropriate lock is one that can also be opened by staff from the outside in case of an emergency and a requirement to fit such a lock is made. See requirement Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 13 Martham Lodge DS0000027450.V256366.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): 30 The service provides staff with the training needed to do their jobs. EVIDENCE: The service continues to provide staff with a good range of training and at the time of inspection a training session on optical awareness was taking place. The home has a good record in delivery of NVQ, however as a result of some recent changes in the staff team they are currently not meeting government targets in this area. Despite this the inspector is confident that the services positive commitment to staff training will address this. Two staff members on duty were interviewed and both felt well supported and that they were in an environment where training was seen as essential and opportunities were given. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 15 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): 31,32 EVIDENCE: Discussion with both of the staff members on duty indicated that they felt supported by the homes management and part of a staff team which was well led. The homes manager is working towards achieving the registered managers award, however recent progress has been slowed by the NVQ provider having difficulty in providing adequate provision of assessors. This has clearly been a source of understandable frustration, however the inspector is confident that the manager is committed to the process and would encourage her to continue whatever the difficulties. Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 16 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 2 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x x x Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 17 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 OP21 Regulation 23 Requirement An appropriate lock must be fitted to the ground floor toilet. Timescale for action 01/12/05 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.V256366.R01.S.doc Version 5.0 Page 18 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. Extracts may not be used or reproduced without the express permission of CSCI Martham Lodge DS0000027450.V256366.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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