Inspection on 16/08/05 for Boundary House

This inspection was carried out on 16th August 2005.

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

Boundary House 24/08/09

Boundary House 01/10/07

Boundary House 27/11/06

Boundary House 12/01/06

Boundary House 04/03/05

Boundary House 15/09/04

Boundary House 11/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Boundary House Haveringland Road Felthorpe Norwich NR10 4BZ Lead Inspector Jerry Crehan Unannounced 16 August 2005 th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Boundary House Address Haveringland Road, Felthorpe, Norwich, NR10 4BZ 01603 754715 01603 400418 Telephone number Fax number Email 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 Canabady Mauree Mrs Emma Louise Hopkins Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Home may accommodate up to ten (10) people who have a Learning Disability, one of whom is over 65 years and is named in the Commissions records Date of last inspection 4th March 2005 Brief Description of the Service: The Boundary House provides residential care for up to 10 adults with learning disabilities, it is situated on the outskirts of the village of Felthorpe, which is a few miles from the city of Norwich. The home is situated in extensive grounds containing portacabins, greenhouses and other outbuildings. Bedrooms are located on the ground and first floors. There are communal lounge, dining and kitchen areas. There are two bathrooms and one shower room. Service users living in the home access day services, including those operated by the proprietor in North Walsham. The home has its own transport. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours. Opportunity was taken to tour the internal and external premises, look at care records and policies, and communicate with several of the ten service users accommodated at the time of the inspection. Staff members and the manager were also spoken to. What the service does well: What has improved since the last inspection? What they could do better: Improvements to the exterior of the home will be welcomed, and an issue concerning broken door locks has arisen again that compromises service user privacy at the home. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 6 Given that agency staff are providing significant levels of care at the home, it has been recommended that the manager and proprietor consider ways in which the supervision of these staff can be managed and improved. With the establishment of a full and stable staff team the manager should consider the further development of measures to ensure that the views of service users underpin all aspects of the home’s review, development and selfmonitoring. This will ensure that the home continues to provide the service desired and needed by service users. 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. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 & 5 The home provides the opportunity to visit the home to assess its suitability to individual needs. Individual contracts for each service user at the home are not in place. EVIDENCE: The opportunity for prospective service users to visit the home prior to admission has clearly been available for some time and is reflected in the home’s procedures. In practice this has not happened for several of the most recent admissions. However, it is accepted that this has been primarily due to the request of placing authorities in the interests of the prospective service user. This was the situation for the most recently accommodated service user, though it was apparent that the home facilitated a visit from the service users relative prior to the admission. Individual contracts setting out terms and conditions of residence, including fee’s were evident in some service users files seen. However, not all service users have individual written contracts or statements of terms and conditions with the home. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8 Service users are provided with appropriate support to make decisions. Service users views are sought and acted upon. EVIDENCE: It was evident that the home respects service users rights to make decisions and that this takes place within a context that reflects the wide-ranging needs and abilities of the individuals living at the home. This was illustrated in discussion with a service user who spoke with support about the help they needed to meet their own needs independently, and where they needed assistance. Service users communicated making decisions and choices about individual and collective choices, activities and menu planning in particular. One service user communicated the impending redecoration of their bedroom to a new colour of their choice, and the rearranging of their furniture to accommodate a new computer. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14, 15, 16 The home satisfactorily caters for the lifestyle preferences of service users. Links with the community, with relatives and others are well supported. EVIDENCE: Service users at Boundary House are engaged in day care activities both on and off site. Service users not accessing exterior day service activities are encouraged to play a part in activities within the home. A number of service users regularly attend a local social club on a weekly basis. Service users and the manager describe regular trips to local attractions, and pursuing individual leisure activities and hobbies such as computing and playing music. Service users described contact with friends and relatives, and this appeared to be actively supported by staff. The manager spoke about the home’s approach to supporting appropriate relationships that exist, and that this is dealt with openly within the home making it clear that their responsibility is toward the safety of service users. Rights and responsibilities are respected and recognised at the home; service users have unrestricted access to all areas except the manager’s office the Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 11 kitchen and other people’s bedrooms. Some service users choose to hold their own bedroom door keys. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Service users receive personal support appropriate to their needs and abilities. EVIDENCE: Feedback from service users reflected that they felt well cared for, and that service users have the autonomy to independently attend to those aspects of their care they are able to. This was supported by individual care plans that contain clear information as to where personal support was required, and how it should be delivered. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Arrangements for protecting and responding to the concerns of service users and staff are satisfactory. EVIDENCE: A procedure for responding to allegations of abuse is in place. Staff spoken to appeared aware of the procedure and its function, and had received appropriate training. It is recommended that this procedure is made more readily available for service users and staff at the home. Service users indicated that if they had a concern they would speak to either the manager or their key worker. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27, 30 A comfortable and safe standard of internal accommodation, suitable to individual need is provided. Externally the premises are in need of the anticipated redecoration. EVIDENCE: The home provides an environment that is in a reasonable state of repair. There are substantial grounds and garden areas that were being used by service users. The manager advised that a number of the exterior window frames that are in a poor state of repair are due to be replaced, and that some other external redecoration is also due. Service users bedrooms had evidently been personalised to suit individual preference and needs. One service user’s bedroom has objects providing sensory stimulation, and specially protected objects and ornaments to suit his individual requirements. The home are commended for their efforts to provide this. Two of the three shared toilets and bathrooms have doors that are not lockable, thereby restricting the privacy of service users. However, it is acknowledged that these had relatively recently been repaired. Toilets and bathrooms should be lockable, with staff using an override device only as indicated by a service user’s risk assessment. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 15 The home is kept clean, there are good practices (and appropriate policies) to maintain hygiene and is free from offensive odours throughout. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 36 An effective staff team supports service users. Arrangements for formal supervision should extend to agency staff. EVIDENCE: Staffing includes approximately 5 staff on duty each morning shift and 5 staff each afternoon/evening. Two waking night staff are available at night. The home remains reliant on a high proportion of agency staff to meet service user need. Four out of six staff on duty at the time of the inspection were agencyemployed staff. However, the proprietor has evidently attempted to address this situation. The manager described the appointment of several new staff and a number of other active applications in process, which is welcomed. It was also apparent that care agencies have been able to provide continuity of staff to the home, some of whom have worked at the home for several years and are consequently familiar with the needs of service users and the policies of the home. There is evidence of a programme of regular staff supervision to benefit service users. Whilst it is acknowledged that there are some supervisory practices in place to meet the needs of agency staff employed to work at the home, these are not of the same standard as those for the home’s employees. It is recommended that the manager and proprietor consider ways in which the supervision of agency staff can be managed and improved. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41 The manager provides clear leadership and is well supported by the staff team. The systems for service user consultation are good and improving. EVIDENCE: It was apparent that service users and staff have respect for, and confidence in the manager (who has recently embarked on the Registered Managers Award programme). The views of service users are sought on every day issues associated with the running of the home, though not necessarily on the development of policies and procedures. In addition to this there are more formal means for the expression of views and comments. A questionnaire has been developed to ascertain views of service users and others, and evidence of its implementation seen. The home demonstrated good record keeping practices ensuring service users confidentiality. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 2 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Boundary House Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 3 x x I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 19 No 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 5 Regulation 5 Requirement The registered person must ensure that service users are provided with individual written and costed contracts. The registered person must ensure that the home is conducted in a manner that respects the privacy and dignity of service users by providing lockable toilets and bathrooms. Timescale for action 31st October 2005 30th September 2005 2. 27 12(4)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 23 36 39 Good Practice Recommendations It is recommended that the whistleblowing procedure is made more readily available for service users and staff at the home. It is recommended that the manager and proprietor consider ways in which the supervision of agency staff can be managed and improved. It is recommended that the home further develops service user input into quality monitoring to include the development of policies and procedures. Boundary House I55 s27402 boundaryhouse v244646 160805 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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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