Inspection on 01/06/05 for Broad Horizons & Marmalade House

This inspection was carried out on 1st June 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

Broad Horizons & Marmalade House 08/11/06

Broad Horizons & Marmalade House 11/01/06

Broad Horizons & Marmalade House 02/12/04

Broad Horizons & Marmalade House 04/05/04

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 BROAD HORIZONS & MARMALADE HOUSE 5 Kittens Lane Loddon Norwich NR14 6SU Lead Inspector Roger Andrews Unannounced 01 June 2005 12:30 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. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Broad Horizons & Marmalade House Address 5 Kittens Lane, Loddon, Norwich, Norfolk, NR14 6SU 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) 01508 528163 01508 520604 Orwell Housing Association Limited Mrs Delyth Spring Care Home 10 Category(ies) of LD Learning disability registration, with number of places BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02 December 2004 Brief Description of the Service: Broad Horizons and Marmalade House offer care and support for up to ten adults with learning difficulties. The resource comprises of two bungalows with all accommodation and communal areas located on the ground floor. Each bungalow is built on a small domestic scale to create a domestic home environment. Marmalade House aims to offer supportive care with tenants being encouraged to achieve greater independence in meeting their personal and social care needs. Broad Horizons and Marmalade House are located in the village of Loddon to the south east of Norwich. They are situated in their own grounds with pleasant enclosed garden areas. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted approximately four hours. Discussion took place with the manager, some staff and tenants. A number of records were looked at. Each building was looked at. Broad Horizons and Marmalade House have been inspected for some years. The Commission enjoys a good relationship with the acting manager and with the organisation responsible for running the home. The home informs the Commission of any problems when they happen. There is no history of complaints being made about the home which readers of this report should be aware of. The registered manager has been off sick. There is an acting manager in place. The registered manager is expected to return to work in a few weeks time. What the service does well: What has improved since the last inspection? Out of date records kept on each tenant have been removed from tenant files to make other information easier to find by the staff and to make the information less confusing. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 6 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. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 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 BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 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) 2 Tenants needs are assessed prior to moving into either house on a full time basis. Changing needs are appropriately discussed with relevant people. EVIDENCE: Care plans contain assessments and profiles. Information from previous placements and relevant professions is gathered. All prospective tenants undergo a process of pre-admission visits and overnight or weekend stays as preparation to moving in. One tenant has recently been displaying more challenging behaviour. A meeting took place on the day of the inspection with the tenant’s social worker and other professionals to discuss how these changing needs could be handled. Notes were also seen on the tenant’s file to show these matters had been discussed with the tenant’s next of kin. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 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) 6 & 9 The tenants benefit from care plans and daily notes which contain appropriate details and are informative. Tenants are encouraged to participate in a range of activities that are risk assessed. EVIDENCE: Four care plans were examined, (two in each house). Some of the older information has now been removed in line with a recommendation made in a previous inspection report. Care plans were observed to contained detailed assessments and profiles, weekly activity schedules, healthcare needs and contact with the G.P. One tenant was noted to have an allergy to dairy products. This was noted in both the care plan and on a prominent sign on the fridge in the kitchen. One tenant has an eating care plan to help staff monitor progress with continence issues. Care plans contain photographs of tenants, inventories of property, and a tenancy agreement amongst other information. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 10 Day to day notes are maintained. One example was viewed of a communication book in which staff keep a daily record so that the tenant’s parents can review progress from time to time. Detailed risk assessments are on individual tenant files. They cover, with the exception of one example, both in-house and external activities such as using kettles, toasters, swimming and travelling in vehicles. Depending on capability tenants are encouraged to participate in domestic activities such as cooking and making hot drinks and one of the tenants made hot drinks for several visitors during the inspection visit. Some of these require updating as review dates have expired. However, a member of staff is currently embarking on this process so this is not made a recommendation in this report. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 11 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) 11, 12 & 16 Tenants can and are encouraged to progress towards greater independence. Tenants have an active and interesting range of activities each week. Tenants rights are respected and their views and requests are taken into account. EVIDENCE: In Marmalade House tenants actively participate in preparing evening meals, (there is a rota in the kitchen). One tenant reported that she cleaned her own room and did her own laundry. Other tenants are helped to participate in the day to day routine to the extent that they are able to do so. In the past tenants have moved on from the home to more independent settings. One tenant reported that she goes to the local shops on her own. The majority of tenants have active and interesting weekly programmes. Activity schedules are included in each care plan. Examples of regular work and leisure activities include attending college, social services day centres, art, BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 12 swimming, shopping, pub meals and visits to places of local interest. On the day of the inspection visit one tenant returned from a visit to Banham Zoo. Many of the tenants have recently been on holiday, though one tenant declined to go and reported that she had been to stay with her mum for a few days. She was shortly going to go on a day trip to France. In one or two cases tenants do not have detailed programmes. This is either through choice or because the staff are working towards, (as is the case with one tenant), greater participation with the community on a gradual basis. Daily notes give examples of tenants having a ‘lay in’ in the morning and of flexible routines in terms of meal times, (which include takeaways and pub meals on a regular basis). One tenant reported that she had a key to her own room and a key to the front door of the home as well. One tenant is getting a pet rabbit in one of the houses. Another has inquired into keeping a cat which the other tenants will discuss with staff. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 13 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) 20 Tenants are protected by the home’s practice as medication is properly stored and appropriate practices are in place regarding administration. EVIDENCE: The daily administration records for medication were examined in each house. Both records were up to date. Medicines are stored in locked cabinets. In Broad Horizons a member of staff described the administration process, which is always undertaken by two staff, both of whom sign the medication record. Stock taking is undertaking by staff who have completed the organisation’s medication training. Other staff receive in-house training. A medication procedure is in place. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 14 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) 22 & 23 The home’s complaints system could be improved, but there was no evidence that tenants’ concerns have not been listened to and acted upon. EVIDENCE: Each house has a complaints procedure. In both houses staff were not entirely sure where this procedure was located. See recommendation. In Marmalade House each tenant has a copy of the procedure in a more simplified form, (using plain language and pictures), in their bedrooms. However, some of the information in these procedures requires updating, for example, names of people within the organisation whom tenants can complain to. One of the tenants said that she couldn’t read, but her key worker has explained the complaints document to her. However, this tenant could understand an audiotape version of the procedure which could be listened to. This may also apply to other tenants. See recommendation. Both house have an adult abuse policy, (though these refer to Suffolk procedures), and in discussion staff were clear about whistle blowing and reporting observations to a senior person. The manager has just completed the Organisation’s vulnerable adults training which will be cascaded to other staff. Staff will also be re-visiting the ‘no-secrets’ video. No-secrets leaflets are available and the home has a copy of Norfolk’s vulnerable adult procedures. In discussion with the acting manager it was suggested that staff are made aware of the Norfolk vulnerable adult reporting and strategy process as part of their understanding of adult abuse issues. See recommendation. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 15 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 & 30 Each house provides a clean and comfortable environment at ground floor level. EVIDENCE: Each house has domestic style furniture. Rooms are personalised and communal areas have a range of pictures and colour schemes that add to the homely feel. Marmalade House has recently had new carpet laid in the communal and corridor areas. In Broad Horizons the large kitchen dining room is very much the centre of activity. Pictures are used to convey to tenants which staff are on duty and what is on the menu for each meal. It was reported that the dining area and conservatory are due for redecoration shortly. Both houses were clean and free from unpleasant odours. Each house has its own utility room and laundry facilities. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 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 Staffing levels are sufficient to meet the needs of tenants. EVIDENCE: At the time the inspection took place there were five tenants living in Broad Horizons and four tenants living in Marmalade House. Broad Horizons had five staff scheduled for the early shift, (7am-2/3pm), and three staff scheduled for the late shift, (2pm-9.30pm & 2.30pm-9.30pm). Marmalade House had two staff scheduled for early and late shifts. An additional member of staff was scheduled for 8-4 to assist a tenant on an outing for the day. Broad Horizons has one waking and one sleep-in member of staff. Marmalade House has one sleep-in member of staff. The lower staffing provision for Marmalade House reflects the greater independence of the tenants who live there. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 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) 41 & 42 Records are generally well maintained and processes are in place to protect tenants. Improvement is needed in making sure weekly fire point tests are carried out. EVIDENCE: Fire records were checked. In Broad Horizons the record indicated that weekly checks of fire points had not occurred on a weekly basis during March and April 2005. See requirement. Fire instruction was last given by the manager on 31/05/05. Monthly fire risk assessments are carried out. Fire equipment certificates were seen in respect of servicing. Missing persons profiles are in place on each tenant’s care plan and include a photograph. Records kept of tenants’ finances were examined at random and a member of staff was observed making an entry into the record. She also described the process of auditing which takes place daily for each record. Receipts are kept. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 18 Excess monies are put into bank and savings accounts, which are held in the name of individual tenants. The accident record was up to date. No obvious hazards were noted in either house during the course of the inspection. Cleaning materials are locked away. Risk assessments are in place in respect of individual tenants. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 19 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 3 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 BROAD HORIZONS & MARMALADE HOUSE Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 2 x I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 20 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 42 Regulation 23 Requirement Fire points must be tested in rotation at least on a weekly bsis as recommended by the Fire Officer Timescale for action Immediate and ongoing 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 22 22 23 Good Practice Recommendations It is recommended that procedures are easily located and identifiable so that staff can access them without difficulty. It is recommended that information provided to tenants are made available in audio form. It is recommended that all staff are made aware of the reporting and strategy process that operates when allegations of abuse are made. BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI BROAD HORIZONS & MARMALADE HOUSE I55 S27485 Broad Horizons V230945 010605 Stage 4.doc Version 1.30 Page 22 - 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. 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