Inspection on 11/01/06 for Broad Horizons & Marmalade House

This inspection was carried out on 11th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broad Horizons & Marmalade House 08/11/06

Broad Horizons & Marmalade House 01/06/05

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 Norfolk NR14 6SU Lead Inspector Mr Roger Andrews Unannounced Inspection 11th January 2006 3:30 Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 Adults 18-65. 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. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Broad Horizons & Marmalade House Address 5 Kittens Lane Loddon Norwich Norfolk NR14 6SU 01508 528163 01508 520604 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) Orwell Housing Association Limited Mr Jason Davies Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2005 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 DS0000027485.V278050.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Its focus was to follow up outstanding matters from the previous inspection, look at staff recruitment and staff training. Additional matters have also been commented upon. A previous inspection was carried out in June 2005 and readers may wish to view that report in addition to this one for a fuller picture. Since the previous inspection the Commission has not received any complaints about this service. In the Commission’s view this service offers a good standard of care and support to the residents who live there. What the service does well: What has improved since the last inspection? What they could do better: Orwell Housing who run Broad Horizons, take up proper checks on new staff. However, evidence of these checks must be held on staff files on site for inspection so that inspectors can see that unsuitable people are not being employed. A record of the training completed by each member of staff is needed so that inspectors can see that staff have the proper training to help them support residents. Two recommendations have been made. One suggests making some of the information available on tape or CD so residents who are unable to read can listen to it. This might be about how they can complain if they are unhappy. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 6 Another suggestion was made about checking the temperature of the conservatory as it was rather cool which might make residents not want to use it. 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 DS0000027485.V278050.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): 12 & 17 Residents have equipment and outings that help them enjoy their leisure time. Residents have a varied menu with nutritious home cooked food and a pleasant environment to eat their food. EVIDENCE: The residents in Broad Horizons have a new television and DVD and the father of one of the residents had been in that afternoon to connect this equipment up. The tenants also had new furniture in the lounge. The day before the inspection they had been to the pantomime in Norwich at the Theatre Royal. The tenants were observed relaxing in the lounge, having drinks in the kitchen area and generally doing whatever they wished. The residents in Broad Horizons were having roast chicken for their tea. Pictures of each meal are displayed in the kitchen for residents. The menu reflected a good variety of meals served and examples included sweet and sour pork, breaded fish, sausage casserole and takeaways. Residents eat their meals around a large kitchen table with the staff. The large kitchen/dining area remains very much the central point of gathering for residents and staff. The Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 11 table and chairs in this room have been renewed. Meals are usually home cooked, though residents also have meals out from time to time. The service has achieved the Gold Award in food hygiene standards from the local Environmental Health Department. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): 22 The complaints procedure has been simplified and is prominently displayed. EVIDENCE: A prominent complaints procedure is displayed and this is in pictorial form. The poster contains photographs of the people that residents can complain to. This is good practice. Audio versions are under development. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 the following standard(s): 24 The environment is well maintained and homely. The Conservatory could be warmer. EVIDENCE: All areas of Broad Horizons and Marmalade House seen during the visit were clean, tidy and free from any unpleasant odours. The kitchen has had a new floor laid. Apart from the lounge there is a large conservatory that residents can use. The temperature in this area was quite cool at the time of the visit which was likely to deter any resident from spending time in there had they wished to do so. See recommendation. However, all other areas were warm and homely in style. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 15 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 There is an excellent commitment to NVQ training for staff. Other training is in place, but a record needs to be kept on site. Evidence of an enhanced Criminal Records Bureau check and a recent photograph of each staff member must be on file. Supervision is in place and set up to occur on a regular basis. EVIDENCE: New staff receive a three-day induction programme by an external training body. A formal internal induction programme/checklist needs to be developed. See recommendation. Other training is recorded and scheduled from Orwell head office where training records are kept. However, a record of training undertaken needs to be kept on site. See requirement. To date twelve staff have completed NVQ 3 and one member of staff has completed NVQ 2. Three staff have just commenced their NVQ 3 training, (including a member of night staff). Broad Horizons meets the NVQ training standard. Fire training and food hygiene training took place in November 2005. Appointed Person Emergency Aid training took place in December 2005. Three Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 16 sessions on adult protection issues have been organised for January and early February and a ‘Train the Trainers’ course is organised for late February. Two staff files were selected randomly and checked. Both files contained two written references and a full application form including employment history. One file contained evidence of an enhanced Criminal Records Bureau check being carried out. The other did not, though this check had been undertaken and a copy of the record was faxed from the head office. However, evidence of such a check needs to be kept on site. One file also requires a recent photograph of the member of staff. See requirement. Supervision records are kept on file. The next round of supervision is being organised and this process should take place every two months. The last round of supervision took place in October. Staff appraisals are also on file. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The manager is now registered and working towards completing NVQ 4. Weekly fire point checks are now being undertaken. EVIDENCE: The manager has recently been registered by the Commission for Social care Inspection. He has been in place for some time, originally covering for the previous manager whilst she was on sick leave. The manager has many years experience working with adults with learning difficulties. The manager is supervised by his line manager. He also attends ‘senior meetings’ with his line manager and other project managers every three weeks. He is currently working towards achieving the NVQ 4 and Registered Managers Award. Now that he is in post on a permanent basis the manager feels he will be able to give a better focus to improvements. Fire records were checked in both Broad horizons and marmalade house. In both instances they were up to date with weekly fire point checks being carried Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 18 out and recorded. This satisfies the requirement made in the previous inspection report. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X X X X 3 X Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 Page 20 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 YA35 Regulation 18 Requirement A record of the training undertaken by each member of staff should be available for inspection. Evidence of Criminal Records Bureau checks and a photograph of each member of staff must be on their file. Timescale for action 31/03/06 2 YA34 19 28/02/06 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 Refer to Standard YA22 YA24 Good Practice Recommendations It is recommended that information provided to tenants is made available in audio form. It is recommended that the conservatory be maintained at a comfortable temperature to allow its use in cold weather. Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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. Extracts may not be used or reproduced without the express permission of CSCI Broad Horizons & Marmalade House DS0000027485.V278050.R01.S.doc Version 5.1 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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