Inspection on 04/01/06 for Merle Boddy House

This inspection was carried out on 4th 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Merle Boddy House 06/12/06

Merle Boddy House 12/08/05

Merle Boddy House 09/11/04

Merle Boddy House 13/07/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Merle Boddy House 55 Norwich Road Dereham Norfolk NR20 3AX Lead Inspector Mrs Susan Golphin Unannounced Inspection 4th January 2006 10:00 Merle Boddy House DS0000027459.V277347.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 Merle Boddy House DS0000027459.V277347.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. Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Merle Boddy House Address 55 Norwich Road Dereham Norfolk NR20 3AX 01362 694643 01362 699403 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) Mid Norfolk Mencap Society Mr Christopher Alexander Towndrow Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 Brief Description of the Service: Merle Boddy House is a detached building set back slightly from one of the main roads leading out of Dereham. There is parking on the gravel driveway to the front, and it is in keeping with other properties in the area. The home is registered to provide personal care and accommodation to up to 10 adults with learning disabilities. Nursing care is not provided. Accommodation is spread over two floors, with the majority of service users bedrooms, and all communal space, being on the ground floor. Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place between 10.00am and 2pm with the Residential Support and Development Manager Chris Towndrow and Head of Care Helen Luxon. A brief tour of the premises was undertaken, and the inspector was able to speak briefly to two residents during the course of the visit. A small sample of resident’s care plans; policies and procedures for the home and staff supervision were also seen during the day. Feedback on the day was given to the Manager at the end of the inspection. What the service does well: What has improved since the last inspection? The recommendations from the previous inspection have been taken up by the manager and head of care, and the work is in progress. The policies and procedures for the home are continuing to be revised and some progress has been made. Minor changes to the staffing structure have been made and a new support worker post created. The manager and the head of care have commenced NVQ 4 and NVQ3 (in management) respectively. Work on the review of development and modernisation of services (day and residential), which will have some impact on Merle Boddy House and those who live there, is also continuing Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 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. Merle Boddy House DS0000027459.V277347.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 Merle Boddy House DS0000027459.V277347.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): 2,3,5 Residents needs and aspirations can be met by the home. Residents or their representatives are issued with written contracts and terms and conditions of the service. EVIDENCE: There is a stable resident group who have lived at the home for some time. Each resident’s need wishes and aspirations are taken into consideration when their care support is planned. The information is recorded and maintained in a personal plan of care and reviewed regularly or where changes may indicate. Feedback from residents and their families or their representatives confirmed that they are always involved in the process Merle Boddy House DS0000027459.V277347.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): 6,7 Resident’s personal goals and changing needs are reflected in their individual plan of care. Support staff consult residents about everyday routine and encourage personal independence and individual lifestyles. EVIDENCE: From the documentation available through the care plans, risk assessments and from the discussions it is evident that residents’ individual wishes and needs are promoted by staff, and have comfortable relationships with each other. Discreet information around the home helps residents to follow their own agreed plan of care. There are weekly meeting with the residents where a wide range of topics including choice of meals; activities; social events and outings and annual holidays are discussed. Resident’s views or requests and suggestions are recorded and simple or straightforward requests are usually actioned immediately. At the last inspection a recommendation was made to review the care planning process to reduce some of the bulk within the documents and refine the information so that the care plan is easier to use. It was acknowledged by the head of care and the manager that some small progress has been made with this piece of work; but that they have been unable to give it any high priority Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 Page 10 because work commitments with residents or covering unplanned absences by staff have taken precedence. The management need to consider ways in which the work on the care plans can be completed, so that the information on file is relevant and recent and easily accessed as a working tool. (Repeated recommendation) Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 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 the following standard(s): 14,16 Residents have the opportunity to engage in their chosen leisure activities. Residents rights and responsibilities are respected and upheld by both the support staff and peer group EVIDENCE: From the information in the residents plan of care and from the discussions on the day resident’s can access a range of different occupations and activities. The group interact positively with each other and some have wider network of friends through day services and clubs and through community social events. Only two residents were at home and briefly spoken to during the visit. Residents participate in the meal preparation and planning as well as domestic tasks. The routines tend to be flexible and can vary depending on the planned activities for each day. Merle Boddy House DS0000027459.V277347.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): 18,19 Personal support is offered in such a way as to promote the well-being and independence of residents. EVIDENCE: Each resident has a plan of care. The plan gives a clear account of how the healthcare needs will be met and monitored, and how the resident would like their support to be provided. Multidisciplinary reviews take place on a regular basis. Residents, their representatives or relatives are involved in the process. Resident’s files are currently being reviewed and ‘filleted’ to reduce the bulkier documentation and to ensure that information on file is current and up to date. (See recommendation) Merle Boddy House DS0000027459.V277347.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): Not inspected on this occasion EVIDENCE: Not inspected on this occasion Merle Boddy House DS0000027459.V277347.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): 24,30 The standard of the environment within this home is good and provides residents with a comfortable and homely place to live. EVIDENCE: This standard was not inspected in full on this occasion. A brief tour of the premises was undertaken, and all areas were in good order and well maintained. There are plans to replace the front door and frame, which is showing signs of wear and is in need of attention. (See recommendation) Merle Boddy House DS0000027459.V277347.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): 33,36 The staff team work effectively to meet the needs of the residents. The staff group are appropriately supervised but not at the required frequency or within a consistent process. EVIDENCE: There have been some small changes to the staff group since the last inspection. An additional 37-hour post has been agreed as an outcome of a recent review. The manager and the head of care are looking at ways in which they can improve on the relief /bank staff system so that unplanned absences by support workers can be more easily managed. As a small resource any sudden absence by staff has an immediate effect on the resident group and planned activity for the day. Support worker absences are usually filled by the head of care or the manager and as a result impact on some of the administration and management tasks, which have to be given a lower priority. The management team will also be looking at some of the reasons for sudden and unplanned absences including periods of sickness over the last year to see if better safeguards can be built in to deal with the problem as they occur. (See recommendation) There is a staff supervision process in place but the sessions are not taking place on a regular basis and at the required frequency. There is also a noticeable difference in the way in which supervision sessions are recorded and this needs to be reviewed to ensure the process is consistent and clear to both Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 Page 16 supervisors and supervisees. Staff who have a responsibility for the supervision of others should receive appropriate and relevant training. (See requirement) Merle Boddy House DS0000027459.V277347.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): 42 The home is well managed and puts resident’s interests, lifestyles, and safety to the fore. The health and safety and welfare of residents is promoted and protected through good risk assessments and maintenance management. EVIDENCE: This standard was only inspected in part. A small sample of individual risk assessments were seen, and records relating to health and safety and fire protection are in place and up to date. Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 x 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x x x x x x 3 x Merle Boddy House DS0000027459.V277347.R01.S.doc Version 5.1 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 YA36 Regulation 18(2) Requirement The registered providers must ensure that all staff receive appropriate supervision within the required frequency and that the process and recording style are consistent and clear. Appropriate training should be undertaken by all staff with responsibility for supervision. Timescale for action 31/03/06 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. Refer to Standard YA6 Good Practice Recommendations It is recommended that the management continue with their plan to review the care planning system for the home to ensure the process is easy to use and provides a positive working tool for the staff group. Also see standard 18 ( repeated recommendation) It is recommended that the planned work on the front door and frame of the home should be carried out as soon as possible. It is recommended that the management team undertake to review the levels of staff sickness and unplanned or DS0000027459.V277347.R01.S.doc Version 5.1 Page 20 2 3 YA24 YA33 Merle Boddy House sudden absences in the past year and seek ways in which replacement /relief staff can be easily accessed to maintain consistency and continuity of care for residents and allowing the management to prioritise and complete outstanding administration and management tasks. Merle Boddy House DS0000027459.V277347.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 Merle Boddy House DS0000027459.V277347.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. 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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