Inspection on 05/10/06 for Merlewood

This inspection was carried out on 5th October 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Merlewood 08/09/09

Merlewood 16/08/07

Merlewood 02/03/06

Merlewood 14/09/05

Merlewood 14/12/04

Merlewood 19/07/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Merlewood 52 Park Lane Great Harwood Lancashire BB6 7RF Lead Inspector Mrs Lynn Mitton Key Unannounced Inspection 5th October 2006 10:00 Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 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 Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 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. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Merlewood Address 52 Park Lane Great Harwood Lancashire BB6 7RF 01254 885355 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) Vanessahalfacre@nas.org.uk National Autistic Society Mrs Sharon Clough Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 Brief Description of the Service: Merlewood is registered with the Commission for Social Care Inspection to provide personal and social care for up to 6 adults with a learning disability aged over 18 years. At the time of the inspection there were six people accommodated. Merlewood is a detached property located on a busy main road in a popular residential area, within walking distance of local shops and bus routes. Parking is available at the front of the home. Merlewood had been decorated and furnished to meet the needs of service users, being mindful of the specific needs of those with Autistic Spectrum Disorder. A range of communal ground floor space was available. All service users had their own bedroom, but share bathing facilities. At the rear of Merlewood is a large secure garden and a games room. At the time of the inspection the out buildings could not be used due to dry rot. Fees for the cost of a weeks care at Merlewood is £1817.45. There was information available to potential service users advising them of the home and giving them details about the type of service they could expect. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 5th October 2006. There were 5 service users accommodated at this time. A tour of the home took place. Over the course of the inspection 2 of the staff on duty, plus the registered manager were spoken to, and interaction between the service users and staff members were observed. Throughout the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of service users. Records regarding these people were inspected. Policies and practices were also read. Four service users relatives had completed the Commission’s comment card, and these indicated that overall they were satisfied with the level of service at Merlewood. What the service does well: The 4 relatives comment cards received by the Commission indicated that they were satisfied with the care provided at Merlewood. Service users care plans contained detailed health and care information to ensure their needs would be met. Service users were supported in taking responsible risks. Personal support was offered to service users in a way that promoted empowerment, choice, dignity, respect and autonomy. The home was run to make sure the service users had opportunities to enjoy their life and to fulfil their potential. Service users had regular access to their local community, and were supported in maintaining family links. There were sufficient staff on duty to ensure that service users needs could be met. One member of staff told the inspector; “the ethos at Merlewood is great I think we work really well as a team and that benefits the service users”. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 6 Another staff member said “I feel very positive about where the house is – good staff team and good mix – feel that we are all working well together”. The home was well managed, and recruitment records demonstrated efforts to ensure the safety of service users were in place. What has improved since the last inspection? What they could do better: Contracts needed to be reviewed and updated in order to explain what service users could expect, and what was expected of them in order for them to live at Merlewood. Updating the adult protection policies and procedures would ensure the service users were safeguarded. Re-building the homes outbuildings will improve the standard of the home and ensure its fitness for its purpose. Service users and their families should be consulted about the day-to-day running of the home and their views acted upon. The lack of appropriate appliance safety certificates and risk assessment leaves service users and staff at risk. Please contact the provider for advice of actions taken in response to this Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 8 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 Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 9 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): YA2 & YA5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Needs assessments were in place identifying the care needs of service users so that support staff would have a clear understanding of how they needed to support them. Contracts did not fully explain what service users could expect, and what was expected of them in order for them to live at Merlewood. EVIDENCE: There had been no new admissions to the home since the last inspection. Whilst case tracking the inspector noted that assessments had been undertaken prior to service users admission to Merlewood and these were suitable documents to ascertain service users needs prior to admission. Service users contracts were in place. The registered manager advised the inspector that the format and content was currently being re-developed, to be more appropriate to the residential service, the service users level of understanding, and to include recent policies such as the no smoking policy. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 10 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): YA6, YA7 & YA9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information on care plans ensured that support staff could meet service users needs in a thorough and consistent way. Risk assessments were a fundamental element of the service users care plan. Service users were supported in taking responsible risks. EVIDENCE: One service users care plan was examined. This document contained comprehensive information about the service users and the level of support needed for staff to ensure continuity of care. The care plan had been recently reviewed. The registered manager advised the inspector that the staff team were working towards person centred planning. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 11 Numerous risk assessments were seen on the care plan. These included information explaining, once the risk had been identified, how it would be managed, and what action was to be put in place to reduce the risk to an acceptable level. All service users had a next of kin who represents their best interests. The registered manager is appointee for all the service users. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 12 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): YA 12, YA13, YA 15, YA16 & YA17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run to make sure that service users had opportunities to enjoy their life and to fulfil their potential. Service users were able to make day-to-day decisions about their lives, and had opportunities to fulfil their potential. Individual dietary needs were catered for. EVIDENCE: Service users had regular access to their local community; and activities accessed within the local community include swimming, walking, trampolining, horse riding, local supermarket, Gateway social club, Space (soft play area) and local pubs for meals. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 13 Each service user had an individual activity programme, which included community-based activities. The inspector noted that the service user case tracked had an up to date activity programme in place. Lifelong learning goals were included in the service users care plan, and included personal skills, domestic skills, community participation, independent living, relationships, communication and leisure. How service users cultural and religious issues were being met was discussed with the registered manager. All service users living at Merlewood access the NAS Atlas St day centre facilities 5 days per week. Service users had access to 2 vehicles, which they used to access the wider community. Service users were supported in maintaining family relationships, and reference to this was made in the care plan. The inspector was advised that all the service users had had a holiday or days out. The inspector observed service users being spoken to with respect and support staff were also observed respecting service users rights and wishes. The 6 weekly menu was seen, this appeared balanced and nutritious. The inspector was advised that this was being reviewed as it was last updated in September 2004. During the inspection it was observed that alternatives to the menu were offered to accommodate all service users preferences. A record of food eaten was also kept. Staff were observed working closely and flexibly with individuals, knowing their likes and dislikes, monitoring food intake, staggering mealtimes and accommodating “fads”. Service users are regularly weighed. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 14 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): YA18, YA19 & YA20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support was offered to service users in a way that promoted empowerment, choice, dignity, respect and autonomy. Service users health needs were well documented and being met. Good practice was in place with regards to the administration, safekeeping, storage and disposal of service users medication. EVIDENCE: Service users required varying degrees of prompting, guidance and one to one personal support. The inspector observed that the care staff team endeavour to ensure sensitive, consistent and flexible support for service users by understanding each persons preferred routines, likes and dislikes, and by working in close partnership with the service users, their families and other significant people involved in the service users life. One staff member told the inspector; “We work well as a team, and there is a good mix of experience and youth”. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 15 The service user case tracked had a health check document dated January 2006. There was detailed information regarding meeting all the service users health needs. This included regular weight checks and dietary intake, and records of all optical, dental GP, chiropody and hospital appointments. Policies and practices for managing and administering medication were in place. Medication was administered using the Boots Monitored Dosage System. All service users had their medication administered by care staff. Information regarding consent to medication being administered by staff was on each service users care plan. All staff had completed basic Boots medication system training, and accredited training for staff regarding the safe administration of medication was ongoing at the time of the inspection, and it was expected that all staff team will of completed this training by November. Administration records were completed correctly. Patient information leaflets were in place. Medication not suitable for the MDS was stored in plastic boxes named for each service user. The registered manager advised that she had recently attended a seminar regarding using medication to manage behavioural problems. And that service users medication was regularly reviewed. The registered manager is working towards a clearer definition of medication administration and procedure. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 16 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): YA22 YA23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and adult protection policies and procedures safeguarded service users from harm and abuse. EVIDENCE: There had been three informal complaints to the home since the last inspection. The inspector was satisfied that these had been dealt with satisfactorily. The complaints procedure was in a pictorial format, which was appropriate for some service users living at Merlewood. The complaints and prevention of abuse policy and procedure were seen – these had not been reviewed since publication in March 2004. The inspector was advised they were now being reviewed and were due to be published in Nov/Dec 2006. Staff spoken to were able to describe the complaints procedure and how they would deal with someone making a complaint. All staff had undertaken prevention of abuse training. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 17 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): YA24 & YA30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements as identified below will improve the standard of the home and ensure its fitness for its purpose. The standard of cleanliness and hygiene in the home was good. EVIDENCE: At the time of the inspection the homes out buildings, which included a games room for service users, continued to be out of commission. In addition, staff sleeping in facilities, which also doubled up as the homes office, were not suitable for their purpose. There were no facilities within the home to conduct private discussions, or private staff changing facilities. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 18 The inspector was advised that financial and building plans to build an extension to the home had now been approved within this financial year. The plan is to knock down the out buildings and re-build a single storey building which would consist of a food store, laundry, staff room, office and sleep-in and en-suite. Also the oil storage tank is to be removed and the fuel supply be converted to gas. The spare bedroom was being used as an additional office whilst it was vacant. The conservatory roof was in need of repair as the roof was leaking. The home employed domestic support staff for 15 hours each week, which helped to maintain the cleanliness of the home. One service user had a trailing lead across the room – this was discussed at the time of the inspection and the inspector advised a risk assessment must be completed. The home was clean, tidy, warm, and free from offensive odours. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 19 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): YA32, YA34 & YA35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skills of the staff team ensured that service users needs are met. The recruitment practices and staff training protect service users. EVIDENCE: The inspector noted that 7 out of 17 care staff members had now obtained their NVQ level 3. A further 4 staff had completed the NVQ 3 coursework and were awaiting verification. All new support staff completed induction and foundation training to TOPPSS specification. Each member of staff had a training and development programme. A training matrix was in place. Staff training was ongoing and relevant to the service users living at Merlewood. Staff were undertaking accredited medication training. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 20 The inspector case tracked two staff member’s files. There contained information which demonstrated that checks had been taken to ensure that service users were safeguarded. The staffing rota was seen this demonstrated that there were at usually 4 members of staff on duty during the waking day, and 1 wake and watch and 1 sleep in person during the night. The inspector observed service users being supported by competent and caring staff. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 21 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): YA37, YA39 & YA42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced and competent manager. Service users and their families were not consulted about the day-to-day running of the home and their views acted upon. The lack of appropriate appliance safety certificates and risk assessment leaves service users and staff at risk. EVIDENCE: The registered manager had completed her NVQ4 in Health and Social care and the Registered Manager’s Award training in March and August 2006. The Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 22 inspector was satisfied that there were clear lines of accountability within the home and with the registered person. A service users and families quality assurance survey had last taken place in April 2005. The inspector advised that these should take place at least annually and that good practice would be for staff surveys also to be conducted. Appropriate accident records were being completed. Fire evacuation drills were completed monthly, and fire alarm tests were completed weekly. The inspector advised that the fire safety file be reviewed in order to improve clarity. Safety certificates were seen for gas and electrical installations and appliances. The PAT electrical test had been completed in September but the certificate had not yet been issued. However, the safety certificates for emergency lighting and an annual electrical installation report had expired in September 2006. Risk assessments for around the home had been completed, the inspector advised that a risk assessment for the loose electrical flex in one service users bedroom must be completed. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 23 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 24 Yes 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 YA5 Regulation 5(1)(b) Requirement Timescale for action 01/12/06 2. 3. YA24 YA39 23(2)(3) 24(1) 4. YA42 23 (4) 13 (4) The registered person shall produce terms and conditions in respect of accommodation to be provided including the amount and method of payment of fees. The homes premises must be 30/03/07 suitable for their stated purpose and safe and well maintained. The registered person shall 01/12/06 establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered person must take 01/12/06 adequate precautions against the risk of fire. Unnecessary risks to the health and safety of residents are identified and as far as is possible, eliminated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Merlewood Refer to Good Practice Recommendations DS0000009586.V310668.R01.S.doc Version 5.2 Page 25 1 2 Standard YA22 YA23 Policies and procedures should be routinely maintained and kept up to date with current practices. Policies and procedures should be routinely maintained and kept up to date with current practices. Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Merlewood DS0000009586.V310668.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!