CARE HOME ADULTS 18-65
Merrywick Hall 41 New Road Hedon East Yorkshire HU12 8EW Lead Inspector
Sarah Sadler Unannounced Inspection 7th March 2006 10:00 Merrywick Hall DS0000019695.V285908.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 Merrywick Hall DS0000019695.V285908.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. Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Merrywick Hall Address 41 New Road Hedon East Yorkshire HU12 8EW 01482 899477 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) Willerfoss Homes Mrs Margaret Rose Scott Care Home 27 Category(ies) of Learning disability (27) registration, with number of places Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: Merrywick Hall is a care home providing personal care and accommmodation for up to twenty seven service users who have a learning disability. It is owned by Willerfoss Homes, which is a private company. The home is located in the town of Hedon which is situated on the border of Hull and the East Riding. It is close to all local amenities including shops, the post office, local pubs and gives access to local transport. The home comprises of a large detached property set in its own well maintained grounds and has been adapted and converted for use as a residential care home and an additional bungalow that has been adapted and converted for use as a residential care home. There are fourteen single bedrooms and four shared rooms in the main house and the bungalow provides independent living accommodation for up to five. Wheelchair users are accommodated on the ground floor as there is no passenger or stair lift at the home. Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was undertaken over four hours by two inspectors Sarah Sadler and Rob Padwick, with a previous two hours preparation time. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, service users staff and the registered manager were spoken to. Some time was spent with service users, observing their everyday life. Service user files and other records within the home were read. The majority of the key standards were assessed at the last inspection therefore, this inspection concentrated on the remaining standards and any outstanding requirements and recommendations. What the service does well: What has improved since the last inspection?
Staff have been trained in the ‘Protection of Vulnerable Adults’, assisting service users to continue to be protected from abuse. Service user meetings are held regularly; with records kept of the decisions and requests people make for the continuing meeting of their needs. All radiators are now guarded, protecting service users from the potential of burns from these. Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 6 The gas systems have been professionally assessed as safe, ensuring that health and safety needs of service users continue to be met. Weekly fire alarm checks are completed, to ensure this equipment is fully operational and would assist service users to escape should a fire occur, protecting their welfare. 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. Merrywick Hall DS0000019695.V285908.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 Merrywick Hall DS0000019695.V285908.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): None of these standards were assessed at this time. EVIDENCE: Merrywick Hall DS0000019695.V285908.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): 6,7,9 Service users are enabled to take risks and make choices in their everyday lives. EVIDENCE: Service users’ files include individual plans of care that have been developed from the Local Authority’s community care plan. These have monthly key worker reviews, however one of these had not been reviewed since November 2005. Regular reviewing of the care plan ensures that care is provided to meet the service users’ current needs. One service user moved into the home in December 2005 and is to shortly have a care review, the registered manager detailed that a full care plan and risk assessments are not normally completed until this point. However as this poses a health and safety risk the registered manager is to complete this from the day of admission for all future service users. Care plans included risk assessments; the registered manager confirmed that these are reviewed on a six monthly basis.
Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 10 The registered manager confirmed that service user care plans continue to be written in plain English only, this was discussed at the inspection and the registered manager is to address this further. Service user files included details of different activities, which, service users undertake. The details included; ‘Sat with….’, ‘ Went out with carer’, ‘ watching TV’, ‘Out with brother’. The service user meetings minutes reflect that service users have choices in their lives the notes included, planning parties/ evenings out and requests for specific outings, as well as a request for a new pair of curtains. Service users talked about the different choices they made in their lives, which included the times for getting up and going to bed and the choice of what to eat. Merrywick Hall DS0000019695.V285908.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): 15 Service users are supported with their relationships. EVIDENCE: One service user confirmed they go away with their family and another service user stated that she is supported to visit their relative on a weekly basis. Two service users discussed how they are supported to maintain personal relationships. One service users notes confirmed ‘ Out with brother’. Merrywick Hall DS0000019695.V285908.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): None of these standards were assessed at this time. EVIDENCE: Merrywick Hall DS0000019695.V285908.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): 23 Service users are protected from abuse. EVIDENCE: The registered manager confirmed that staff had undertaken training in relation to The Protection of Vulnerable Adults and staff files included certificates confirming this. Merrywick Hall DS0000019695.V285908.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): None of these standards were assessed at this time. EVIDENCE: Merrywick Hall DS0000019695.V285908.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 Service users are supported by good recruitment practices, but the staff training needed to be improved EVIDENCE: The registered manager and registered person confirmed that Learning Disability Award Framework (LDAF) training has not yet been accessed. Staff have undertaken the ‘Protection of Vulnerable Adults’ training. A new person has now been employed to organise the training of the staff team and this person is currently developing the training within the home, including the budgets for training and access of courses. Staff have all been assessed to ascertain what training is required. There are 5 staff who require NVQ level 2 training. The registered manager confirmed and staff files examined included evidence that all staff have undertaken a Criminal Records Bureau check (CRB) as part of their recruitment, including that the Protection of Vulnerable Adults (POVA) list had been checked. Two references are undertaken on staff prior to commencement of employment, which includes wherever possible one from the persons last employer.
Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 16 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): 37,39,42 Service users live in a home, which meets their health, and safety needs and supports them to be involved in the decisions in the home. EVIDENCE: The registered manager is a qualified nurse and has managed the home for a number of years. She confirmed that she has undertake some mandatory training over the last year. There is a resident’s committee book, which holds the minutes of the service user meetings, which now take place on a regular basis. The registered manager confirmed that all radiators were now guarded. There is a fire file, which includes a fire risk assessment, reviewed in December 2005 and records that weekly checks of the fire alarm, doors and emergency lighting are completed.
Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 17 There is a landlord’s gas safety record, which details that the tumble drier and gas boiler are safe to use. The registered manager confirmed that the gas cooker required repair and that a new cooker was purchased. The health and safety files include details of a health and safety audit; lift service, and portable appliance test (PAT). There is a quality assurance file; however there is not an annual quality assurance report and assessments to gather information in order to produce a report have not all been completed. Merrywick Hall DS0000019695.V285908.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 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 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 1 X X 3 X Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 19 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 YA35 Regulation 18 (1(a)) Requirement The registered person must encourage staff to undertake LDAF training and register on an NVQ training programme to ensure they are appropriately qualified. The registered person must ensure that there is a system in place to review the quality of care and includes seeking the views of service users. Timescale for action 07/06/06 2 YA39 24 07/05/06 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 Care plans, including risk assessments should be completed from arrival at the home. • To aid service user understanding of the care plans the manager should consider developing the plans in a pictorial format. The registered person should ensure that 50 of the stafff team are qualififed to NVQ level 2 in care. The registered person should ensure that the registered
DS0000019695.V285908.R01.S.doc Version 5.1 Page 20 • 2 3 YA32 YA37 Merrywick Hall manager has a management qualification. Merrywick Hall DS0000019695.V285908.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Merrywick Hall DS0000019695.V285908.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. 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!
