Merle Boddy House

Merle Boddy House is a residential care home providing personal and nursing care to people with learning disabilities or autistic spectrum disorder. The service can support up to ten people. At the time of our inspection there were eight people using the service.

The service had not been developed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

People’s experience of using this service and what we found

People were not always supported to have maximum choice and control of their lives.

Risk assessments were not robust enough to ensure people were kept safe. Not all risks had been identified to ensure people were supported appropriately. Staff did not always keep up to date with changes to people’s risk assessments.

Staffing levels were not managed to ensure that staff could support people to access the community on an individual basis. People were not always supported to develop their interests and take part in their preferred activities. People were not being supported to develop in areas that were important to them.

People were not always supported with maintaining a healthy diet. People were not always involved with their care and support.

Staff received training, however, training in relation to supporting people with learning disabilities could be improved. We have made a recommendation in the report.

The service was not well-led and lacked leadership. Staff did not feel supported. Quality assurance systems did not identify issues which could pose a risk to people’s health and safety. Audits had failed to identify issues. Not all actions from the previous CQC inspection were completed to ensure the required improvements were made and lessons were learnt. Files were not always updated to be kept in line with best practice and to reflect people’s personal care needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people.

The service used positive behaviour support principles to support people in the least restrictive way. No restrictive intervention practices were used.

Rating at last inspection and update

The last rating for this service was Requires Improvement (report published 22 September 2018) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches at this inspection in relation to person centred care and good governance.

For requirement actions of enforcement which we are able to publish at the time of the report being published:

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Merle Boddy House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service can accommodate up to ten people who have a learning disability. Accommodation was spacious and provided easy access to Norwich. Everyone had their own bedroom and generous communal space.

The care service had been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

There was a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

In summary we found, since the last inspection to this service the manager had become registered having only been in post a couple of weeks at the last inspection.

They had made efforts to change the environment and this was generally suited to people’s assessed needs. However, we identified several potential risks posed both by the environment but also from the lack of assessment and planning around individual risks.

We found records were not sufficiently robust in illustrating changes to people’s needs or how these were being addressed. Staff were familiar with people’s needs so this lessoned the risk of people not getting their needs met. However, there was still a risk in staff not being fully aware of changes to the persons plan of care or treatment because this was not accurately reflected in the records.

The above gave us concerns about the oversight of the service and how robust the quality assurance systems were in identifying concerns.

We found them to be open, friendly and knowledgeable. They told us the ethos of the service had been poor and people did not have sufficient opportunity to develop their skills and confidence through increased participation in the community. They had worked hard to change the culture of the service and help each person develop and grow. This had meant changing the staffing culture through regular support, challenge and providing the necessary training to develop staff. In addition, they had asked for support from the trustees to change the way they worked and to have a more hands on approach.

There were systems in place to help ensure the environment and equipment on the premises was in good order and staff were trained to act in an emergency, including fire evacuation.

Staff understood what constituted abuse and how to protect people from potential harm. Staff receiving training and updates for adult protection. Incidents/accidents and safeguarding concerns were documented and showed lessons learnt.

The service had an adequate staff recruitment programme aimed at ensuring only staff who were suitable for the role were employed and of good character.

There were systems in place to help ensure sufficient numbers of staff were employed to meet people’s assessed needs and facilitate their choices.

Medicines were administered as intended by staff qualified to do so.

The service was hygienically clean and infection kept to a minimum.

Staff received the necessary support, guidance and training for their job role. This helped them to meet the needs of people they were supporting.

People were supported to eat and drink sufficient to their needs. Staff monitored people’s health and encouraged and supported people to see a GP or other health care professional as required. However, we found records to support this were not always adequate.

People were supported in their decision making and valid consent was sought before care and treatment was given. This was being reviewed in line with existing applications for the Deprivation of liberties safeguards.

People had adequate activity around their individual needs and choices. We could not see how people were always supported to achieve their goals and what they had achieved.

There was an established complaints procedure and the service considered feedback from people and families and adapted the service accordingly.

End of life planning was not in place but staff were sensitive to the issue and knew how they would support people to ensure they received the care they needed.

Staff were kind and caring and respected people they supported. They upheld their dignity and privacy and supported them with their daily routines.

Staff encouraged people to retain their independence and to learn new skills. People were encouraged to make their own decisions and be involved in decision making about the service they received.

The manager was approachable and knowledgeable. They had set about to change the service to help ensure it reflected the needs and wishes of people it was supporting. They had provided leadership and support to staff. They had created a more open person-centred culture. They were addressing some of the issues created by the environment to help ensure it reflected the needs of people using the service.

Merle Boddy House provides a home and support for up to ten people with a learning disability. There are bedrooms on both floors of the home with two sitting rooms, dining room and kitchen on the ground floor. There is level access to the garden through patio doors from one lounge. At the time of our inspection, there were eight people living in the home.

The home had been without a registered manager for about five months before we inspected. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The providers had appointed a manager who started work just over a month before our inspection. The manager was intending to register with CQC.

At our last inspection of the service in May 2015, we found that outcomes for people were good in all areas. At this inspection, we found that the lack of consistent leadership had led to the need for improvement and there were two breaches of regulations.

There were enough staff to support people safely. However, the provider’s recruitment processes were not wholly robust in protecting people from the employment of staff who were unsuitable to work in care. Staff had enhanced disclosure checks on their backgrounds to ensure they were not barred from working in care services. However, other checks were not fully completed to contribute to protecting people and obtain the information the law requires. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider’s systems for overseeing the quality and safety of the service, particularly when there was no manager in post, were not effective. They did not result in shortfalls in the service being identified and addressed. There were some gaps in records and some records were not up to date. Where a contractor’s report indicated the need for remedial work, the providers had not acted promptly. There was a lack of formal consultation with people, their relatives, staff and other stakeholders for their views to determine what improvements should be made. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we have told the provider to take at the back of the full version of the report.

Staff understood the importance of reporting any suspicions that people were at risk of harm or abuse. They were confident about contacting either the local safeguarding team or CQC directly if they could not raise concerns within the service for any reason.

Staff supported people with their medicines in a safe way so that they got the right medicines at the right time. Staff supported people to seek advice from health professionals about this and other aspects of their health and wellbeing. This included advice about their diet when this was necessary, and people had a choice of enough to eat and drink for their needs.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. Systems within the service supported their practice and staff understood the importance of following guidance about people’s rights and freedoms.

Staff knew about people's interests, like and dislikes and supported them with active social lives. The manager was reviewing with staff, how they could deliver care that was more specifically centred on each person's individual needs. This included the way that risks to each individual were assessed and addressed.

People or their relatives expressed confidence that staff listened to their concerns and complaints, and took action where they needed to. They were hoping that the new manager would help improve things further, and that they would be more involved discussions about care.

The appointment of the new manager was very recent but staff welcomed the leadership, support and guidance they were now getting.

People were provided with a choice of suitable and nutritious food and drink. The menu we saw showed balanced and nutritious meals for the week of this inspection, which we were told by one person were liked. Dislikes were written on menu's to ensure staff were aware of what and what not to offer.

Medication procedures were in place for the majority of management of medicines but some concerns were found in the administration process for creams and eyedrops. The home did not have a method of recording returned medication.

The home was undergoing structural changes and although beneficial, risks had not been assessed/identified/recorded while the work was taking place. Some appliances within the home had not been serviced as required.

Staff who worked in the home had suitable training opportunities and were offered support and supervision at appropriate times to ensure they had the competency to carry out their role.