Inspection on 10/02/06 for Belmont Road (9 & 10)

This inspection was carried out on 10th February 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belmont Road (9 & 10) 11/05/07

Belmont Road (9 & 10) 17/05/06

Belmont Road (9 & 10) 29/07/05

Belmont Road (9 & 10) 07/03/05

Belmont Road (9 & 10) 07/09/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Belmont Road (9 & 10) March Cambridgeshire PE15 8RQ Lead Inspector Alan Buttery Unannounced Inspection 10 February 2006 13:00 th Belmont Road (9 & 10) DS0000015298.V281811.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 Belmont Road (9 & 10) DS0000015298.V281811.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. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belmont Road (9 & 10) Address March Cambridgeshire PE15 8RQ 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) 01354 660623 01354 653851 Conquest Care Homes (Peterborough) Limited Linda Jane Day Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD only in association with LD Date of last inspection 29th July 2005 Brief Description of the Service: 9/10 Belmont Road provides accommodation for 13 adults with a learning disability, many of whom have an associated physical disability. The home is purpose built and operated by Craegmoor Healthcare. The accommodation consists of two bungalows linked together at the end of a small cul-de sac in the small town of March. The bedrooms are all single, and each has its own washbasin. Each bungalow has its own lounge and dining room and separate kitchens and bathrooms, and the two bungalows share a sensory room There is a shared garden, which can be accessed directly from a number of the bedrooms, and which is used extensively in the better weather. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the current year and an unannounced visit. During the two inspections, all key standards have been inspected. The service users in the home have a variety of complex needs, with only 2 of the service users who do not require assistance with manual handling. The group of service users living in the home has remained the same, and changes are unlikely, and the home has a stable and dedicated staff group, with only one vacancy. Since the last inspection, the regional director has moved on, and a new regional director and area manager are in post. What the service does well: What has improved since the last inspection? What they could do better: The outstanding issue remains with the bathrooms in the home, which are no longer suited to the needs of the service users. Following the last inspection in July 2005, a requirement that the work be undertaken as a matter of urgency was acknowledged buy the provider, who stated that the work had been approved. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 6 This work has not taken place, and unless details of when it will be done are provided, enforcement action will now be considered. Other ongoing redecoration, and issues regarding the replacement of dining room furniture should also be resolved as soon as possible 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. Belmont Road (9 & 10) DS0000015298.V281811.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 Belmont Road (9 & 10) DS0000015298.V281811.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): 1 and 2 Service users and families are all given detailed information on the service, and polices in place to ensure full assessments of their needs are made. EVIDENCE: The homes Statement of Purpose and Service User Guide are up to date, and available to all service users, and changes identified at the last inspection have been incorporated. There have been no changes to the service users living in the home, and none are expected. However, policies and procedures are in place to manage a new admission should a vacancy occur, ensuring a full assessment of need would be carried out, and any prospective service user would spend time in the home. Belmont Road (9 & 10) DS0000015298.V281811.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 and 8 Individual care plans ensure all staff are aware of how to support the service users, enabling them to make decisions wherever possible and take carefully assessed risks in their day-to-day lives. EVIDENCE: The care plans and risk assessmentS in the home are very comprehensive, covering all eventualities, and kept under very regular review. Service users are involved in the care plans wherever possible, as are families where appropriate. Service users are encouraged to take decisions around the home, and to assist with all day-to-day aspects of their home. Risk assessments are very comprehensive, and are used to maintain the safety of service users, and not to avoid situations. Consideration could be given to the number of different risk assessments on file, and whether some of these could be combined. Belmont Road (9 & 10) DS0000015298.V281811.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, 13 and 16 Service users are supported to be involved with the local community and take part in various social and recreational activities with their peers EVIDENCE: Service users living in the home take part in a variety of structured and ad hoc daytime activities, both within the local community and with their peers, and also have a variety of social activities available, including trips to local pubs and restaurants and pubs, a local theatre and leisure facilities. Holidays are currently being discussed with service users, and all thirteen service users will be having a holiday in the next year, some taking short breaks others longer trips. Service users are involved in planning the holidays as far as possible, and care staff all keen to be involved. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 11 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 and 19 The emotional and physical health needs of service users are identified and met with support from healthy professionals in the area. EVIDENCE: Service users are all involved as far as possible in how their care needs are met, and this is reflected in their individual care plans, as indicated above. The home continues to have a good relationship with local health professionals, and support is provided in addressing some of the complex needs of those living in the home. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 12 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 and 23 All complaints are appropriately dealt with and the comments of service users encouraged and listened to. EVIDENCE: The home uses policies and procedures of its parent company, and policies are in place to ensure that all complaints are appropriately managed. There have been no complaints since the last inspection, ether direct to the home or to the CSCI. In addition policies and procedures are in place, and training provided, to ensure staff are aware of adult protection matters and actions that must be taken, to ensure service users are safe. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 13 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, 27 and 30 The home is clean and homely but bathroom facilities are not suited to the needs of service users, and must be replaced. EVIDENCE: Since the last inspection, new furniture has been provided in the lounge area of one part of the home, as suggested at the last inspection, and both lounges now offer good quality furniture appropriate to the service users living there. It has been suggested that the dining room furniture be replaced, and this is now being looked at, with an assessment being made of the type and nature of the furniture to ensure it meets the needs of all service users, and us suited to those in wheelchairs. A major area of concern relates to the bathroom facilities in the home. Although it has been agreed previously that the current situation in untenable, and that the bathrooms available do not meet the needs of the service users living in the home, the required work has not been done. 11 of the 13 service users need the assistance of a hoist when bathing, but existing facilities are not suitable. As a result, service users are being placed at risk, and this must cease. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 14 This has been identified previously, and accepted by the company, and the required works acknowledged in monthly management reports. Following the last inspection, the requirement that this work be undertaken was accepted by the providers, and their response on the inspection report stated ‘Baths have been approved, awaiting quotes and agreement for building works that need to make good during and after installation’ Since then, nothing has happened, and this situation will not be tolerated. The required work must take place as matter of urgency, and full details of the work to be done, and when it will happen, must be provided to the CSCI. Unless this is received by the CSCI within the next 30 days, legal action to ensure compliance will be considered. The home was clean and tidy on the day of the inspection, and regular maintenance and redecoration take place. At previous inspections, the need to replace flooring in two of the rooms has been identified, which was put on hold while service users were unwell, but should now be actioned. Belmont Road (9 & 10) DS0000015298.V281811.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): 34 The homes recruitment policy ensures service users are not placed at risk of abuse EVIDENCE: The homes recruitment policy was discussed with the manager, and a sample of staff files examined, all contained the required information as detailed in the regulations. It was recommended that any reference received should be verified if not on official stationery to ensure its accuracy. CRB records for all care staff currently in the home were examined by the inspector, and seen to be in order. Belmont Road (9 & 10) DS0000015298.V281811.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 and 42 The home is managed very effectively, for the benefit of the service users, and detailed health and safety policies ensure the safety of service users and staff. EVIDENCE: The home is well managed, and the manager and deputy have an excellent working relationship. Staff appear committed to the work they do, and happy to take on additional responsibilities. Policies and procedures are in place to ensure the health and safety of staff, and training provided to staff through the homes induction training and regular updates. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 17 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 3 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X X X X 3 X Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 YA27 Regulation 23(2)(j) Requirement Urgent attention must be given to the bathrooms in both sides of the home as these no longer meet the needs of the service users, and must be updated. Details of the action and the timescale by when it will be taken by must be submitted to the CSCI This timescale has been carried forward as previous requirements have not been met. Plans for the work, and a timescale, must be submitted by the date shown or enforcement action will be considered. 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 YA27 Good Practice Recommendations Consideration should be given to updating lounge and DS0000015298.V281811.R01.S.doc Version 5.1 Page 19 Belmont Road (9 & 10) 2 YA34 dining room furniture All references received should be verified. Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Belmont Road (9 & 10) DS0000015298.V281811.R01.S.doc Version 5.1 Page 21 - 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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