Inspection on 17/05/06 for Belmont Road (9 & 10)

This inspection was carried out on 17th May 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 2 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) 10/02/06

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

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

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

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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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 Key Unannounced Inspection 17th May 2006 10:00 Belmont Road (9 & 10) DS0000015298.V291331.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.V291331.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.V291331.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.V291331.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD only in association with LD Date of last inspection 10th February 2006 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 Cambridgeshire 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 Fees charged range between £675 and £1309 per week, depending on assessed need, and copies of previous reports are available either in the reception area or from the office. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. During the inspection, all key standards were assessed. The service provides support for service users with complex needs, aged between 18 and 65. 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. What the service does well: What has improved since the last inspection? Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 6 The budget for the replacement of two bathrooms has been agreed, and work should start shortly, with completion expected by the end of August. There have no other significant changes since the last inspection 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. Belmont Road (9 & 10) DS0000015298.V291331.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.V291331.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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. Policies and procedures are in place to ensure service users would be involved in any prospective move, and full assessments undertaken to ensure needs could be met. EVIDENCE: The home has been established for a number of years, and the group of service users living there remains stable. It is viewed as a long term home, and it is unlikely that service users would move from the home unless their needs changed to the point at which they could no longer be met at this home/. In the event of a vacancy occurring, the home does have policies and procedures in place to ensure that a detailed assessment of need is carried out, and a planned series of visits would be arranged to ensure that both service users, their families, and service users already living in this home were happy. Belmont Road (9 & 10) DS0000015298.V291331.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 9 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. Detailed care plans are available to ensure staff aware of how service users should be supported. EVIDENCE: Individual care plans and risk assessments are in place for each of the service users in the home, and three of these were examined `as part of this inspection. Service users are involved in reviewing their individual plans as far as possible, and evidence was seen on the files examined that these plans are reviewed on a regular basis, generally once a month. Complex risk assessments are in place to ensure that all activities both in and out of the home take into account any risks, and detail how these risks can be overcome, without unduly restricting service users from taking part in everyday activities. Discussions with the manager, and observations of staff working at the time of the inspection clearly demonstrated that service users are helped in making Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 10 decisions about their lives, and things they do, for example activities and holidays. Belmont Road (9 & 10) DS0000015298.V291331.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. Service users are able to participate in a variety of appropriate activities. EVIDENCE: Service users living in the home take part in a number of activities, both in the home and outside. The activities involve a mixture of work and leisure related activities and some of these take place at a local further education centre. Activities include art and craft, swimming, horse riding, gardening and cookery, although this is not currently available. In addition, the home has its own sensory room, and a well-equipped garden, which is used extensively during warmer weather. Other leisure activities include meals or drinks at local pubs and restaurants, trips to the theatre, both locally and to the west End and shopping trips and the staff are currently discussing this years holiday arrangements with service users. These are likely to include trips to Euro Disney, Centreparks, Holiday cottages and visits to London. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 12 The families of the service users continue to be involved in discussions, and most are able to visit regularly, and take part in reviews. The support that the home receives from local health and social care professional is very good, with a good working relationship, and advice and training is available whenever it is needed, for example around mobility or diet issues. Advice from local dieticians ensures that the service users receive a well balanced and health choice of food, with consideration where needed to health and weight issues. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 13 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. Health needs are identified and arrangements in place to meet these needs. EVIDENCE: As indicated earlier in the report, the home has an excellent working relationship with the local health professionals and GP surgeries, and this helps the home to ensure that the physical and emotional health needs of the service users are met. The personal support, and the way this is provided is detailed within the service users individual plans and kept under review on a regular basis. The home has a detailed medication policy. A recent incident highlighted the need for more detailed training, and this has been arranged for all staff. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. All complaints are appropriately dealt with and the comments of service users encouraged and listened to. EVIDENCE: Policies and procedures are in place to ensure that complaints or concerns raised by service users, families or other involved parties are listened to and acted upon where necessary. A log of complaints is kept, and since the last inspection, 1 complaint has been made to the home, which was quickly and appropriately dealt with. All staff currently working in the home have received training in adult protection issues and are aware of the procedures to be followed in the event of suspected abuse, although no incidents have occurred. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is poor. This judgement has been made using available evidence and a visit to the premises. Improvements have been agreed, and must now be completed. EVIDENCE: On the day of the inspection, the home was clean and tidy, and there were no offensive odours. Both the individual service user rooms, and communal areas are generally homely and provide safe accommodation but further consideration must be given to the condition of some of the furniture, for example the dining room furniture is in a poor state of repair, and carpets in the home need to be replaced, as many are stained and worn, a fact noted on a recent visit by the providers regional director. The required refurbishment of the bathrooms remains outstanding, and the timescale on the last inspection report for the work to be done has not been met. The manager was able to confirm that a budget has now been agreed, and contractors were due to visit the week after the inspection visit, but this work is long overdue, and leaves service users without appropriate bathroom facilities. This is clearly unacceptable, and further action will be taken, unless detailed plans and schedules are provide to the commission by return. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 16 Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 17 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. EVIDENCE: Staff records were examined as part of the inspection process, and clearly demonstrated that the recruitment processes are robust and offer protection to service users. The providers deal with recruitment centrally, but local interviews are held, and all required records were available in the home. Staff working on the day of the inspection were clear in their roles, and the staff team appear to work extremely well as a team. There are currently two vacancies, and recruitment into these posts is underway. The training provided to staff is very comprehensive, and a record of the training received was seen on the three staff files examined, which included all mandatory training as well as other more service users specific courses. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 18 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the premises. 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 service users are involved in all aspects of the running of the home, as far as they are able and wish to be. Regular monitoring visits are undertaken by the area manager, and submitted to the CSCI. Policies and procedures are in place to protect the health and safety of service users and staff, and during the course of the inspection a number of records were examined including fire and lighting checks, maintenance records and equipment records. These were all satisfactory. Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 19 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 3 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 2 25 X 26 X 27 1 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 3 X X X 3 Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 20 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 YA24 Regulation 23(2)(d) Requirement The general decoration of the home must be improved, and further replacement furniture purchased The agreed works to the to the bathrooms in both sides of the home must now be completed, and details of the timescale submitted to the CSCI This e has been carried forward as previous requirements have not been met. Timescale for action 31/08/06 2. YA27 23(2)(j) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belmont Road (9 & 10) DS0000015298.V291331.R01.S.doc Version 5.1 Page 21 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.V291331.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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