Inspection on 14/11/06 for Conquest Lodge

This inspection was carried out on 14th November 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conquest Lodge 07/08/07

Conquest Lodge 09/02/06

Conquest Lodge 04/05/05

Conquest Lodge 13/10/04

Conquest Lodge 08/06/04

Conquest Lodge 05/03/04

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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 Conquest Lodge Dagless Way March Cambridgeshire PE15 8QY Lead Inspector Andy Green Key Unannounced Inspection 14th November 2006 10:00 Conquest Lodge DS0000015195.V321019.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 Conquest Lodge DS0000015195.V321019.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. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conquest Lodge Address Dagless Way March Cambridgeshire PE15 8QY 01354 659708 01354 658683 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) Conquest Care Homes (Peterborough) Limited Kerry Dring Care Home 19 Category(ies) of Learning disability (19), Physical disability (19) registration, with number of places Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disabled service users only to be admitted if they also have a learning disability 9th February 2006 Date of last inspection Brief Description of the Service: Conquest Lodge is situated in a residential area of March, Cambridgeshire, for 19 adults with a learning and/or physical disability. Service users have a range of disabilities and challenging behaviour. The home is approximately 11 years old and was purpose built. It is single storey and is divided into four living units. Corridors link three of these units; a fourth is a separate dwelling to the rear of the main building. There is a range of outdoor space in the back garden, including an enclosed garden for the use of residents in Windsor Unit. There is a staff and visitors car park to the front of the building. Conquest Lodge is owned by Conquest Care Homes (Peterborough) Limited, which is a wholly owned trading subsidiary of Craegmoor Group Limited. The Registered Manager is Mrs Kerry Dring. The weekly charge range from £855 - £1300. Copies of inspection reports are made available to service users and visitors on request. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 14th November 2006. The inspector met with the manager, senior staff, support workers and service users to gather views regarding the services that are provided in the home. A number of records were inspected including care plans, training records, staff files, medication records and fire testing records. A tour of the building and grounds was also undertaken. What the service does well: What has improved since the last inspection? The care planning processes are well co-ordinated and reviewed to ensure consistency. The home is in the process of providing all care plans in a person centred approach to ensure that service users are involved as much as possible in making choices about their lives. Staff supervision has improved and the manager and senior staff are developing this further to ensure that all staff are adequately monitored. All fire doors have magnetic closures to ensure that service users are protected from potential fire hazards. Testing of alarms and emergency lighting has also Improved. Staff records are now improved with photographs in place. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 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 Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have access to good information, and can make an informed choice regarding the home’s services. EVIDENCE: The Statement of Purpose and the Service User Guide have been reviewed to ensure that they remain up to date. The manager also showed the inspector a new leaflet that has been produced by Craegmoor Healthcare, which gives additional information regarding the home. The home continues to obtain detailed information via the care management process to ensure that they can meet the individual’s assessed needs. Reports are received from Psychiatrists, Psychologists and Speech and Language therapists. There have been two admissions to the home since the last inspection. Two senior staff are involved in completing assessments. Relatives are encouraged to be involved in the referral process where appropriate. A number of visits to the home can be arranged for prospective service users before moving in. There have been no changes to the assessment procedure since the last inspection Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 9 All records held about service users are kept securely and staff are aware of the policies regarding confidentiality. Conquest Lodge DS0000015195.V321019.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are treated with dignity and respect and receive personal care to meet their assessed needs. Detailed care plans are kept to make sure each service user receives appropriate care and support. EVIDENCE: The care plans of four service users were seen and they contained appropriate information. The care plans are presented in a professional manner with clear guidelines to ensure that the care and support needs of each service user can be appropriately provided. There is a risk assessment procedure in place to ensure that service users are protected from harm both within the home and when accessing the community. Care planning meetings are held and one of the Senior Team Leaders coordinates reviews with key workers and other team leaders to ensure that there is a consistent approach. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 11 Regular reviews of care plans take place and include any updates or changes in care. This was evidenced in the care plans seen during the inspection. Service user plans are currently being amended to a “Person Centred Plan” format to give a more holistic approach and incorporate the service users views, choices and preferences as much as possible. Each service user has a key worker and link worker to ensure that care is consistently delivered to meet individual needs. Staff members spoken to during the inspection confirmed that they continued to be regularly involved in the care planning process. Conquest Lodge DS0000015195.V321019.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff provide appropriate support to ensure that service users can access the community to engage in activities appropriate to their needs. Service users have a choice of meals, which are prepared and served in a homely manner. EVIDENCE: The home promotes access to a wide variety of activities both in house and in the community for service users. During the inspection there was clear evidence of service users and staff busily involved in numerous trips to the local town and attendance at local colleges and sport facilities. Each service user has a weekly programme, which is recorded in their care plan. Examples include programmes at local colleges involving cookery, computing, art and crafts, local day centre. Service users make regular trips to the local community, with staff assistance. This includes personal and house shopping, meals in restaurants, bowling, gym, fishing, dog walking via the Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 13 RSPCA, swimming, pub trips and cinema. Trips to local theatres are also organised throughout the year. A variety of in-house activities continue to be provided including cookery, art sessions, hairdressing and visits from a reflexologist. Service users are encouraged to furnish their bedrooms and have equipment eg television, DVD’s and music facilities etc so that they are they able to enjoy spending time in their own rooms as well as using communal facilities. Holidays and day trips are organised throughout the year and examples included self-catering cottages in Norfolk and Lincoln. Daytrips have been organised to London and a summer open day party was also held in the home/gardens this year. Service users benefit from a varied menu in the home and service users receive a choice of meals to meet their dietary needs and preferences. Service users continue to be involved in the shopping and preparation of food where possible. The manager stated that a dietician remains available to give advice regarding service users requirements as necessary. Conquest Lodge DS0000015195.V321019.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. Care is provided appropriately in the home. There are clear guidelines regarding the safe administration of medication. A risk assessment procedure is in place to protect service users. EVIDENCE: Service users continue to receive care from a wide range of healthcare professionals including GPs district nurses, occupational therapists, chiropodist and speech & language therapy. Outpatient appointments to psychiatrists are also arranged as required. The manager stated that there had not been any new contacts with healthcare professional since the last inspection. Staff assist service users with personal care where appropriate and clear guidelines are recorded in care plans. Healthcare is well documented in individual care plans along with assistance to access outpatient appointments at local hospitals or surgeries. Visits from healthcare professionals are recorded as appropriate. Individual risk assessments are recorded on individual files and are reviewed to ensure that service users are protected from potential harm. Four service user files were inspected and risk assessments were in place. Medication records were accurate and up to date. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints process to make sure that service users and their representatives are able to raise concerns and have them dealt with appropriately. There are suitable arrangements for ensuring the protection of service users from neglect or harm. EVIDENCE: The home’s complaints procedure ensures that all concerns are fully investigated and actioned appropriately. The complaints policy/procedure is clearly displayed near the front entrance. There have been no complaints raised with the home since the last inspection. CSCI has also not received any complaints since the last inspection. The home ensures that adult protection issues are dealt with in line with local authority policies, to ensure that service users are protected from potential abuse. Care staff continue to receive appropriate training to ensure they are aware of adult protection procedures. Staff confirmed this to be the case during the inspection and was also evidenced in the home’s training programme. It was observed that care staff interacted and spoke with service users in a friendly and social manner, which was appropriate to their individual need. Comment cards received by CSCI regarding the home were complimentary about the staff and the care and support provided. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,30 Quality in this outcome area is poor . This judgement has been made using available evidence including a visit to this service. The environment of the home provides service users with a safe, comfortable, clean place to live. However, there are a number of areas in the home which need refurbishment and redecoration. EVIDENCE: The home is generally suitable for the needs of the service users. The handyman continues to deal with day-to-day repairs and refurbishments in the home and the maintenance of the attractive gardens. A number of service users bedrooms were seen and they are personalised, furnished and decorated to meet the individual service user’s needs and preferences. The home was generally clean and free from odours. There is however a number of refurbishments needed in the individual units as follows; Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 17 Windsor • Corridors and walls have been decorated but remain sparse and need to have further creative decoration to give a more homely feel. Sandringham • Carpets need to be replaced in the dining area and corridors as they are deteriorating and stained. • Corridors and bedroom doors are showing signs of age and are becoming scuffed and need decorating Kensington • A carpet in one of the service users bedroom had an odour of urine and needs to be replaced with more suitable flooring to meet the service user’s continence needs. Burleigh • Carpets need to be replaced in the dining area and corridors as they are deteriorating and stained. • Corridors and bedroom doors are showing signs of age and are also becoming scuffed and need decorating. The inspector discussed the above with the manager and has requested that a programme of refurbishments/decorations be provided to CSCI to evidence how the work will be actioned. Consequently requirements will be made regarding the environment. It was also noted that fire doors now have magnetic closures installed since the last inspection to provide appropriate fire safety. These closures are linked to the main fire safety system and the doors close automatically when the alarm is triggered. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The agency’s recruitment policy and processes makes sure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver personal care to the service users they support EVIDENCE: Three staff files were seen and they contained appropriate information including two references and evidence of satisfactory POVA/CRB checks. All recruitment is dealt with via the organisation’s Personnel Department to ensure a consistent approach. The home receives copies of documents that are required to be kept in the home. Staff training in the home continues to be well co-ordinated and a programme is in place to ensure that mandatory and client specific training is delivered. Refreshers and regular updates continue to be organised throughout the year. The inspector was shown the training matrix that has been produced which evidenced training that had been given and dates for forthcoming courses and dates for refreshers. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 19 NVQ training is also in place for care staff and managers to meet expected nationally agreed standards. 3 members of care staff spoken stated that they had received a variety of training in the home including induction, moving & handling, fire safety, first aid, food hygiene, moving and handling, medication administration, dementia awareness, COSSH, POVA, challenging behaviour, person centred planning, epilepsy and NVQ training. Care staff confirmed that they felt well supported by the management team and that they were actively encouraged to be involved in the development of the service. There are no staff vacancies at present following a recent successful recruitment drive. Staff supervision has improved since the last inspection. The manager supervises the seniors who also have delegated groups of care staff that they supervise. The manager stated that this area would continue to be monitored to ensure that individual members of staff receive regular sessions so that performance, training and development needs are monitored on at least 6 occasions during the year. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed and the manager provides supportive leadership to ensure high quality care is delivered and monitored through quality assurance processes. EVIDENCE: The manager has relevant managerial and supervisory experience and she has completed an NVQ level 4 in Care & Management. The manager continues to undertake regular training to update her knowledge and skills. She stated that she is receiving marketing and budgeting training via the organisation’s management training. She continues to provide, with her senior staff team an inclusive and supportive management style in the home. Staff spoken to during the inspection confirmed that the management team in the home are supportive, available and actively involved in assisting with Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 21 personal care and activities for service users when necessary. Fire safety testing has improved since the last inspection. Weekly alarm and monthly emergency light testing records were inspected and were recorded accurately. An organisational quality assurance process continues to be in place to gauge service users, staff and healthcare professionals views to provide feedback regarding the quality of the service that is provided. Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 22 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 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 3 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 23 No 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) (b) Requirement Refurbishments and redecoration must be made to corridors, doorways and walls as outlined in this report Carpets must be replaced in the areas detailed in this report. The registered provider must forward a programme to CSCI detailing how the required refurbishments and decorations contained in this report will be actioned including timescales. Timescale for action 31/01/07 2 3 YA24 YA24 23(2) (d) 23(2) 31/01/07 31/12/06 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 Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Conquest Lodge DS0000015195.V321019.R01.S.doc Version 5.2 Page 25 - 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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