Inspection on 04/05/05 for Conquest Lodge

This inspection was carried out on 4th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Conquest Lodge 07/08/07

Conquest Lodge 14/11/06

Conquest Lodge 09/02/06

Conquest Lodge 13/10/04

Conquest Lodge 08/06/04

Conquest Lodge 05/03/04

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Paradise Lodge

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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 Announced 04 May 2005 @ 10:00 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Conquest Lodge Address Dagless Way March Cambridgeshire PE15 8QY 01354 659708 01354 658683 conquest.lodge@craegmoor.co.uk Conquest Care Homes (Peterborough) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Kerry Dring Learning Disabilities 19 Category(ies) of LD, PD registration, with number of places Conquest Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Physical disabled service users only to be admitted if they also have a learning disabilty Date of last inspection 13/10/2004 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. Three of these units are linked by corridors, 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. Conquest Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on 4th May 2005. It was found that most of the National Minimum Care Standards had been met and that the overall quality of care was of a high standard. Comment cards were received from a number of service users and their relatives. Service users met on the day of inspection appeared to be content with the services and support that they received. The following summary covers the main points. What the service does well: What has improved since the last inspection? What they could do better: Windsor unit needs to be refurbished as the doors and walls in the corridors are damaged and deteriorating. Advice from an Occupational Therapist may be helpful to offer creative solutions regarding improvements in Windsor unit. Review dates need to be added to some care plan documents held in service user files. It is also recommended that advice is sought from the Fire Safety Officer regarding the efficiency of a number of fire doors in the building. Conquest Lodge Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Conquest Lodge Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Conquest Lodge Version 1.10 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 standard(s) 1-5 Prospective service users have access to good information, and can make an informed choice regarding the home’s services. EVIDENCE: The home obtains detailed information via the care management process to ensure that they can meet the individual assessed needs. The manager stated that the assessment procedures have been developed further and a copy of the assessment form was seen during the inspection. All records held about service users are kept safely and staff are aware of the policies regarding protection and confidentiality The agency’s Statement of Purpose and the Service User Guide were seen and amendments to these documents have been recently made. A contract has also been developed in a pictorial format to aid service user’s understanding of services provided in the home. Detailed assessments are undertaken using information provided by social workers. The agency’s policy on confidentiality was seen; any breaches are treated as disciplinary offences. Issues regarding confidentiality are included in the induction and supervision processes. Conquest Lodge Version 1.10 Page 9 Conquest Lodge Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6-10 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 good quality information, presented in a professional manner, to give clear guidelines about the care and support that is required how it should be given. Reviews of care plans take place every month to include any updates or changes in care. Dates need to be added to some documentation held in individual files. The manager said that a “Person Centred Plan” is being evolved in the home to give a more holistic approach and involve the service user as much as possible to determine choice and independence. Staff members confirmed that they were involved in the care planning process as key workers to ensure that care is tailored to meet individual need. Considerable improvements have been made to the care planning documentation in the home and specific clinical information was seen in care files to ensure that staff have knowledge and up to date information. Conquest Lodge Version 1.10 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 standard(s) 11-17 Staff provide appropriate support to ensure that service users have access to leisure activities in the community that are appropriate to their needs and abilities. Service users have a choice of meals, which are prepared and served in a homely atmosphere. EVIDENCE: Service users have access to two local colleges and can be involved in a variety of activities including cookery, computing, art and woodwork. There is also access to a community arts project and participation at a local day centre. Two members of staff take have the delegated task to seek further opportunities in the community and activities in the home. There are regular trips made to the local restaurants, pubs and the cinema. The home places great emphasis on providing access to the community and during the inspection a number of service users had been involved in a shopping trip and one service user had been to a swimming and Jacuzzi Conquest Lodge Version 1.10 Page 12 facility. A variety of in-house activities are also arranged including cookery, art hairdressing and regular visits from a reflexologist. Many service users have their own music facilities in their bedrooms and are they able to spend time on their own if they so wish. A varied menu is provided in the home and service users receive a choice of meals to meet their wishes and preferences. The home has access to a dietician to gain specific advice on an ongoing basis. Conquest Lodge Version 1.10 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 standard(s) 18-21 Care is provided appropriately in the home. Service users physical, emotional and health needs were being met. There are clear guidelines regarding the safe administration of medication. A risk assessment procedure is in place to protect service users. EVIDENCE: Service users receive care from a wide range of healthcare specialists. Visits from GPs and Community Nurses are documented in individual care plans along with any outpatient appointments at local hospitals or surgeries. Individual risk assessments are recorded on individual files and are regularly reviewed to ensure that service users are protected from potential harm. There is a clear policy regarding the storage and administration of medication in the home. Medication records were accurate and up to date. The manager said that it is proposed to store medication in each of the individual units rather than using the portable medication trolley. She is taking appropriate advice from the pharmacist regarding the safe storage of medication. Conquest Lodge Version 1.10 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 standard(s) 22-23 The home has a satisfactory complaints process to make sure that service users and their representatives have their complaints or concerns listened to and acted upon properly. There are suitable arrangements for ensuring the protection of service users from neglect or harm. EVIDENCE: The home has a complaints procedure including agreed timescales to make sure that all complaints are fully investigated and actioned appropriately. The home has not received any complaints since the last inspection. The home has a satisfactory policy in place, which is in line with local authority policies, to make sure that service users are protected from abuse. Care staff confirmed that they receive appropriate training to ensure they are aware of adult protection principles and procedures. It was observed that care staff spoke to service users in a friendly and respectful manner appropriate to activities and individual needs. Conquest Lodge Version 1.10 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 standard(s) 24-30 The environment of the home provides service users with a safe, comfortable, clean and a well-maintained place to live. One of the units, however, is in need of refurbishments to meet service users needs. EVIDENCE: The home is, in general, suitable for the needs of the service users. There is an ongoing programme of decoration and the handyman deals with day-to-day repairs and refurbishments. Individual bedrooms are decorated and furnished to meet individual service user’s preferences. The home is kept in a clean and hygienic manner and is free from unpleasant odours. The gardens are particularly well presented and a variety of sensory areas are being planted and further developed. There are a number of seating areas so that service users can enjoy the gardens during the summer months. Conquest Lodge Version 1.10 Page 16 Windsor unit is showing signs of deterioration especially to doors, walls and paintwork in the corridor. The damage is usually caused by one of the service users with particularly challenging behaviour. It was discussed with the manager that an assessment by an occupational therapist may offer creative solutions regarding the environment and be more suitable to the service users needs. It was noted however that the home does not have access to an occupational therapist so this service may have to be purchased privately. The manager said that she would be discussing these issues with her line manager to implement a programme of refurbishments. Advice from the Fire Safety Officer needs to be sought regarding the fire doors in the connecting corridors between Kensington and Burleigh units as they do not have self closers installed as there is doubt about there effectiveness. Conquest Lodge Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 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: All staff are issued with contracts, detailed job descriptions and clear details of their areas of responsibility. Four staff files were seen and they contained appropriate information including two references and evidence of satisfactory CRB checks. All staff appointments are dealt with via the organisation’s Personnel Department, in Worcester, to ensure a consistent approach. Some staff files need to have a recent photograph included. The deputy manager has the delegated task of monitoring training in the home and a detailed matrix is in place to ensure that staff receive mandatory and client specific training with regular updates as required. The manager said that NVQ training is in place for care staff and managers to meet expected nationally agreed standards. Care staff confirmed that they had received recent training in the home including moving and handling, fire safety, first aid, NVQ2, LDAF and Communication (Makaton). Conquest Lodge Version 1.10 Page 18 Staff receive regular recorded supervision to ensure that their work performance and development is monitored and actioned appropriately. Care staff confirmed that they were supervised four-six weeks. Conquest Lodge Version 1.10 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-43 The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care, which will be monitored through quality assurance processes. EVIDENCE: Service user records indicated that a well managed and person centred service is delivered. The home’s manager is in daily contact with staff and service users to monitor care practice. The home maintains relevant records, although the files of some service users and staff need to be updated to include a recent photograph. The agency has the required policies and procedures in place. The views of service users, relatives and staff are sought and listened to. There is a clear and detailed complaints procedure in place. Conquest Lodge Version 1.10 Page 20 A quality assurance process is in place and this will be developed further to gauge service users, staff and healthcare professionals views. This will ensure that the service receives feedback regarding the quality of the service that is delivered and to identify areas for development and improvement. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Conquest Lodge Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Version 1.10 Score 2 3 3 3 3 3 3 Page 21 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 3 3 Conquest Lodge Version 1.10 Page 22 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. 2. Standard 6 24 Regulation 15(2)(b) 23(2)(b) Requirement Dates of reviews and documents need to be included in service user plans The premises need to be kept in a good state of repair and decoration particularly in Windsor Unit. Photographs need to be included on all individual service user and staff files Timescale for action July 31st 2005 August 31st 2005 July 31st 2005 3. 41 17 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. 2. Refer to Standard 42 20 Good Practice Recommendations Advice should be sought from the Fire Safety Officer regarding fire doors in the home. Advice should be sought from a Pharmacist regarding the proposed storage of medication in the individual units within the home. Conquest Lodge Version 1.10 Page 23 Commission for Social Care Inspection 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 Conquest Lodge Version 1.10 Page 24 - 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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