Inspection on 07/08/07 for Conquest Lodge

This inspection was carried out on 7th August 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conquest Lodge 14/11/06

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

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 Conquest Lodge Dagless Way March Cambridgeshire PE15 8QY Lead Inspector Andy Green Unannounced Inspection 7th August 2007 10:00 Conquest Lodge DS0000015195.V349574.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.V349574.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.V349574.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.V349574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disabled residents only to be admitted if they also have a learning disability 14th November 2006 Date of last inspection Brief Description of the Service: Conquest Lodge is situated in a residential area of March, Cambridgeshire, and provides care and support for 19 adults with a learning / physical disability. The premises are divided into four living units with a range of garden space to the rear, including an enclosed garden for the use of residents in Windsor Unit. Car parking is available at the front of the building for visitors and staff. Conquest Lodge is owned by Conquest Care Homes (Peterborough) Limited, which is a wholly owned trading subsidiary of Craegmoor Group Limited. The weekly charges range from £875 - £1300. Copies of inspection reports are made available to residents and visitors on request. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green, Regulation Inspector, undertook this key unannounced inspection on 7th August 2007. A number of records were inspected including care plans, training records, health and safety records and staff files. A tour of the building and grounds was also undertaken. The inspector also met a number of residents to gather their views regarding the services offered in the home. Three members of staff were also interviewed to gather their views of the service, training and support they received. Comment cards were also received from residents and relatives. What the service does well: What has improved since the last inspection? What they could do better: Weight charts must be accurately kept in resident care plans to ensure that adequate monitoring is in place. Paintwork to a number of doors remain unfinished and decoration must be undertaken to finish them to a professional standard. The flooring in the Sandringham unit dining area is stained and worn and must be replaced. The weighing scales provided for residents with mobility difficulties are broken and must be repaired so that accurate monitoring of weights can be made. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 6 It is recommended that the room that is used to store medication be reorganised to make it less cluttered. It is recommended that protective plates are added to the bottom of doors to prevent continuing damage. 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.V349574.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.V349574.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments are undertaken to ensure that the home can meet the prospective resident’s needs. EVIDENCE: Detailed assessment information is received to ensure that the home can meet the individual’s assessed needs. Reports are received from a variety of healthcare professionals. The manager stated that the two residents who had moved in recently had settled in well and were enjoying living in the home. There have been no changes to the assessment process since the last inspection and two senior staff from the home continue to undertake assessments. Relatives are also encouraged to be involved in the referral process where appropriate. All resident records held about residents are kept securely and staff are aware of the policies regarding confidentiality. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 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. 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. Detailed care plans are kept to ensure that each resident receives appropriate care and support. EVIDENCE: The care plans of three residents were seen and they contained detailed guidelines to ensure that staff are clear about the care and support that is required. The care plans are presented in a new person centred format which the organisation is now using in all of their homes. There was evidence to show that residents participate as much as possible in the care planning process and their personal needs, preferences and dislikes are clearly recorded. There was evidence that regular reviews of care and support take place to include any updates or changes in care. Each resident 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 were fully involved in the care planning process. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 10 The home is currently in the process of transferring all information from existing care plans to the new format and the manager stated that they should all be finished by the end of September 2007. It was noted, however, that weight charts need to be updated in a number of care plans. A requirement will be made regarding this issue. It is also recommended that any unused charts or documents kept in care plans are removed to avoid confusion for care staff as to whether these forms need to be used. The risk assessment procedure ensures that residents are protected from harm both within the home and when accessing the community. Care planning meetings continue to be held to ensure that there is a consistent approach. The manager stated that a report writing training session has been organised for later in the month to provide staff with clear guidelines when completing care plans and daily notes. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 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 residents can access the community to engage in activities appropriate to their needs. EVIDENCE: Residents have a weekly programme recorded in their care plan. There is access to a wide range of activities both in the home and in the community including local colleges, cookery, computing, art and crafts and local day centre, meals in restaurants, bowling, gym, swimming, pub trips and cinema, discos and nightclubs. Regular trips to local towns are arranged, with staff assistance for personal and house shopping. Residents can personalise their bedrooms and have equipment eg television, DVD’s and music facilities so they can enjoy spending time in their own rooms as well as using the communal facilities provided by the home. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 12 Holidays and day trips are organised throughout the year and examples included the local Centre Parcs and Blackpool. Daytrips are also regularly organised to local towns and seaside resorts during the year. A varied menu is provided in the home and residents are fully involved in the choice of meals to meet their dietary needs and preferences. Likes and dislikes regarding food are recorded in individual care pans. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is provided appropriately in the home to ensure that their assessed needs are met. EVIDENCE: Residents continue to receive care from a wide range of healthcare professionals and staff provide assistance for residents to attend outpatient appointments as required. The manager stated that there had not been any significant changes in healthcare arrangements since the last inspection. Health and personal care is documented in individual care plans and visits from healthcare professionals are recorded as appropriate. Individual risk assessments are recorded and there was evidence that they are reviewed to ensure that residents are protected from potential harm. Three resident files were inspected and risk assessments were in place . Examples included bathing, eating, using transport and accessing the community. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 14 Medication records were accurate and up to date. It is recommended, however, that the room used to store medication be reorganised to make it less cluttered. Conquest Lodge DS0000015195.V349574.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 ensure that concerns are dealt with appropriately. EVIDENCE: The home ensures that all concerns are fully investigated and dealt with appropriately. A copy of the complaints procedure is clearly displayed near to the front entrance. There has been one complaint raised with the home by the local authority concerning the recording of an incident of challenging behaviour. Appropriate action has been taken to resolve the issue with input from a local Learning Disability Community Nurse. The home ensures that adult protection issues are dealt with in line with local authority policies, so that residents are protected from any potential abuse. Care staff receive appropriate training to ensure they are aware of adult protection procedures and a training session to update POVA has been organised for later in the month. Staff spoken to confirmed that they had received POVA training and were aware of forthcoming training. Throughout the day it was observed that care staff spoke with residents in a friendly and social manner appropriate to their individual need. Feedback from comment cards received by CSCI regarding the home was given to the manager. Comments received were complimentary regarding the care and support provided. Conquest Lodge DS0000015195.V349574.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): 24,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment of the home provides residents with a safe, comfortable, clean place to live. However, there are areas that need attention. EVIDENCE: The home is comfortable, homely and generally suitable for the needs of the residents. Since the last inspection there has been a variety of decoration and refurbishment carried out to bedrooms and corridors throughout the home. Four of the residents bedrooms were seen and they were personalised to meet the individual resident’s needs and preferences. The home was clean and free from odours. Windsor unit has particularly benefited from decoration to the corridors and attractive pictures have been added which has greatly improved the environment for residents. A new cooker has also been installed in Windsor’s kitchen. However, the bathroom in Windsor would benefit from an upgrade. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 17 The handyman continues to deal with day-to-day repairs and refurbishments in the home and the gardens are attractively maintained with a variety of planted areas and spaces to sit and enjoy the warmer summer days. It was noted however, that the paintwork to a number of doors are still poorly finished and must be redecorated. A requirement will be made regarding this issue. It is recommended that protective plates are also added to the bottom of doors to prevent damage from wheel chairs etc. The flooring in the dining area in the Burleigh unit must be replaced as it is stained and worn. A requirement will be made regarding this issue It was noted that the weighing scales provided for residents with mobility difficulties are not functioning. The manager stated that she had reported this to the maintenance dept three months ago but no action had been forthcoming. A requirement will be made regarding this issue. Conquest Lodge DS0000015195.V349574.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): 32,34,35,36 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 and training processes ensure that residents are protected from harm. EVIDENCE: Four staff files were seen and they contained appropriate recruitment information which included two references, application form and satisfactory POVA/CRB checks. The human resources department continues to deal with all recruitment to ensure a consistent approach. The home then receives copies of recruitment documents to meet the requirements of records that need to be kept in the home. Staff training in the home is well co-ordinated and a programme detailing all training provided ensuring that all mandatory and client specific training is delivered. Refreshers / updates are organised as part of an ongoing process throughout the year. There was clear evidence, contained in the training matrix, that updates had been organised and dates for forthcoming courses and dates were clearly displayed. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 19 The inspector met with 3 members of care staff and they all stated that they received regular ongoing training throughout the year in both mandatory health & safety issues and care related topics. NVQ training courses continue at both levels 2 & 3 to meet nationally agreed standards. Care staff confirmed that they felt well supported by the management team and that they received recorded supervision on a 6-weekly basis to monitor their performance and development needs. They also stated that they were encouraged to participate in the development of the service and that they were able to raise ideas and issues in staff meetings. Conquest Lodge DS0000015195.V349574.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): 37,39,42 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 care and support is well delivered and monitored through quality assurance processes. EVIDENCE: The manager continues to provide an inclusive and supportive management style in the home. She undertakes regular training to update her own knowledge and skills. She stated that she is a member of the ‘Fenland Locality’ meeting where local providers of other care services and local authority commisioners meet to discuss local developments and creative opportunities for residents. Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 21 Weekly alarm and monthly emergency light testing records were inspected and they are recorded accurately. Quality assurance process are in place to monitor the service and surveys are sent to residents, staff and healthcare professionals to provide feedback regarding the quality of the service that is provided. Conquest Lodge DS0000015195.V349574.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 X 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 X 28 2 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 X Conquest Lodge DS0000015195.V349574.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(1) Requirement Weight charts must be accurately kept in resident care plans to ensure that adequate monitoring is in place. Paintwork to a number of doors remain unfinished and decoration must be undertaken to finish them to a professional standard. The flooring in the Sandringham unit dining area must be replaced as it is stained and worn to. The weighing scales provided for residents with mobility difficulties must be repaired so that accurate monitoring of weights can be made. Timescale for action 07/08/07 2 YA28 23(2)(b) 30/11/07 3 YA28 16(2)(c) 07/08/07 4 YA29 23(2)(n) 07/08/07 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 YA20 Good Practice Recommendations It is recommended that the room used to store medication DS0000015195.V349574.R01.S.doc Version 5.2 Page 24 Conquest Lodge be reorganised to make it less cluttered. 2 YA28 It is recommended that protective plates are added to the bottom of doors to prevent continuing damage. 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