Inspection on 09/02/06 for Conquest Lodge

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 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 14/11/06

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 11:40 9 February 2006 th Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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.V272200.R01.S.doc Version 5.0 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.V272200.R01.S.doc Version 5.0 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.V272200.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disabled service users only to be admitted if they also have a learning disability 4th May 2005 Date of last inspection Brief Description of the Service: Conquest Lodge is a purpose built care home 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 some present challenging behaviour. It is single storey and 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 DS0000015195.V272200.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 9th February 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? What they could do better: Although some improvements have been made in the Windsor unit the doors and walls in the corridors remain damaged. Solutions regarding improvements in Windsor unit need to be identified to improve the environment for all service users. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 6 The frequency of recorded supervision sessions for staff members needs to be improved to ensure performance and development is formally monitored. Although some improvements have been made in the Windsor unit, the doors and walls in the corridors continue to be damaged. Fire doors must not be wedged or propped open and advice needs to be sought from the Fire Safety Officer regarding appropriate door closers. The recording of fire alarms/emergency lighting testing needs to be improved. Photographs identifying staff need to be added to a number of personnel files. 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. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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.V272200.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 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 were seen and there have been no changes made to these documents since the last inspection. The manager stated that these documents would be reviewed during the year to ensure that they accurately reflect the services that are provided. The home obtains detailed information via the care management process to ensure that they can meet the individual’s assessed needs. Usually two senior staff carry out assessments incorporating a visit to the prospective service user. Relatives are also encouraged to be involved in the referral process where appropriate. A number of visits to the home are arranged so that prospective service users can “test drive” the home before moving in. There have been no changes to the assessment procedure since the last inspection All records held about service users are kept securely and staff are aware of the policies regarding confidentiality. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 6,7,8,9 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. They are presented in a professional manner and give clear guidelines regarding the care and support needs that each service user requires and how it should be given. Regular reviews of care plans take place and include any updates or changes in care. Dates and the names of the staff carrying out reviews have now been added to all documents. A “Person Centred Plan” is being used in the home, which gives a more holistic approach and involves the service user as much as possible to ensure they can maximise their choice and independence. Staff members confirmed that they were involved in the care planning process. There are regular care planning meetings, co-ordinated by the senior staff to monitor whether needs are being met. Each service user has a key worker and Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 10 link worker to ensure that care is consistently delivered to meet individual need. The improvements made to the care planning documentation have been maintained and specific information was seen in care files including a “pen picture”, healthcare, and activity programmes to ensure that the staff have guidance and up to date information. It was noted that although the date of admission is recorded in a card file this detail needs to be added to the information sheet at the front of each service user file. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 11,12,13,14,16,17 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: Service users continue to have access to a wide variety of activities both in house and in the community. Examples include programmes at local colleges involving cookery, computing, art and woodwork. There is also continued access to a community arts project and participation at a local day centre. Service users make regular trips to the local community, with staff assistance. This includes personal and house shopping, restaurants, bowling, pub trips and cinema. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 12 The home ensures that access to the community is maintained and during the inspection it was noted that two service users had been involved in a shopping trip. A variety of in-house activities are also maintained including cookery, art sessions, hairdressing and visits from a reflexologist. Many service users have their own television and music facilities in their bedrooms and are they able to spend time on their own if they wish. One service user was actively enjoying her karaoke music system in one of the units. A varied menu is provided in the home and service users receive a choice of meals to meet their dietary needs and preferences. Service users are involved in the shopping and preparation of food where possible. The home has access to a dietician who gives advice regarding individual service users requirements and general advice on an ongoing basis. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 18,20 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. Healthcare is documented in individual care plans along with outpatient appointments at local hospitals or surgeries. 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. The manager stated that there is still a plan to store medication in each of the individual units rather than using the portable medication trolley. She was advised to contact the CSCI Pharmacist regarding the safe storage of medication prior to installing storage cupboards in each unit. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 22,23 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 procedure is clearly displayed near the front entrance. The home has not received any complaints since the last inspection. The inspector did advise the manager of some concerns that a relative had raised. The manager stated that she would address these concerns where possible with the relative. The home ensures that adult protection issues are dealt with in line with local authority policies, to make sure that service users are protected from abuse. Care staff receive appropriate training to ensure they are aware of adult protection procedures. It was observed that care staff spoke to service users in a friendly manner appropriate to individual need. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 24,25,26, 29,30 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 suitable for the needs of the service users. There is an ongoing programme of decoration and the handyman continues to deal with day-to-day repairs and refurbishments. A number of service users bedrooms were seen and they are creatively furnished and decorated to meet individual service user’s preferences. The home was observed to be in a clean and hygienic manner and was free from odours. Decoration has been carried out to communal lounges and new furniture has been installed. A variety of attractive pictures have also been added to communal areas and corridors. The home is also converting two of the dining rooms to provide small lounges with the dining areas being incorporated in the larger lounge spaces. This will provide space for service users to enjoy quieter communal facilities and for viewing television or listening to music. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 16 The payphone has been moved to an area in the corridor to provide more private space for service users to make or receive calls instead of the lounge, which was more public and gave less privacy. The gardens continue to be well maintained with a variety of sensory areas and plants. There are also a number of seating areas so that service users can enjoy the gardens during the warmer months of the year. Although some improvements have been made in the Windsor unit the doors and walls in the corridors remain damaged, mainly by one of the service users with particularly challenging behaviour. It was discussed with the manager that creative solutions need to be implemented regarding the environment to meet all of the service users needs in this unit. It was noted that the home has access to an occupational therapist and an art therapist who may be able to give some ideas regarding improving this area for more challenging service users. The kitchen venting in the Windsor unit needs to be given attention as staff reported that the room can become uncomfortable to work in during cooking times. These concerns regarding the Windsor unit were raised during the last inspection and the manager stated that she would discuss these issues with her regional manager to give priority to a programme of refurbishments. It was also noted that a number of fire doors were wedged/propped open and the manager was advised that this practice must cease immediately. Advice from the Fire Safety Officer needs to be sought regarding appropriate door closers if fire doors are required to be kept safely open by service users. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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): 32,33,34,35,36 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: Four staff files were seen and they contained appropriate information including two references and evidence of satisfactory CRB checks. All staff appointments continue to be dealt with via the organisation’s Personnel Department to ensure a consistent approach. Some staff files need to have a photograph included. Staff training in the home is well co-ordinated and a detailed programme is in place to ensure that members of staff receive mandatory and client specific training. Refreshers and regular updates are organised throughout the year. NVQ training is in place for care staff and managers to meet expected nationally agreed standards. Members of care staff spoken to confirmed that they had received recent training in the home including a programme of induction, moving & handling, fire safety, first aid, food hygiene and NVQ training. Staff supervision needs to be improved as records showed that sessions had been infrequent. The manager stated that this area would be improved to ensure that individual members of staff receive at least six sessions per year to ensure that performance and development needs are monitored and actioned Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 18 appropriately. Care staff confirmed that they felt well supported by the management team in the home but that formal recorded supervision had been infrequent. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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 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): 37,38,41,42 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 recently completed an NVQ level 4 in Care & Management. She continues to provide an inclusive and supportive management style. This was confirmed by staff spoken to during the inspection. Service user records indicated that the home continues to be well managed and person centred in its delivery. The home’s manager is in active contact with staff and service users to monitor care practice. The manager continues to undertake regular training to update her knowledge and skills. The home maintains relevant records, although the files of some staff still need to be updated to include a recent photograph. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 20 Fire records are kept, however weekly alarm and monthly emergency light testing needs to be improved, as there were some gaps in recording during December 2005 and January 2006. The manager stated that this would be actioned immediately. The agency has the required policies and procedures in place, which are reviewed, at intervals throughout the year. The views of service users, relatives and staff are encouraged and there is a clear and detailed complaints procedure in place. An organisational quality assurance process is in place 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. Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conquest Lodge Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 2 X DS0000015195.V272200.R01.S.doc Version 5.0 Page 22 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 2 3 4 Standard YA24 YA36 YA41 YA42 Regulation 23(2) (b) 18 (2) 17 23(4) (c) (v) 13 (4) (c) Requirement Refurbishments need to be made to corridors and doorways in Windsor Unit. Care staff must receive regular recorded supervision. Photographs need to be included on all staff files Regular testing of fire alarms and emergency lighting must be carried out to ensure service users safety. Fire doors must not be wedged or propped open. Timescale for action 30/04/06 30/04/06 30/04/06 09/02/06 5 YA42 09/02/06 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.V272200.R01.S.doc Version 5.0 Page 23 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 Conquest Lodge DS0000015195.V272200.R01.S.doc Version 5.0 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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