Inspection on 10/04/07 for Creek Road (79)

This inspection was carried out on 10th April 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creek Road (79) 18/10/06

Creek Road (79) 21/02/06

Creek Road (79) 28/06/05

Creek Road (79) 21/12/04

Creek Road (79) 12/08/04

Creek Road (79) 11/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Creek Road (79) March Cambridgeshire PE15 8RE Lead Inspector Dragan Cvejic Key Unannounced Inspection 10th April 2007 10:00 Creek Road (79) DS0000015296.V335833.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 Creek Road (79) DS0000015296.V335833.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. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creek Road (79) Address March Cambridgeshire PE15 8RE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01354 654575 Conquest Care Homes (Peterborough) Limited ***Post Vacant*** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: 79 Creek Road provides accommodation and support to four adults with mild to moderate learning disabilities. All those living in the home are female as are the support staff. The home is in an ordinary house in a residential area of March close to local amenities. Each bedroom is for single occupancy and each has a washbasin. Service users share the bathroom facilities, the lounge, and the kitchen and dining area. To the front of the building is a parking area; to the rear is an enclosed garden. The home is provided by Conquest Care Homes which is a trading subsidiary of Craegmoor Healthcare Ltd. The average fee was £319, calculated from the lowest £ 288.84 and the highest £344.79. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out in the evening hours when all the service users were at home and lasted for 2.5 hours. The main methodology was case tracking whereby 2 service users were case tracked. Other methods used were observation, a tour of the house, talking to the manager and to the visitor. What the service does well: What has improved since the last inspection? Three quotes were obtained for a carpet that needed replacing and the process was on-going. The manager expected approval during this month. New staff, when they start, would reduce the pressure on existing staff and ensure consistency of care when a staff member takes her maternity leave. The written rota showed the working pattern and demonstrated how the new staff would be engaged. A new cooker, to the delight of service users, replaced an old one. A user satisfaction survey was just carried out, as a part of the quality assurance review and the new questionnaires were given to service users. Creek Road (79) DS0000015296.V335833.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. Creek Road (79) DS0000015296.V335833.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 Creek Road (79) DS0000015296.V335833.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): 1,2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were properly assessed and could choose the home, resulting in service users feeling at home and getting on with each other and with staff. EVIDENCE: The manager had just reviewed the home’s statement of purpose, updating relevant parts. Two files were checked and both contained a detailed initial assessment carried out on admission. Service users were able to provide comments and express their views and these were recorded. There were no restrictions imposed on service users in the home. A service user describing her life in the home confirmed that her and others needs were met. Records also showed through continuous daily entries how the users were helped, supported and their needs met. A user commented on staff support explaining her respect for the manager: “She is my inspiration, she motivates me and makes me positive even when I get upset.” All service users had been in the home for a considerable time and there were no new recent admissions. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 9 Service users’ contracts were updated by adding the room number on them, although service users did not want rooms actually numbered in the home and this was respected. Creek Road (79) DS0000015296.V335833.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 excellent. This judgement has been made using available evidence including a visit to this service. Service users were respected as individuals and appreciated the fact that they could express their wishes and choices. The level of individuality exceeded the minimum standards. EVIDENCE: The existing care plans were checked through inspection of two case tracked users’ files. They were detailed and contained risk assessments. A part of the plans called “And this is my story…so far” were made by each individual. They presented a picture of themselves, their likes and dislikes, and decorated this document with their photographs and drawings. Two checked care plans were reviewed the previous month, showing regularity in monthly reviews. The manager started changing the files so that the new, Person Centred Planning process was presented in files too. The manager explained that would take her about two months to transfer relevant details into new file for each individual. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 11 Risk assessments were also reviewed regularly, as one stated: “Service user will have own soap and towel in her room as she wishes.” This measure would also improve infection control. A letter from a GP stating “…a user cannot self medicate safely”, showed that any restrictions would be recorded. Daily records were detailed, accurate and up to date. Service users were encouraged to make their own decisions about their lives. Service users managed their money and were now signing their benefit books. The money held in the home for them was regularly audited and two records checked contained accurate balances. Service users were allowed to explore new initiatives, such as learning to swim instead of just getting in and out of the pool. Service users confirmed that they could come and go when they wanted. On the day of the inspection, they all went out in the evening for an external activity. The home remained highly scored on a few standards from this outcome group. Creek Road (79) DS0000015296.V335833.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. Service users created their lifestyle as they preferred and were supported by staff to carry out their planned activities. They were in charge of their own home. EVIDENCE: Service users had completed almost all the courses at the local college that were appropriate for them, so they continued with their daily programmes at day centres and with voluntary work and activities. Since the last inspection, one service user started learning to swim. Staff also helped users develop financial skills and users had started signing their own benefit books. All service users were very connected with the local community and, especially with families and friends. Two very close male friends were visiting two ladies living in the home. One of them stated: “I feel very welcome here. I get on Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 13 with all the users. This is a very nice home. She comes to mine alternate weekends.” Service users planned their holiday, 3 of them to Majorca and one to the Isle of Wight. The site visit was carried out in the evening hours, as service users spend every weekday on their daily activities outside the home, and returned back in the late afternoon. They also chose to go out most evenings, to the local pub, to the disco etc. Service users were fully in charge of planning their routine. They were shopping in pairs, alternative weeks, and were cooking according to their rota. During the site visit, a user was observed cooking, while the very pleasant smell of food made everyone hungry. Creek Road (79) DS0000015296.V335833.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. This judgement has been made using available evidence including a visit to this service. Service users general health was good and they only needed support to deal with their healthcare and to maintain good health. The medication process was also appropriate, ensuring protection for service users. EVIDENCE: Service users were able to control their healthcare and staff only supported them to achieve what users wanted. Two checked files showed records of checking blood pressure, eye tests and checking of hearing and ears. All service users were in good general health. A service user stated: “We can get up and go to bed when we want. We lay in at weekends, as during the week we get up for our daily programme. It is lovely to stay in bed longer.” The files contained appropriate charts when they were needed. The files also contained records of external medical professionals’ visits. Medication process was appropriate and records were accurate for the two case tracked service users. A letter from a GP explained why service user was not self medicating, explaining that it was safer for the home to do that for her. Creek Road (79) DS0000015296.V335833.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 had the measures in place to protect service users from potential abuse and users felt safe and protected. EVIDENCE: A visitor commented on a user’s satisfaction expressed to him in private: “She is well looked after here. She has never complained and she said that she would complain if she wanted to.” Two service users confirmed, when speaking to the inspector, that they did not have any complaints, but would complain if they thought there was something that “was not good.” The statement of purpose contained the complaints procedure with the time scale for investigation. The manager stated that there were no complaints. In addition to service users capacity to stand up for themselves, the manager stated that they emphasised the protection of service users. A user commented that she felt safe and protected. Creek Road (79) DS0000015296.V335833.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): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were proud of their home and enjoyed a homely atmosphere created by them and staff in an environment that they liked. However, not all replacement were carried out in a timely manner. EVIDENCE: The home was clean and pleasant. Service users were proud that it was their home and that they were responsible for keeping it clean and tidy. They moved freely through the home. When the inspector asked a service user for a chat, she took him to the lounge, demonstrating the ownership of all areas within the home. The home was appropriate for service users needs. As users were capable, not much extra equipment was needed and this fact made the house even more homely. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 17 Although the staff’s computer was in a communal room, users stated that they did not mind and liked the solution, as they had staff around at any time available to support and chat to them. A service user was risk assessed as progressing and soap and a towel were now, placed in her room, as she wanted. This measure improved infection control measures that were in place. A service user who cooked on the day of the site visit was reminded to wash her hands prior to cooking. A visitor also commented on the cleanliness of the home. The carpet replacement that was addressed on a previous site visit had not yet been replaced, but the manager stated that this was on the agenda of the company’s Kapex meeting and was waiting for approval. Service users regretted that the carpet was not yet replaced. The new cooker was welcomed by service users and they found it easier to use it for cooking and to keep it clean. Creek Road (79) DS0000015296.V335833.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): 31,32,33,34,35,36, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefited from two workers working alternate shifts in the home and their knowledge of users and their needs. EVIDENCE: The manager reported that two new staff were about to start. One was offered a full time position, to cover a planned maternity leave and the other was a bank staff member who would cover for absences and holidays. The manager explained that she was waiting CRB disclosures for both recruited workers, as working here means working alone and she did not want any of them to start before she checked their CRB disclosures. The new, printed staff rota, now indicated where and how new staff would be engaged. The manager confirmed that the staffing level was appropriate and planned shifts would meet the users’ needs. Service users stated that staff were able to meet all their needs. A user stated that it was a shame that the manager could not be there 24 hours a day every day, as she felt so encouraged and positive about herself when the manager was nearby. Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 19 There were no staff in the home while service users were out for their daily programmes, but staff were present an hour before users returned home. Staff had a very good training programme, provided by the organisation. All mandatory training was up to date and the manager attended Person Centred Planning training, as well as some management training. She prepared an induction programme for two new staff members. This induction was in line with LDAF guidance. Current recruitment demonstrated that all safety checks were carried out prior to employing new staff. The staff file checked all documents in it. Supervision was planned to monitor staff progress on their induction. The manager received her supervision about every 3 months, but she stated that she could call her line manager at any time. Creek Road (79) DS0000015296.V335833.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. Safe working practices, staff’s knowledge of service users and regular quality assurance reviews now introduced, all contributed to safety and welfare of service users and their satisfaction with services and provisions. EVIDENCE: The manager was working in this position for a number of years. She had skills and experience and knew service users very well. However, she still had not submitted her application to register with the CSCI, although her CRB disclosure had arrived two months prior to this site visit. Quality assurance results were just collected. The users’ questionnaires demonstrated 97 satisfaction with the service and provisions. The new set of Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 21 questionnaires was already given to the users and to the staff, announcing the start of the new review. Safe working practices were in place and ensured protection of service users. All staff were trained in mandatory subjects and the manager had already planned this training for new staff as part of their induction. The manager planned to provide a combined induction for both newly recruited staff members. The home had been inspected by the fire officer. The manager showed a separate holder where accidents/incidents records were kept, but there were no new entries, as there were no recent accidents/incidents. Creek Road (79) DS0000015296.V335833.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 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 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 4 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Creek Road (79) DS0000015296.V335833.R01.S.doc Version 5.2 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 16(2)(c) Requirement The carpets referred to must be replaced with a suitable floor covering. Previous timescale 15/09/06, 30/04/06 and 30/12/06 was not met. This requirement was partly met, while the final outcome, replacing the carpet (approved) was given a new time-scale. This repeated requirement to replace the carpet is addressed once more before enforcement action is taken unless the carpet is replaced by new time scale Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 31 Refer to Standard YA37 Good Practice Recommendations The manager should submit her application for registration, as this process was delayed for more that 3 months. DS0000015296.V335833.R01.S.doc Version 5.2 Page 24 Creek Road (79) 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 Creek Road (79) DS0000015296.V335833.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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