Inspection on 21/02/06 for Creek Road (79)

This inspection was carried out on 21st 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creek Road (79) 10/04/07

Creek Road (79) 18/10/06

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 Andy Green Unannounced Inspection 21st February 2006 15:00 Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 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.V261111.R01.S.doc Version 5.1 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.V261111.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 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 two 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. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this unannounced inspection on 21st February 2006. The inspector met with the assistant manager and service users to gather views regarding the services provided in the home. A number of records were inspected including care plans, training records and fire 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: Requirements from the previous inspection have not been met including the appointment and application to register a manager, the replacing of the lounge carpet, the replacement of furniture in the lounge, decoration to the dining room ceiling and arrangements for the maintenance of the home and gardens. Requirements regarding staffing arrangements have also been made. Consequently these requirements have been made again in this report. They must be actioned with some urgency by the registered provider as failure to comply may result in legal action being taken against the home. It is most disappointing that the registered provider continually fails to meet these requirements as they give a very poor impression of what is otherwise an excellent home offering service users a good quality of life. The staff continue to remain committed to the service but their good will should not be taken for granted. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 6 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. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 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.V261111.R01.S.doc Version 5.1 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 Service users have access to good information, and can make an informed choice regarding the home’s services. EVIDENCE: The statement of purpose has been updated to reflect changes within the organisation providing the service and that the home does not have a registered assistant manager. There have been no admissions to the home since the last inspection and the current service users have lived at the home for a number of years and are very settled. Consequently there have been no referrals made to the home and there are no plans for people to move out of or into the home. The four people living at the home are very able, so the staff member’s role is mainly to offer assistance and support in daily living and to develop their abilities as far as possible. Through observations made during the inspection it was clear that the assistant manager has the skills, knowledge, expertise and experience to deliver the services and care provided. Service users continue to receive help and advice from specialist learning disability services when required. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 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): 6,7,8,10 The care and support provided at the home is of a high standard. Detailed and proactive care plans are in place to ensure that staff have sufficient information to satisfactorily meet the service users assessed needs. EVIDENCE: Two care plans were inspected and they contained up to date information regarding the support needs of the individual service users. The inspector was particularly impressed with the way in which the “life Stories” had been presented with the creative use of photographs illustrating particular moments in the service users life, so far. Through discussions with the assistant manager and service users it was clear that those living at the home are fully involved in the running of the home and that their views are always sought. Menus, household chores, outings and other tasks that need to be done are discussed regularly with the four service users and staff provide assistance where required. Discussions with the assistant manager showed that she has a good understanding of a person’s right to make decisions and to take acceptable risks. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 10 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): 12,13,14,15,16,17 Staff provide appropriate support to ensure that service users have access to activities in the community. EVIDENCE: Each of the service users are involved in household tasks and they are encouraged to develop independent living skills as much as possible. None of the service users has paid employment, however, each individual is involved in a daily programme of activities including a range of further education courses, voluntary work at a home for older people, working in a shop, and accessing community facilities through specialist day services. The home is close to the town centre, and service users continue to use local amenities facilities including shops, swimming pool, the library, and pubs and clubs and involvement with the local church. Service users maintain contact with their families and friends and they are free to visit at all times in accordance with service users wishes. Each of the four service users are free to use the communal areas as they choose and have private time in their own bedroom. Routines are very flexible Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 11 to reflect the homely quality of the service. This includes meals, which are planned at varying times depending on individual need. During the inspection one service user was preparing the evening meal and given assistance by the assistant manager when required. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 12 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): 18,19 Service users receive appropriate health and personal care to meet their assessed needs together with support in taking prescribed medication. EVIDENCE: Service users manage their own personal care needs with assistance from staff when necessary mostly in the form of prompting. None of the service users are currently taking any prescribed medication. Discussions with service users, the assistant manager, and observations made during the inspection showed that assistance and support is provided in a friendly and sensitive way in accordance with the preferences of each person. All of the service users and staff are female. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 13 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 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. CSCI has not received any complaints regarding the service. The home has a satisfactory policy in place to ensure that service users are protected from abuse. The assistant manager confirmed that she and the other member of staff receive ongoing training to ensure that they are aware of adult protection principles and procedures. It was observed that the assistant manager spoke to service users in a friendly and respectful manner appropriate to the individual’s needs. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 14 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): 24,25,26,27,28,30 The environment is homely and clean and suitable for the needs of those living in the home. Some improvements to the premises need to be made. EVIDENCE: The premises are generally well maintained, clean, and free from odours. Furnishings, fittings, adaptations and equipment are generally good quality and domestic in style. However, the suite in the lounge is still in need of replacement, as it is showing significant signs of wear and is in need of replacement. Additionally the carpet in the lounge was showing some signs of wear. These concerns were a requirement resulting from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. The leak from the roof above the dining area has now been repaired, however the ceiling in the dining room is still stained from the water leak and therefore needs redecorating. There are four single bedrooms and service users spoken to expressed their continued satisfaction with the accommodation provided. Each service user chooses the style of decoration of their bedrooms and their own furniture. Two service users’ rooms were seen, and each room was comfortably furnished and decorated, and the occupants confirmed that they could choose their own pictures, ornaments, and furnishings. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 15 Refurbishments have been carried out to the bathroom as required from the last inspection of the home. Shared space includes a kitchen/dining room, lounge, and to the rear is a garden with lawn, mature shrubs and other plants. Garden furniture has been purchased since the last inspection. The assistant manager expressed her continued frustration that the home did not have a gardener and had no tools or a lawnmower. Her husband had recently come in to remove weeds and to cut the lawn. The inspector also expressed his concern that the there is no clear access or guidance regarding maintenance of the home. The registered provider must put in place appropriate ongoing arrangements to ensure that the home and gardens are properly maintained. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 16 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): 31,32,33,34, The home’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 care to the service users they support. EVIDENCE: The assistant manager and one other staff member who work flexible split shifts in order to be on duty at the times when service users are at home and need support. Staff receive appropriate mandatory training via Craegmoor in house training programme. The assistant manager was on duty at the time of the inspection and demonstrated that she is competent and knowledgeable about the needs of the individuals she is supporting; she also has many years experience of working with people with a learning disability. She did inform the inspector that her other staff member would be leaving the service at the end of February 2006. Consequently this will leave only the assistant manager to run the service including sleep-ins. Recruitment has commenced to fill this post but the inspector expressed his concern that the arrangements to provide interim staffing during this time are vague. It is anticipated that staff from other local Craegmoor homes will cover some shifts but this is yet to be confirmed. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 17 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): 37,38,42,43 The home is well managed and the assistant manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: The home still does not have a registered manager. The assistant manager has day-to-day responsibility for the home and has worked at there for many years and has considerable experience in working with people with a learning disability. Following a requirement made at the last inspection the provider stated that an application had been made to register a manager but to date no application has been received. A manager must be appointed, and an application for their registration must be submitted to the Commission. This was a requirement resulting from previous inspections; failure to comply with this requirement may result in further action being taken against the service. The provider has sent out questionnaires to service users and their relatives, however, and a number have now been returned. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 18 Service users spoken to were clearly content with the support they received in the home and are fully involved in the running of the service. Service users have busy lives and frequently visit friends and make trips to the local town. Fire records were inspected and they are accurately recorded. Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 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 2 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 2 X X X 3 X Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 20 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 suitable floor covering. Previous timescale 15/09/06 not met The ceiling in the dining room must be redecorated The lounge suite must be replaced with one suitable for service users needs replacing. Previous timescale 31/08/05 not met Arrangements must be made to provide appropriate ongoing maintenance of the premises and gardens. Previous timescale 15/08/06 not met A manager must be appointed and an application for their registration must be submitted to the Commission. Previous timescale 31/08/06 not met The registered provider must ensure that there is sufficient staff in the home to meet the stated purpose and needs of the service users. Timescale for action 30/04/06 2. 3. YA24 YA24 23(2)(b) 16(2)(c) 30/04/06 30/04/06 4. YA28 23(2)(o) 30/04/06 5. YA37 8 30/04/06 6. YA33 18(1) (a) 21/02/06 Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 21 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 Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 22 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 Creek Road (79) DS0000015296.V261111.R01.S.doc Version 5.1 Page 23 - 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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