Inspection on 28/06/05 for Creek Road (79)

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Creek Road (79) 10/04/07

Creek Road (79) 18/10/06

Creek Road (79) 21/02/06

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 Creek Road (79) March Cambridgeshire PE15 8RE Lead Inspector Matthew Bentley Unannounced 28 June 2005 16:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Creek Road (79) Address 79 Creek Road March Cambridgeshire PE15 8RE 01354 654575 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Conquest Care Homes (Peterborough) Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21 December 2004 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. Residents 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 v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of 79 Creek Road, for the period 2005/6. The unannounced inspection took 1.5 hours and took place between 16.30 and 17.00. On the day of inspection all four service users were at home and the inspector spoke to each person. The inspection also included reading documents, speaking to the assistant manager, and a brief tour of the communal parts of the home. Two residents also showed the inspector their rooms. What the service does well: What has improved since the last inspection? What they could do better: Several requirements from previous inspection have not been met: the home has been without a registered manager for more than a year. The requirement that a manager be appointed and an application for that person to be registered with the Commission has been made as a result of previous inspections. Furniture in the communal areas is worn and uncomfortable, and a number of carpets need replacing due areas of wear and staining. This was a requirement resulting from previous inspections. Failure to comply with the requirements may result in legal action being taken against the home. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 6 The home’s garden is secure and easily accessible, however, its maintenance relies on the good-will of the husband of one of the staff members, and no tools or garden furniture are currently provided. 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 v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 Information is available to help prospective service users make an informed choice about whether the home is suitable for them, however, the home’s statement of purpose needs to be updated. Staff know each service user as individuals and have helped each person to work towards achieving and identifying goals, and the home is supported by healthcare professionals. EVIDENCE: A statement of purpose has been developed for the home, however, the document is in need of updating to reflect changes within the organisation providing the service and the fact that the home does not have a registered manager. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. The residents have lived at the home for some considerable time and are well settled. A full assessment of each person’s needs took place before they moved in; this involved health and social care professionals, the individuals themselves, and some members of their families. There are no plans for people to move out of or into the home. The four people living at the home are relatively able, so the staff member’s role is mainly to support them in what they want to do and help them to Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 9 develop their abilities as far as possible. Through watching what was going on, and talking to the residents and the assistant manager it was clear that staff have the skills, knowledge, expertise and experience to deliver the services and care offered, and residents are assisted to get help and advice from specialist learning disability services if they are needed. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Residents are involved in making decisions about their lives to the best of their abilities with help and guidance from staff when necessary. EVIDENCE: Through discussions with the assistant manager and residents, and watching what was going on in the home it was clear that those living at the home have full involvement in how the home is run, and are asked their views about what happens in the home. Menus, household tasks, outings and other tasks that need to be done are worked out between the 4 residents, with staff providing guidance if needed. 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 v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 Each of the four people living in the home takes part in a range of activities to suit their individual needs and interests, and each person’s independent living skills have been maintained and developed. Staff provide appropriate support to facilitate contact with family and friends, and service users have access to leisure activities in the community, that are appropriate to their needs and abilities. Residents are encouraged to maintain a healthy diet, and meals are taken in a homely atmosphere. EVIDENCE: As noted in previous standards, each resident is involved in household tasks and is encouraged and helped to develop the skills they need to live as independently as possible. None of the four people living in the home has paid employment, however, each has been helped to find useful and interesting things to do during the day, 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. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 12 The home is close to the town centre, and residents are able to use all of the relevant facilities including shops, the library, and pubs and clubs, and each person is involved in the local church. At the beginning of the inspection one person was out at the Post Office with the assistant manager. Part of the staff members’ role is to help maintain links with families and friends at an appropriate level. Family members and friends are free to visit whenever they want, though it is a good idea to phone beforehand to make sure the person they are planning to visit is at home. Each of the four residents has her own key to her room and they are free to use the communal areas as they choose. Routines are very flexible, as anyone would expect to find in an ordinary home. Each of the four residents is involved in what goes on in the home and meals are planned at varying times depending on what is going on. During the inspection one resident was preparing the evening meal; she was given guidance by the assistant manager when it was needed, and some of the residents chose not to have the full meal, as it was a hot day. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Care is provided in a manner which suits those living in the home, and residents’ physical, emotional and health needs are being met. EVIDENCE: Service users manage their own personal care needs with assistance from staff when necessary; mostly in the form of verbal reminders. Discussions with residents, the assistant manager, and observation during the inspection showed that personal support is provided in a sensitive way in line with the wishes and preferences of each person. All of the residents are female, as are the staff. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home’s systems for dealing with complaints are satisfactory, as are the arrangements for ensuring the protection service users from neglect or harm, however, the complaints procedures needs minor amendments. EVIDENCE: The home has a policy and procedure to follow if a person feels the need to make a complaint about the service. The procedures are generally in order, however, the contact details for the local office of the CSCI need to be included; a requirement has been made about this. The home has satisfactory Adult Protection policies, which include ‘WhistleBlowing’. There have been no allegations of mistreatment at the home. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,30 The building is homely and clean, and is suitable for the needs of the residents, however, a number of items of furniture and fittings, and some carpets, let down the appearance and overall high standard of the home and compromises service users’ dignity and safety. EVIDENCE: The service is provided in an ordinary house in the Fenland market town of March. The home is located close to the town centre which has shops, places to eat and other community facilities. The premises are generally wellmaintained, 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 showing significant signs of wear and is in urgent need of replacement. Additionally the carpet in one service user’s bedroom had a noticeable stain, the carpet in the lounge was showing visible signs of wear and the floor covering in the bathroom was also worn and stained. This was a requirement resulting from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. The ceiling in the dining room is stained and has a hole from a water leak and therefore needs repairing and repainting. All bedrooms are for single Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 16 occupancy and have a washbasin and service users spoken to expressed their continued satisfaction with the accommodation provided. Each resident chooses, or are helped to choose, the style of decoration of their bedrooms and their own furniture. Two residents’ 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. The home has two toilets, one bath, and one shower, however, one of the toilets is broken and needs replacing urgently, and the suite itself is rather old fashioned and should be replaced. The bath panel is damaged and must be replaced. Requirements have been made about these matters. Bathroom and toilet doors were fitted with appropriate locks. Shared space includes a kitchen/dining room, a large lounge, and to the rear is a garden with lawn, mature shrubs and other plants. The assistant manager expressed her frustration that the home did not have a gardener and had no tools or a lawnmower and her husband had recently had to come in to cut trim some trees and cut the lawn. A requirement has been made to ensure that arrangements are made to make sure the garden is properly maintained. One of the residents was planning a birthday party at the weekend, however, the fact that there would be nowhere for guests to sit outside (as there was no garden furniture) was causing some considerable frustration; a recommendation has been made about this. The home was clean and free from offensive odours. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 The home has a staff team which means that service users’ needs are properly met, however, due to the size of the team, any personnel changes would be likely to have a very marked effect on the service. Staff were clear about their roles and were competent and appropriately experienced. EVIDENCE: Residents are supported by the assistant manager and one other staff member who work flexible split shifts in order to be on duty at the times when residents are at home and need support. Both members of staff are to be commended for their high level of commitment. 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. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 The home is being managed adequately, however, an application should be made to register a manager with the Commission. Continued failure to do so suggests that the provider may not be ‘fit’ to provide a service to vulnerable people. EVIDENCE: The home 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. 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 sends out questionnaires to service users and their relatives, however, the home was not given the results or findings and neither were they passed on to the participants. This was a requirement resulting from Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 19 previous inspections; failure to comply with this requirement may result in legal action being taken against the service. Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 20 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 2 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 1 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Creek Road Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 1 x 2 x x x x v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 21 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 1 Regulation 4 & Sch1 Requirement The homes statement of purpose must include all of the information required to meet this standard and regulation. Previous timescale 31 March 2005 not met The homes complaints procedures must include the current contact details of the Commission The carpets referred to must be replaced with suitable floorcovering. Previous timescale 30 April 2005 not met The ceiling in the dining room must be repaired and redecorated The lounge suite must be replaced with one suitable for service users needs The toilet and wash basin in the shower room must be replaced The damaged bath panel must be replaced Arrangements must be made to provide appropriate maintainance of the gardens including the provision of suitable equipment and furniture A manager must be appointed and an application for their Timescale for action 15 August 2005 2. 22 22(7)(a) 15 August 2005 15 September 2005 31 August 2005 31 August 2005 15 August 2005 15 August 2005 15 August 2005 3. 24 16(2)(c) 4. 5. 6. 7. 8. 24 24 27 27 28 23(2)(b) 16(2)(c) 23(2)(j) 23(2)(b) 23(2)(o) 9. 37 8 31 August 2005 Page 22 Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 10. 39 24 registration must be submitted to the Commission. Previous timescale 31 March 2005 not met The home must have effective systems of quality assurance based on seeking service users views. Previous timescale 30 April 2005 not met 31 August 2005 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 Good Practice Recommendations Creek Road v234597 i53 i03 15296 creek road v234597 280605 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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