CARE HOME ADULTS 18-65
Belmont Road March Cambridgeshire PE15 8RQ Lead Inspector
Alan Buttery Unannounced 29th July 2005 @ 13:00 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. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Belmont Road 9 and 10 Address Belmont Road, March, Cambridgeshire, PE15 8RQ. 01354 660623 01354 653851 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 Ms Linda Day Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 7th March 2005 Brief Description of the Service: 9/10 Belmont Road provides accommodation for 13 adults with a learning disability, many of whom have an associated physical disability. The home is purpose built and operated by Craegmoor Healthcare. The accommodation consists of two bungalows linked together at the end of a small cul-de sac in the small town of March. The bedrooms are all single, and each has its own washbasin. Each bungalow has its own lounge and dining room and separate kitchens and bathrooms, and the two bungalows share a sensory room There is a shared garden, which can be accessed directly from a number of the bedrooms, and which is used extensively in the better weather. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 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 the current year, and an unannounced visit. The inspection started at about 1pm, lasting three hours. Belmont Road is one of several homes in the area operated by Craegmore healthcare. During the inspection, staff and service users were able to make their views known, and service users and relative’s comments cards were left with the manager to arrange for their completion and return. What the service does well: What has improved since the last inspection?
There have been few changes since the last inspection, and a stable staff team is in place. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 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. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 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 Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 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) 2 EVIDENCE: Belmont Road has a stable group of service users, and there have been no changes in the group since the last inspection. Evidence was seen on the files examined during the inspection of the pre admission assessment that is used, and as a result of the information gathered, the home are able to decide that they are able to meet the identified needs. The assessment information is reviewed on a regular basis. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 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 standard(s) 6, 7 and 9 EVIDENCE: As mentioned above, care plans are written following the initial assessment information gathered. Care plans were seen on the files of two service users examined during the inspection, and evidence was also available to show that the care plans are regularly evaluated and reviewed, more frequently than is required by the standards. Service users living in the home are supported as far as possible in making informed choices about their lives. Extensive risk assessments were also seen, providing a detailed assessment of the risks to service users, and the actions required manage the risks. It may be beneficial to the home to look further at the risk assessments, as some could be combined, making the documentation slightly easier for staff to use, and ensuring service users are able to maintain an active lifestyle, and are supported in taking well managed risks.
Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 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 standard(s) 12, 13, and 16 EVIDENCE: Service users living in the home are encouraged to take part in a variety of appropriate activities, using local resources and including in some cases specific day services. They are also supported in all taking a variety of holidays or weekends away, and over this year, all of the service users will have been away at least once, to a variety of places. They are also supported in using local facilities, pubs, restaurants and leisure services and local shops, and are well known to the local community. Service users rights to a service which offers them respect and understanding are taken into account at all times, and staff interactions were observed during the inspection, and seen to be very appropriate. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 11 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) 19 EVIDENCE: A number of the service users living in the home have complex health needs, both physical and emotional, and these are met with the support of local GP’s and district nurses, and of the local learning disability team, as well as support from care managers from teams outside the area who have placed service users in the home. Staff are also assisted in their roles by the training provided in health related matters specific to service users in the home, and provided through a number of sources. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 12 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 and 23 The home has suitable policies and procedures in place to manage any complaints received effectively and efficiently, ensuring service users and relatives are kept informed of developments. EVIDENCE: There have been no complaints received by the home since the last inspection, and no complaints or comments have been made to the CSCI. Service users and relatives comments cards were left with the home, and any issues raised form these will be reflected in the next report. The home also has an adult protection policy, and has ensured that all staff have or will receive the necessary training. There have been no adult protection issues since the last inspection. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 13 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, 27 and 30 Belmont Road is an established homely service, must identified works must be carried out to ensure service user’s needs can be met. EVIDENCE: Concerns were raised at the last inspection regarding bathrooms in both sides of the home, which are no longer suited to the needs of the service users living in the home. In spite of agreement that remedial work was required, it is disappointing to note that this has still not happened, and it is questionable whether the remaining 2 bathrooms are sufficient to meet the needs of the service users living there. The manager informed the inspector that the work is in hand, but an urgent plan including timescales must be submitted to the CSCI, showing when the work will take place. Further issues were noted regarding floor coverings in some bedrooms, which in one room in particular need urgently replacing.
Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 14 In the last few months, a long running issue regarding the lounge furniture in one side of the home has been resolved, however, the lounge furniture in the other part of the home is now in need of attention, as is the dining room furniture on both sides, which is now ten years old. The garden is well maintained, and offers a pleasant alternative dining area, but a recent visit highlighted an issue with access to a rear gate in property, which is signed as a route of exit in the event of a fire, but would not be easily accessible to any of the service users who use a wheelchair. It is recommended that the path to this gate be paved as soon as possible. Apart from these issues, the home was well decorated, and clean, showing obvious signs of the involvement of service users in decoration, and free from any offensive odours. Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 15 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) 35 The home has extensive training arranged which will ensure service users and appropriately supported. EVIDENCE: The home offers a variety of training to staff, and this is very well collated by the homes deputy manager. At the present time, all mandatory training for the year has taken place or is arranged, and additional training courses arranged covering Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 16 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) 39 and 42 The home ensures service users views are taken into account, \and health and safety issues are identified and dealt with at all times. EVIDENCE: The homes review and quality assurance processes were discussed with the manager, and copies of their questionnaires seen. These should now be collated, and a brief report into the results sent to the CSCI. It was clear from discussions that service users are involved in the review process in the home, but a number of service users do not receive regular care management support from their placing authority, particularly those form the local area. Policies and procedures are in place to manage the health and safety of service users in the home, and regular checks of equipment made. These records will be examined in more detail at the next inspection.
Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 17 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 x 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x 1 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Belmont Road Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 18 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 27 Regulation 23(2)(j) Requirement Carried Forward Urgent attention must be given to the bathrooms in both sides of the home, these no longer meet the needs of the service users, and must be updated. Details of the arrangements are to be submitted to the CSCI Timescale for action 30/09/05 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 27 Good Practice Recommendations Consideration should be given to updating lounge and dining room furniture Belmont Road I53 I03 S15298 BELMONT ROAD V230325 290705 STAGE 4.doc Version 1.30 Page 19 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
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