Inspection on 21/06/05 for Fen Road

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Fen Road 08/05/07

Fen Road 25/09/06

Fen Road 31/10/05

Fen Road 07/09/04

Fen Road 19/06/04

Fen Road 17/02/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Fen Road 71 & 73 Fen Road Cambridge Cambridgeshire CB4 1UN Lead Inspector Elaine Boismier Unannounced 21 June 2005 @ 09:45 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. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fen Road Address 71 & 73 Fen Road Cambridge Cambridgeshire CB4 1UN 01223 425634 01223 515960 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) Granta Housing Society Limited Mary Moore Care home with nursing 10 Category(ies) of Learning disability (10, Physical disability (10) registration, with number of places Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 07/09/04 Brief Description of the Service: 71 & 73 Fen Road provides accommodation, support and care for up to 10 people below 65 years of age with profound learning and physical disabilities. The home is arranged in to 2 separate bungalows: number 71 provides accommodation for up to 6 places and number 73 provides accommodation for up to 4 places. Each bungalow provides individual communal seating and kitchen areas; laundry facilities are provided in both bungalows. The home, owned by Granta Housing Society Limited, is situated in a quiet residential area, approximately 3 miles from Cambridge City centre. The bungalows are surrounded by large gardens with a vehicle parking space to the front of the complex.Two minibuses are available to transport service users to day care services, visits and outings. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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 that was unannounced, of Fen Road for 2005/6. The inspection was carried out by two inspectors between 9:45 and 13:00 and took 3.25 hours to complete. At the time of the inspection there were 7 residents at home and 4 were spoken to although none were able to tell the inspectors of their views of the home, due to their communication difficulties. The remaining residents were attending day services. The manager, present for part of the inspection, and staff were spoken to. Documentation was seen and a tour of the premises was carried out. Information provided to the Commission each month has been referred to in this report. What the service does well: The home does well in a number of areas: • The home excels the minimum standard for care plan documentation. These are extremely detailed with comprehensive assessments and clear guidance for staff on how to meet the complex health and social needs of the residents. Residents’ bedrooms are decorated and furnished in an individualised manner; none of the bedrooms are the same. Relatives have made favourable comments in questionnaires sent by the home. These include, “staff are always helpful and work well with me,” and, “ It is a very good service.” The home excels the minimum standard for food provided at the home due to the varied menus. Choices of food available originate from different cultures that are available in England today. Residents are enabled to visit local events and take holidays. There are very good quality assurance systems in place to ensure the home is run for the best interests of the residents. • • • • • Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 6 What has improved since the last inspection? The home has improved in 3 noticeable areas since the last inspection: • • No requirements were made following the last inspection and only one recommendation was made. This has been considered. Carpets in a bedroom in number 71 bungalow and the corridor carpet in number 73 bungalow have been replaced to provide a more homely environment for residents. Overhead tracking has been introduced to some bedrooms for residents to be safely transferred with the help of staff. • What they could do better: The home could improve in 3 noticeable areas: • Records for the administration of medication must be completed to protect residents from the risk of being given insufficient, or too much, medication. A requirement has been made about this. The carpet area in the front lounge and the main entrance area of number 71 bungalow must be kept clean, and free of stains. A requirement has been made about this. Staff recruitment and vetting procedures must explore, and record, any gaps in employment history of staff, to prevent any risk of abuse or harm to residents. A requirement has been made about this. • • 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. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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 Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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 Prospective residents are assessed to ensure the home can met their needs. EVIDENCE: Two care plans were seen and these contained detailed assessments of the residents, before they moved into the home. These assessments included contributions by the placing authority. Staff confirmed that the home admits residents only if the home can meet their needs. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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 & 9 Care plans and risk assessments are detailed to reflect the individual needs of the resident. EVIDENCE: Two residents’ care notes were seen and these contained a high standard of the residents’ assessments and there was clear guidance for staff in how to meet the complex needs of the residents. Risk assessments were in place and these demonstrated how staff were to support residents, without restricting individual abilities. Care plans were reviewed every 6 months, or sooner and annual reviews, including family members, key workers and outside professionals, were recorded. Due to the complex communication difficulties of residents the Manager said advocacy services are available and have been accessed for residents’ “felt” views to be known. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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, 15, 16 &17 Residents’ social care needs are valued and respected. EVIDENCE: Due to the complex disabilities of the residents’ no resident is able to engage in educational or employment activities. However, residents’ files that were seen suggested residents are actively enabled to visit local community events take holidays, attend day services (as confirmed by the Manager) or engage in entertainments provided in the home, including television and DVDs. During the tour of the premises, including areas of the garden, the home has provided items to provide auditory and visual stimulation for residents to experience at leisure. Information provided to the Commission prior to the inspection noted that some residents had attended “wheelchair ice skating”. Returned questionnaires sent to families by the home, indicated that links with residents’ families are maintained and the Manager confirmed this also. Staff were noted to interact with residents in an inclusive way and called them by their first (and presumed) preferred names. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 11 A copy of the current week’s menu was seen and this contained a commendable variety and range of foods including a stir-fry, a traditional roast dinner, lasagne and Spanish omelette. On the day of the inspection staff were preparing residents’ lunch of mushrooms, onions and garlic on toast. The local hospital nutrition team and community dietician supports residents’ requiring artificial methods of feeding. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 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 standard(s) 18, 19 & 20 Residents receive individualised care in a supportive way although standards of recording medication could pose a risk of harm to residents. EVIDENCE: Residents were seen to be wearing clothes that were appropriate and fashionable for their age range. Residents’ care notes that were seen included detailed assessments of the physical and emotional/behavioural needs of the residents. Storage and record of medication in number 71 bungalow was assessed. Temperatures of storage rooms for medication were recorded on a daily basis and records of these were satisfactory. Qualified staff are responsible only for the administration and recording of medication. Detailed staff guidance of residents’ special needs about medication was available, including clear photographs of the residents. Records for the administration of medication were incomplete on a number of occasions. The nurse-in-charge considered that medication had been given although not recorded as such. Due to the dispensing arrangements of medication (bottles and packets) this would be difficult to establish if medication had been administered to the resident or omitted. A requirement has been made about the record keeping. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 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 standard(s) 22 & 23 Views of representatives are listened to and there are robust procedures for the protection of abuse against residents. EVIDENCE: Returned questionnaires, from relatives/representatives of the residents, included comments about their satisfaction with the action the home had taken in response to any concern they had had. The home has had no recorded complaints since the last inspection. Staff training files seen indicated staff have attended training about awareness of abuse. Two residents’ monies kept by the home for safe-keeping, were counted and these amounts corresponded with the recorded balances. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 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 standard(s) 24, 29 & 30 Residents live in a fairly well maintained environment that was clean and fresh EVIDENCE: Bedrooms are colourfully decorated and all are of a different décor from each other. The gardens were generally well maintained. During the tour of the premises it was noted that a bedroom carpet in number 71 bungalow had been replaced and the corridor carpet in number 73 bungalow had also been replaced. The carpet area, however, in number 71 bungalow, by the front entrance and in the front lounge, although clean, were stained in a number of areas. A requirement has been made about this. Since the last inspection further overhead tracking has been introduced to some bedrooms for residents that have been assessed requiring this specialist equipment to enable their safe moving and handling. The three training files that were seen indicated staff had attended training in infection control. Laundry facilities are apart from the kitchen areas and during the tour of the premises there home smelt fresh. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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) 33, 34 &35 Residents are cared for by a generally stable team of well trained and qualified staff although the recruitment and vetting procedures pose a risk to residents. EVIDENCE: The Manager said that only one member of staff has left the home since the last inspection and that bank and agency staff that are used are familiar to the home and the specialist needs of the residents. On the day of the inspection there was a sufficient number of staff and the Manager said that all were permanent employees of the home. The three staff training files seen indicated that care staff/support workers attend specialist training in how to care for people with learning disabilities. Qualified nurses, only, are in charge of the home at any one time. Three staff recruitment files were noted to have all the information required with the exception of one file. This file contained no written explanation of a significant gap in employment history of the staff member. A requirement has been made about this. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 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 & 42 The home is managed for the best interests of the residents. EVIDENCE: The Commission receives copies of monthly reports of unannounced visits carried out by Granta Housing Ltd. Other quality assurance systems include detailed reports of audits and surveys and what action is to be taken as part of a business plan. None of the residents of the home are able to communicate effectively their views of what it is like for them living at 71 & 73 Fen Road. However relatives/representatives of residents are consulted on their behalf and copies of completed questionnaires sent to them were seen to include comments such as, “Staff are always helpful and work well with me,” and, “ It is a very good service.” Records of accidents, service checks and staff training in first aid, fire safety and moving and handling were seen and these were satisfactory. Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 17 Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 18 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 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 3 3 Standard No 11 12 13 14 15 16 17 x N/A 3 x 3 3 4 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fen Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 20 Regulation 13(2) Requirement The Registered Person must ensure records for the administration of medication are accurate The Registered Person must ensure all areas of the home are kept clean and free of stains The Registered Person must ensure all required information is obtained about staff before they commence work Timescale for action 22.06.05 2. 3. YA 24 YA 34 23(d) 19 01.08.05 22.06.05 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 Good Practice Recommendations NONE Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI Fen Road I53 I03 S24285 FEN ROAD V230729 210605 STAGE 4.doc Version 1.30 Page 21 - 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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