Inspection on 25/09/06 for Fen Road

This inspection was carried out on 25th September 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 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 31/10/05

Fen Road 21/06/05

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 Key Unannounced Inspection 25th September 2006 9:20 Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 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) Granta Housing Society Limited Mary Moore Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All clients under 65 years of age Date of last inspection 31st October 2005 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. Current fees range from £1147.14 to £1979.77. Additional costs include those for holidays. A copy of the CSCI inspection report is available at the home or via the CSCI website. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary also includes additional inspections carried out between 31st October 2005 and 25th September 2006. An announced additional inspection was carried out on 4th November 2005 to check staff records that were not available during the unannounced inspection of 31st October 2005. The information that was available in these records was satisfactory. Following the unannounced inspection of 31st October 2005 an unannounced inspection was carried out by the Pharmacist Inspector on 23rd November 2005. The findings of this inspection resulted in 5 requirements and 2 recommendations. All of these requirements and recommendations were assessed at this inspection of 25th September 2006. This inspection (of 25th September 2006) is the key inspection of 71 & 73 Fen Road for 2006/7. The inspection was unannounced and was carried out between 9:20 and 12:00 and took 2 hours and 40 minutes to complete. Information provided to the Commission before the inspection has been referred to in this report. Nine residents’ surveys were sent to the home and 3 of these were returned. A telephone call for a representative of one of the residents was made to the Commission before the inspection and a letter has been received from another representative of a resident. Comments made by these people, about the home, were positive. At the time of the inspection there were 9 residents living a the home and some of these were spoken to although none were able to express their views about living at the home due to their complex communication abilities. Documentation was examined , a tour of the premises was made and staff, were spoken to. Although the Registered Manager was not available at the time of the inspection she took time out from her schedule to assist the Inspector in gaining access to staff records. 71 & 73 Fen Road provides an excellent standard of health and social care for people under 65 years of age with learning and physical disabilities. What the service does well: The home does well in the following areas: • A representative wrote, “(I) am more than satisfied with the care and attention given. Staff do everything in their power to give (name of resident) a happy and satisfying life”. DS0000024285.V312800.R01.S.doc Version 5.2 Page 6 Fen Road • • • • Both complex health and social care needs of the residents are well met. Care plan documentation is clear and contains excellent guidance for staff in how to meet the assessed needs of the residents. Residents have access to a range of leisure pursuits. The range and variety of food provided reflects the culture of the age range of the residents. What has improved since the last inspection? 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. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 There has been a good standard of information for prospective residents’ representatives to make an informed decision about where the resident could live in the future. EVIDENCE: Completed residents’ surveys indicated that the representatives were included in pre-admission discussions with the home and social services. There have been no new admissions to the home since the last inspection of October 2005. Staff reported that representatives of a prospective service user had full information before making their decision about the suitability of the home. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 & 9 Care plan documentation reflects the complex communication needs of the residents and provides clear and excellent guidance for staff in how to meet the needs of the residents. EVIDENCE: Both residents’ care plan documentation provided excellent and clear guidance, including photographic guidance, for staff in how to meet the assessed complex needs of the residents regarding their health and social care needs. 71 & 73 Fen Road provides care for people with complex communication abilities. Two residents’ care plans were examined and both of these contained a record of these communication abilities. These communication abilities included how staff might interpret the choice/decisions of the residents through non-verbal communication. Most interpretation was from the intuition of staff. Representatives of the residents were included in the care planning consultation period as were designated key workers. Risk assessments were carried out to include residents participating in leisure activities and during transportation to and from the home and possible risks encountered when residents might experience epileptic seizures. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 Residents live a good quality of life that is excellent in parts. EVIDENCE: Due to the complex abilities of the residents none of the residents are able to engage in educational or employment opportunities; Standard 12 is therefore not applicable. The home is located within a residential area of Cambridge close to shops and pubs. The Commission has received no complaints from the local community about the service. Information provided before the inspection includes a range of leisure activities that residents are able to participate in. These activities include horse riding, attending a folk festival, seaside visits, swimming, aromatherapy, T.V and watching videos and visiting the sensory room. Examination of 2 residents’ care records noted their participation in leisure pursuits to include swimming and aromatherapy. During the inspection it was noted some residents listening Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 11 to music, watching a DVD of a Harry Potter film or lying in the sensory room whilst listening to music. Examination of 2 residents’ care records and discussion with staff indicated that residents have contact with their family and friends including visits to or from the home. During the inspection it was noted that residents were dressed in clothes appropriate to their age and culture. Information provided by the Manager prior to the inspection included a copy of menus. These menus showed that residents are provided with an excellent range and variety of food such as roasts, curries, stir fries and omelettes. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 & 20 Residents receive a good standard of personal health care and support. EVIDENCE: Verbal and written comments made by representatives of residents indicate that residents receive a good standard of care. During the inspection it was noted that residents were receiving one-to-supervision and care from staff including help with having a meal or drink, physiotherapy or having a lie down. Copies of reports sent to the Commission indicate that residents have access to a range of health care services and examination of 2 residents’ files confirmed this to be the case; residents have access to community dietician services, dentists, nutritional teams and local hospitals. An unannounced inspection was carried out in November 2005 by the Pharmacist Inspector. Five requirements and 2 recommendations were made following this inspection. Medication systems were assessed in number 71 bungalow on this occasion: • A requirement was made for medication records to be accurate and up to date. An examination of medication administration records was carried out and evidence suggested that this requirement has been met. DS0000024285.V312800.R01.S.doc Version 5.2 Page 13 Fen Road • A requirement was made for staff who had given medication to residents to sign the appropriate record. Discussion with staff indicated that this was the case. Only qualified nurses administer medication and sign the records. A requirement was made that medication that was no longer in use was to be disposed of. Examination of medication in store and discussion with staff indicated that only medication in use is stored at the home. This requirement has been met. A requirement was made that policies and procedures were to be in force with regards to medication. Although information provided by the Manager indicates that the last review of the organisational medication polices was April 2005 there was evidence that staff at the home had introduced a policy to guide staff about medication procedures. Staff spoken to indicated that they were aware of the policies and procedures of medication. A requirement was made for staff to be competent in the administration of medication. Discussion with staff indicated that only trained nurses now administer medication. By the right of their nurse registration, it is considered that the qualified nurses are competent to give medication. As a result of this finding this requirement has been met. A recommendation was made for the home to retain a copy of the signed prescription. Discussion with staff and examination of these copies, indicated that this recommendation has been considered. A recommendation, that any hand written changes or additions to instructions were to be signed and dated by the person making that entry, was made. Examination of administration records indicated that no records had been changed. However it is reasonable to suggest that, based on the improvement made in complying with the requirements and other recommendation made following the Pharmacist inspection of 23rd November 2005, that this recommendation has been considered. • • • • Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 the following standard(s): 22 & 23 There are good systems in place to protect residents from harm or abuse. EVIDENCE: Information provided by the Manager before the inspection notes that the home has received no complaints. The Commission, before the inspection, has received compliments, from representatives of residents, about the standard of the care provided to the residents. The Commission has received no complaints about the home and there has been no allegations made regarding abuse against any of the residents. Staff spoken to reported that they had attended training in adult protection awareness and procedures against abuse. Evidence of training were also seen during examination of 2 staff training files. Staff were seen to be interacting with residents in an appropriate manner. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 the following standard(s): 24 & 30 The home has a good standard of maintenance and cleanliness. EVIDENCE: 71 & 73 Fen Road are two purpose built bungalows situated on the outskirts of Cambridge City. Information provided by the Manager before the inspection notes that bedrooms and a lounge area have been redecorated and new floor covering has been provided in the hallway and lounge of number 71 bungalow. This areas of improvement were also noted at the time of the inspection. Staff reported that arrangements are in place to replace the stained corridor carpet in number 73 bungalow. Gardens that surround both bungalows were well maintained, accessible for people using wheelchairs and were provided with items for sensory stimulation. At the time of the inspection the home was visited by an internal decorator who, according to staff, was reviewing communal areas for future decoration. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 16 At the time of the inspection the home was clean and free of offensive smells. Two staff training files that were examined indicated that the staff had attended training in infection control matters. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 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 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): 32,33, 34 & 35 The recruitment and training of staff is of a good standard. EVIDENCE: Information provided by the Manager before the inspection noted that the home has 62 of care staff with NVQ level 2 qualification and that residents are supported by 10 registered nurses, including the Registered Manager. At the time of the inspection there were 9 residents living at the home. According to staff there has been a reduction in the number of staff on duty since the home has not had 10 people residing at the home. Staff believed that this reduction in numbers of staff had some effect of the standard of care provided to residents. For example staff reported that 2 staff are required to assist residents with moving and handling and bathing. During this care practice staff considered staff time is taken away from the remaining residents. Staff reported also that time to take and collect residents from day care services reduces the number of staff in the home for the remaining residents. At the time of the inspection, and examination of pre-inspection information and copies of reports provided to the Commission, indicated that on the whole there is sufficient number of staff on duty. However, as a result of staff comments a recommendation has been made for an audit of staff numbers and needs of residents is carried out. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 18 Two staff files were examined and both of these contained full and satisfactory information about these people. Information provided by the Manager before the inspection and examination of 2 staff training files, including discussions with staff, indicated that staff attend a range of training including specialist training in how to assist a person with artificial methods of feeding, equality and diversity and care of a person with a learning disability. Staff reported that qualified nurses have access to the Homerton School of Health Studies, Cambridge, for post- registration courses. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 19 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): 37,39 & 42 The standard of management in the home is good. EVIDENCE: The Registered Manager was appointed to her current position in November 1999 and is a Registered Mental Health Nurse with post registration qualification in teaching and assessing. She is an NVQ assessor and has completed her Registered Managers Award. The Commission receives copies of reports made following monthly visits to the home by a representative of Granta Housing Limited. These reports include audits of staffing numbers, summaries of residents’ health and welfare and health and safety checks to include fire records and service checks for gas and electricity. The home has carried out the Granta Housing Limited quality assurance audit known as “Quartz” and this full audit was seen at the time of the inspection. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 20 Information provided by the Manager before the inspection notes that policies and procedures are reviewed generally each year. Records for temperatures of hot water checks, portable appliance checks, emergency lighting checks, fire alarm checks, services of hoists and records of accidents/incidents an were examined and all of these were satisfactory. Staff spoken to and staff training files that were seen indicated staff attend training to include food hygiene, first aid, moving and handling and fire safety matters. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 21 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 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 N/A 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 YA34 Good Practice Recommendations The Registered Person should consider auditing the needs of residents and compare these needs with the current numbers of staff. Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 23 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 Fen Road DS0000024285.V312800.R01.S.doc Version 5.2 Page 24 - 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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