Inspection on 31/10/05 for Fen Road

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fen Road 08/05/07

Fen Road 25/09/06

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 Unannounced Inspection 31st October 2005 11:00 Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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.V259569.R01.S.doc Version 5.0 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.V259569.R01.S.doc Version 5.0 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.V259569.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All clients under 65 years of age Date of last inspection 21st June 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. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of 71& 73 Fen Road for 2005/06. The inspection was unannounced and was carried out between 11:00 and 13:00 and took 2 hours to complete. On the day of the inspection there were 10 residents and 3 of these were spoken to, although none were able to voice their views about what it is like to live at the home. Also spoken to were staff including the nurse-in-charge of the home. To complete the inspection process a tour of the premises was made and documentation was examined. Information provided to the Commission, following monthly visits by a representative of Granta Housing Society Limited, is included in this report. The Manager provided information to the Commission before this inspection. Some of this information is included also in this report. Following the unannounced inspection of 21st June 2005 a requirement was made about gaps in employment history of staff. Due to the unavailability of both the deputy manager and registered manager at the time of this inspection, the Commission has made the decision that compliance with this requirement will be assessed, in the near future, during an announced additional inspection of Fen Road. 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 are actively included within the community and have opportunities to engage in leisure pursuits. Residents’ bedrooms are decorated and furnished in an individualised manner; none of the bedrooms are the same. 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. • • • Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home could do better in practices of medication. An immediate requirement was made for the following: • The door of the medication cupboard of number 71 bungalow was left wide open, unattended. Within this cupboard medication keys were left unattended also. Recording of medication charts were incomplete. This is a requirement that remains. Some medication had run out for a number of days. • • A requirement has been made for the following: • Medication administration records, with the regards to changes in medication, had been altered without the signatures of individuals responsible for 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 DS0000024285.V259569.R01.S.doc Version 5.0 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.V259569.R01.S.doc Version 5.0 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): EVIDENCE: None of these standards were assessed on this occasion. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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 Care plans and risk assessments are detailed to provide staff guidance in how to meet the residents’ assessed needs. 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. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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): 14 & 17 EVIDENCE: Information provided to the Commission in the monthly report for September 2005 includes details of residents attending wheelchair ice skating. On the day of the inspection it was noted one of the too mini-buses returning to the home. Staff reported that the minibus had taken a resident to a day-service and another to the shops. During the tour of the home it was noted that there were decorations in both bungalows, to celebrate Halloween. Staff stated that some residents were going out that evening to attend a Halloween party, arranged by another care service. Staff were seen engaging with residents in activities that included listening to music, a “ Batman” DVD, sensory lights and foot massaging. Information provided by the Manager in the pre-inspection questionnaire notes that residents receive a variety of menu to include foods originating from different cultures as well as “traditional” English food. On the day of the inspection lunch was cheese and tomato omelette. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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 the following standard(s): 20 Methods for the recording, administration and safe storage of medication pose a serious health risk to residents. EVIDENCE: A requirement was made following the last inspection that medication administration records (MAR) must be completed to reduce the risk of giving too little or too much medication to residents. • During this inspection a number of MAR sheets for number 71 bungalow were seen. On 20th October 2005 three lots of medication prescribed for a resident to be given at 6:00am was not recorded as given, although the nurse-in-charge reported that this medication had been given. For another resident, prescribed medication to be given on 25th October for 8:00am and 12:00, there was no record that this medication had been given, although the nurse-in-charge reported that this medication had been given. Medication records for another resident to have medication three times per day showed that these records were also incomplete: there were no entries of staff signatures for 27th October 2005; on 28th and 29th October 2005 there were signatures that medication had been given at DS0000024285.V259569.R01.S.doc Version 5.0 Page 12 • • Fen Road 21:00 but no other times as prescribed. There were no further entries to state that medication had been given as prescribed for 30th and 31st October 2005. During the inspection the door to the medication cupboard located in number 71 bungalow was left wide open and the keys to access the medication were left, also unattended, on a shelf within this medication cupboard. Due to the serious concerns of the above findings an immediate requirement was made. Examination of the MAR sheets indicated that prescribed medication had not been given to two residents, as the medication was not available for at least 3.5 days. It was also noted that changes had been made to pre-written instructions on the MAR sheet although no names were recorded of those individuals who had made these changes. These changes included changes of medication such as prescribed hyoscine patches were changed to glandosane spray. As a result of this finding a requirement has been made. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards have been assessed on this occasion. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Fen Road provides, and continues to improve, a clean and homely place for residents to live. EVIDENCE: During the tour of the premises at the last inspection it was noted that the carpet areas in number 71 bungalow, by the front entrance and in the front lounge, although clean, were stained in a number of areas. A requirement was made about this. Evidence provided by the nurse-in-charge indicates that the home has taken action to provide more suitable floor covering in areas that are well-used by residents, staff and visitors to number 71 bungalow. A visit was made to number 73 bungalow where it was noted that carpets were clean and well presented. Bedrooms are colourfully decorated and all are of a different décor from each other. On the day of the inspection the home was clean and free from offensive smells. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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 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): 33 Residents receive care in a consistent way. EVIDENCE: On the day of the inspection there were 6 members of staff. The nurse-incharge reported that the home has been successful in the recruitment of qualified staff. It appears following analysis of information, provided by the Manager, in the pre-inspection questionnaire, agency staff numbers are fairly high. The nurse-in-charge, reported that the majority of the agency staff have worked at Fen Road for lengths of time that has enabled them to provide a continuity of care to residents. During the last inspection it was noted that one of three staff files seen contained no written explanation of a significant gap in employment history of the staff member. A requirement was made about this. This will be assessed in the near future during an announced additional inspection of the home. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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 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 & 42 Residents live in a well managed and safe home. EVIDENCE: Information provided by the manager in the pre-inspection questionnaire notes that she has been the Project Manager of 71 & 73 Fen Road since 22nd November 1999. She is a registered nurse for people with learning disability and has completed her Registered Managers Award. She has successfully completed an ENB 998 course in teaching and assessing; is an NVQ assessor and has a City and Guilds certificate in Advanced Management in Care. Information provided also in the pre-inspection questionnaire notes that staff training in the last twelve months has included first aid, fire safety, food hygiene, infection control and moving and handling. Staff confirmed that they had attended training in health and safety matters. Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 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 x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 N/A 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fen Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000024285.V259569.R01.S.doc Version 5.0 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 YA34 Regulation 19 Requirement The Registered Person must ensure all required information is obtained about staff before they commence work. This standard and compliance with the requirement was not assessed on this occasion. The Registered Person must ensure that the safe administration of medication with regards to any changes in prescribed medication. The Registered Person must ensure records for the administration of medication are accurate. This requirement has been brought forward and an immediate requirement has been made The Registered Person must ensure that medication supplies do not run out. The Registered Person must ensure the safe storage of medication Timescale for action 22/06/05 2 YA20 13(2) 01/11/05 3 YA20 13(2) 31/10/05 4 5 YA20 YA20 12(1)(a) 13(2) 31/10/05 31/10/05 Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fen Road DS0000024285.V259569.R01.S.doc Version 5.0 Page 20 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. 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