Inspection on 13/12/05 for Russell Street 40- 44

This inspection was carried out on 13th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Street 40- 44 26/03/07

Russell Street 40- 44 20/06/05

Russell Street 40- 44 05/01/05

Russell Street 40- 44 18/11/04

Russell Street 40- 44 04/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 40 - 44 Russell Street Cambridge CB2 1HT Lead Inspector Nicky Hone Announced Inspection 13th December 2005 10:00 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 40 - 44 Russell Street Address Cambridge CB2 1HT 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) 01223 712261 01223 714297 Cambridgeshire Social Services Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1), Physical disability (7), of places Physical disability over 65 years of age (1), Sensory impairment (3) 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: 40-44 Russell Street is a purpose built home for people with learning and physical disabilities; the home is owned and managed by Cambridgeshire County Council. The home consists of two houses, number 40 being a permanent home for four adults with learning disabilities, and number 44 providing short term respite accommodation for up to four adults with learning disabilities. Both houses have their own kitchen/dining room and sitting room, four single bedrooms and toilet and bathing facilities. All service users accommodation is on the ground floor. The two houses are linked by an internal corridor and share an enclosed garden which is provided with patio furniture. The home is within a short walk of a range of local shops, pubs, restaurants, and a new leisure complex which includes a bowling alley and cinema. The centre of Cambridge is a short bus ride or drive, and Cambridge station is close by, giving easy access to London, Peterborough and other major cities. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of this service for the 2005/6 inspection year. This inspection was announced, so that the inspector could spend time with the manager (acting) and inspect documents and records. To gain a complete overview of the service offered at 40 and 44 Russell Street, the reader should read this report in conjunction with the report of the unannounced inspection carried out in June 2005. Since the inspection in June, the registered manager, Sarah Wells (previously Sarah Swallowe) has formally left the post of registered manager to concentrate on providing management support to a range of services for people with learning disabilities, including 40 and 44 Russell Street. Mrs Wendy Bullivant, the deputy manager, is acting manager and has applied to the CSCI to be registered as the manager. Questionnaires were sent to service users and relatives on behalf of the CSCI before the inspection: five responses were received. What the service does well: What has improved since the last inspection? All four of the requirements made following the last inspection have been met. Care planning has improved and care plans are stored securely. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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): 1, 2, 3 Thorough assessments of service users’ needs are carried out prior to admission to make sure the home can meet those needs. Service users have information about the service they can expect from the home. EVIDENCE: The home has a statement of purpose and service user guide: a slight adjustment is needed to these documents so that the information about complaints meets the regulations. The manager agreed to ensure this is done. Thorough assessments are undertaken by care managers, and agreed by the home, before a new service user is considered. If the home is able to meet the service user’s needs, the care manager will write to the service user to confirm this, and arrange for visits to the home if possible before admission. Service users agree a statement of terms and conditions with the home: a copy of the statement, signed by the service user was seen on file. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 are up to date and give clear guidance to staff so that service users’ needs are met. EVIDENCE: Care plans for two service users were seen. These were much improved since the previous inspection, with evidence of regular reviews of the plans being undertaken. Person-centred planning is now being undertaken for all service users, and staff have started to record ‘circles of support’ for each service user. Daily recording is very good, with clear details about the way each service user has spent their day, what activities they have undertaken, and the outcome for that person. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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, 17 Service users are supported to lead full and active lives. EVIDENCE: Records on their files show that service users are offered a wide range of activities and leisure pursuits, both within and outside the home. Several people attend organised day services. During the morning of the inspection, all the service users were out, undertaking various activities. All the service users in number 40 have families and they are encouraged and supported to maintain contact with family and friends. For example, one person visits family every week, and another’s relatives visit the home every week. Service users usually have a cooked meal in the evenings, as most of them are out during the day. In number 40 there is a meeting each week at which service users decide what should be on the menu for the following week, but this can change if the service users decide they want something different. Service users help with the shopping. In Number 44, staff offer service users a choice of meal on a daily basis. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 11 Service users are offered meals out, for example a pub lunch or a meal in a cafe, which is incorporated into an activity, and which is subsidised by the home. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 Service users’ personal needs and the majority of their healthcare needs are appropriately met. Staff training in medication administration, and delegated nursing tasks must be reviewed to ensure there is no risk to service users. EVIDENCE: Individual care plans, and daily records show that service users receive support in the way they prefer. The manager said that health checks are undertaken for all permanent service users as and when needed. The staff link with the surgery and work hard together to prepare service users for checks which they might find distressing, if they are not prepared properly first, for example a mammogram. This preparation includes looking at pictures, discussion, visiting the surgery and so on. Staff also support service users on respite stays to keep health-related appointments if these fall during the stay. The inspector was not completely satisfied with the arrangements for one service user who has need for a nursing task to be delegated to support staff. Also, the manager has been unable to access training in a nursing task required by another person, which could put them at risk. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 13 An inspection of the medication administration system at the home was carried out on 09/09/05 by the CSCI pharmacist and resulted in nine requirements and four recommendations being made relating to a range of issues. The report of this inspection is available from the CSCI Cambridge area office. The manager said that all the requirements will have been met within the timescales, once staff training is completed by the end of January 2006; the recommendations are being considered. Compliance with these requirements was not checked on this occasion. Staff training is currently undertaken by one member of staff who has been on a medication administration course. This is not acceptable: all staff must receive training from a specialist. Records of the administration of medicines were seen in number 40 and were satisfactory. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 Concerns are responded to quickly, and staff receive training in adult protection, so that service users are kept safe and happy. EVIDENCE: The manager said that complaints are dealt with as they arise, and that there have been no serious complaints. A record is kept of all concerns raised by service users, and the way in which these have been dealt with. The manager will ensure that the minor correction to the complaints procedure in the statement of purpose and service user guide is made. Cambridgeshire County Council’s procedure and protocol for the protection of vulnerable adults from abuse (POVA) is available and understood by staff. Records of training show that all existing staff (except one) have undertaken POVA training. The manager has attended a 3-day POVA course. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not assessed at this inspection. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 16 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, 35, 36 Service users benefit from a staff team that is well trained and supervised regularly. EVIDENCE: The manager reported that recent recruitment has been successful: four new members of staff have been appointed and will start as soon as all preemployment checks have been completed. This will mean the home has its full complement of staff. There are usually four staff on duty in the mornings, with additional staff on the rota when required to meet the needs of particular individual service users. There are two waking night staff, with a senior member of staff on call. There are facilities for a member of staff to sleep-in when needed. Induction for new staff includes one day when policies, procedures and information about training is discussed, and then several days of working alongside experienced staff, with monitoring and supervision from the acting manager. Mandatory training is undertaken as soon as there are places on courses, and Learning Disability Award Framework (LDAF) training is also started as soon as there is a place available. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 17 One staff member is an on-site LDAF assessor: one person has completed this training; eight staff are currently undertaking it; and six staff (including four new staff members) are registered to start the training in 2006. Four of the staff team have been awarded a National Vocational Qualification (NVQ) in care, and six more are due to start in early 2006. All staff are supervised 6-8 weekly by the acting manager, who also carries out annual appraisals, with a 6-monthly update. One relative who responded to the CSCI questionnaire indicated that in their opinion there are not always sufficient numbers of staff on duty: there was no evidence of this on the day of the inspection. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 39, 41, 42 The home has a reasonable quality assurance system to ensure that the home is run in the way service users want it to be. Visits by the provider are not carried out as required, and service users could be at risk from lack of attention to the detail of fire procedures. EVIDENCE: The home has a variety of methods to ensure a quality service is offered. Service user questionnaires are sent out annually and service users are involved in annual reviews carried out by the local authority at which they are encouraged to give their views about the service. Meetings are held weekly in number 40 for the permanent service users, and views of those on respite visits are sought. Under Regulation 26, Care Homes Regulations 2001, the provider (or a representative) is required to visit the home at least monthly and write a report of the visit: these reports must be left in the home and a copy sent to the CSCI. Reports were only available up to December 2004. It is unclear 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 19 whether the visits by the provider have been carried out since then, but no reports were available and none have been received by the CSCI. Records show that tests of the fire alarm system have been carried out weekly as required since 29/10/05: prior to that, tests were not carried out weekly. Tests of the emergency lighting system must be carried out monthly as required: the record showed that the most recent tests had been done on 06/09/05 and 01/11/05. The home has completed a fire risk assessment: this was not checked. Information submitted by the manager in pre-inspection documents indicates that all safety checks of equipment and systems are carried out as required, COSHH data is kept and all chemicals are stored securely. The temperature of hot water at all outlets is controlled: these are checked and the results recorded (not seen at this inspection). According to the manager, training in fire safety awareness is given to all new, relief and agency staff, however, records of staff training did not give clear evidence that staff have received adequate training in fire safety awareness. 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X X X 3 X 2 2 X 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 YA19 Regulation 18(1)(c) Requirement The registered person must ensure that staff receive adequate training, which is appropriately recorded, in delegated nursing tasks to meet service users’ needs. Staff must receive training in the administration of medicine from a specialist. Reports of visits by the provider carried out in accordance with this regulation must be kept in the home and a copy sent to the CSCI. The first visit must take place within the timescale, and the report sent to the CSCI by 28/02/06. Records of tests of fire safety systems must show that tests are carried out as required. All staff must receive adequate and suitable training in fire safety awareness, at appropriate intervals. Timescale for action 28/02/06 2. 3. YA20 YA41 13(6) 26 28/02/06 14/02/06 4. 5. YA42 YA42 23(4)(c) 23(4)(d) 31/01/06 28/02/06 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 Page 22 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 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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 40 - 44 Russell Street DS0000033505.V259668.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!