Inspection on 27/09/05 for Suez Road (128)

This inspection was carried out on 27th September 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Suez Road (128) 14/11/06

Suez Road (128) 09/02/06

Suez Road (128) 18/02/05

Suez Road (128) 24/08/04

Suez Road (128) 10/02/04

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 Suez Road (128) Cambridge CB1 3QD Lead Inspector Mrs Jenny Cangy Unannounced Inspection 27th September 2005 13:30 Suez Road (128) DS0000015168.V250896.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 Suez Road (128) DS0000015168.V250896.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. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Suez Road (128) Address Cambridge CB1 3QD 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 572158 Granta Housing Society Limited Ms Dinah McLeod Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th February 2005 Brief Description of the Service: 128 Suez Road is a detached house situated in a residential area about a mile from the centre of Cambridge. It is a care home for adults with a learning disability. The current age range is approximately 40-70 years. Accommodation is on two floors and consists of eight single bedrooms, a lounge, dining room, kitchen, two bathrooms, 3 WC’s, and a games room. There is also staff accommodation of an office and a staff sleep-in room with en-suite facilities. There are front and rear gardens. The home is within walking distance of all local amenities. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 13.30 and the inspector was admitted to the home by two service users who found a member of staff. Two staff were on duty both agency employees who work full time at the home. The manager was off on family leave. Four service users were at home and all were spoken to initially. The staff member in charge phoned the deputy manager and left a message on his answer service regarding the inspection. The inspection started in the office with an introduction to the inspection process. The staff member in charge appeared to have some knowledge of the function of the CSCI. A permanent member of staff came on duty at 14.00 and took a lead in the inspection process. All the staff on duty participated. Service users came and went while the inspector was in the office. A care plan and medication records were seen and the standards were discussed. This was followed by a tour of the building and meeting the service users all of whom were now at home. The inspection ended at 16.30 It should be noted that not all standards were inspected at this visit. Those not inspected were met at the last inspection and will be inspected at the next visit. What the service does well: What has improved since the last inspection? The inspector found no improvement since the last inspection. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 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. Suez Road (128) DS0000015168.V250896.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 Suez Road (128) DS0000015168.V250896.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): 2,3,4,&5 There are policies and procedures in place to ensure service users know their needs can be met. EVIDENCE: The service users have lived at this home for ten years and over. Some for almost twenty years. The staff were able to tell the inspector how a vacancy would be filled and what procedures would be followed to ensure a new service user was introduced to the home appropriately. Service users have a contract of residence they clearly states the terms and conditions of living in the home. Suez Road (128) DS0000015168.V250896.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): 6,7,8,9&10 Care plans are in need of review as information included does not meet the expectations of National Minimum Standard 6. Staff who do not know the service users would find it difficult to find the information needed to ensure all care needs were met. EVIDENCE: Care plans were found to be basic and did not provide the information needed to ensure all service users have their care needs met. There are no photographs of the service users on their files. Although staff know the service users well the detail in the care plans care plans do not reflect this. Service users have choice in all aspects of their lives but currently do not participate in the selection of new staff. They have monthly house meetings to enable them to express their views on the home. Some risk assessments are in place but these are minimal and insufficient . There were no risk assessments in place regarding the uncovered radiators, use of the bath or shower unattended, going to and from work/day service unattended. There is a confidentiality policy but staff were unaware of whether this is shared with partnership agencies. Suez Road (128) DS0000015168.V250896.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): 11,12,13,14,15,16,&17 Service users have full and active lives. EVIDENCE: Service users have full and active lives and participate in the local community. They have holidays and outings that they help to plan. Some attend college courses or have paid and voluntary work. They go out socially in the evenings Contact with family and friends is encouraged and supported. Daily routines are individual to each service user. They discuss menus at the meetings and help to shop for and prepare meals. Meal times are a social activity when service users and staff all sit down together. Suez Road (128) DS0000015168.V250896.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): 18,19,21 Standard 21 is not met as there are no care plans in place with regard to ageing illness and death. Service users are supported in the way they prefer and all the physical and emotional needs are met. EVIDENCE: All service users are registered with local healthcare facilities and have regular checks. Service users preferences regarding ageing illness and death are not known or recorded. This was a requirement at the last inspection. If some service users are unwilling to discuss these issues the care plan should state this or family member should be approached. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The recording and reviewing of complaints needs to be reviewed as there is no formal record of any issues service users may raise and no proof their views and feeling are listened to and acted on. EVIDENCE: The contact details for the CSCI on the complaint procedure are out of date and inaccurate. The staff were unaware of any method of recording complaints apart from in daily diary notes. There is no formal complaint log or records that the staff knew of or the inspector could see. There was no evidence that complaints are recorded investigated or reviewed. One service user complained about the net curtains in her room that were torn The staff were aware of her concerns but it is a matter of concern that it was not regarded as a complaint. A Service user pointed out that the shower curtain on the shower cubicle was missing. Staff were unaware of its whereabouts but did not regard this as a complaint either. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,28,29,30 The home is not well maintained and some service users were clearly aware of this. The home was clean and fresh EVIDENCE: The home has a domestic style and all service users have their own rooms personalised to them. All areas of the home are due for redecoration and this was highlighted at the last inspection and it was disappointing to find no progress had been made. Service users are aware of the planned redecoration and looking forward to helping choose the colours. A service user pointed out that the shower curtain is missing in the first floor bathroom. Staff on duty were unaware of this and did not know why it was missing. The downstairs bathroom has had grab rails fitted to benefit a service user who is becoming frail. The home was clean and fresh throughout. The decking in the garden is on several levels presenting a tripping hazard. The threshold to the kitchen from the laundry area is uneven and a doormat well is deeper than the doormat, also presenting a tripping hazard. Staff stated this was being rectified as part of the kitchen renovation but did not know when. Action should be taken without delay to reduce the risk of accident. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 14 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 Staff training readily available from Grant Housing Society training department to ensure staff are adequately trained to provide a good quality service to the service users. EVIDENCE: All statutory training is up to date. Several staff have NVQ level2 in care. Of the staff on duty one had NVQ level 2 and two were agency staff who have had an induction to the home that includes fire safety and health and safety training. All staff have to have medication administration training before administering medicines. One of the agency staff stated that NVQ training was not available to him via his employer. There is a high use of agency staff however the home endeavours to use the same staff and is currently recruiting new permanent staff. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 15 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): 37,38,40,42 The home is managed by an experienced manager. There are some failings with regard to communication. Also health and safety issues that could put service users at risk. EVIDENCE: Staff expressed some reservations about the ethos of the home and did not think their views or the views of the service users were listened to or acted on. Despite the requirement at the last inspection to risk assess and cover hot pipe-work this has not been done and service users beds were found up against uncovered radiators. There was no risk assessment found to say whether this was an acceptable risk. Staff stated a named member of staff had a lead responsibility for health and safety. They were unaware of regular hot water temperature testing and stated taps had thermal mixer valves. However they were unaware that the effectiveness of these was tested or any adjustments made. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 16 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 3 3 3 Standard No 22 23 Score 1 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 1 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 X 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Suez Road (128) Score 3 3 X 1 Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X 1 x DS0000015168.V250896.R01.S.doc Version 5.0 Page 17 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 YA6 Regulation 15 schedule 3.1b Requirement Timescale for action 30/11/05 2 YA9 3 YA10 4 YA21 The registered person must review the care plans to ensure they contain sufficient information and ensure that service users know their assessed and changing needs and personal goals are accurately recorded. A photograph should be included and each plan should be signed by the service users to indicate they have participated in and agree the plans. 13(4) The registered person must 30/11/05 assess all risks relating to the service users living an independent life style and record these risks as part of the care plan. 12(4(a)) The registered person must 30/10/05 ensure all partnership agencies giving services to the service users have a copy of the homes confidentiality policy. 12(1,2,3,4,) The registered person must 30/11/05 ensure a care plan relating to the service users wishes regarding ageing, illness and death be compiled to ensure their wishes are known and DS0000015168.V250896.R01.S.doc Version 5.0 Suez Road (128) Page 18 5 YA22 22(1,2,3) &(7) 6 YA38 12(2,3,5) 7 YA42 13(4) x x x respected. This is a requirement outstanding from the last inspection and the time scale of June 2005 has not been met Failure to meet the new time scale will result in regulatory action being taken. The registered person must review the method of recording and investigating complaints. Staff must understand what constitutes a complaint and how to record and action it. The Company complaint procedure must be updated to give the correct contact address and phone number of the CSCI The registered person must ensure that the views and feelings of the service users and staff are heard and acted on accordingly. The registered person must ensure all Radiators and hot surfaces in areas accessed by service users are adequately covered. This is a requirement outstanding from the last inspection and the time scale of June 2005 has not been met. Failure to meet the new time scale will result in regulatory action being taken. An action plan on how the home is going to meet these requirements must be submitted to the CSCI 30/10/05 30/10/05 30/11/05 15/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 Page 19 No. 1 Refer to Standard YA24 Good Practice Recommendations The programme of planned redecoration and refurbishment should be submitted to the CSCI to enable the lead inspector to monitor if the standard is being met. Suez Road (128) DS0000015168.V250896.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. Extracts may not be used or reproduced without the express permission of CSCI Suez Road (128) DS0000015168.V250896.R01.S.doc Version 5.0 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. 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!