CARE HOME ADULTS 18-65
Suez Road (128) Cambridge CB1 3QD Lead Inspector
Mrs Jenny Cangy Unannounced Inspection 9th February 2006 2:30 Suez Road (128) DS0000015168.V276969.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 Suez Road (128) DS0000015168.V276969.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. Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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.V276969.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th September 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.V276969.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 2.30pm. It was conducted with the manager and a senior project worker. Some service users were at home and others returned from day services during the inspection.. The inspection commenced with a review of requirements from the last inspection and a review of National Minimum Standards not inspected at the last visit. Some records were seen. A tour of the home followed and the inspector met all the service users at home. What the service does well: What has improved since the last inspection?
All care plans have been reviewed and updated and now include a plan regarding service user wishes with regard to ageing, final illness and death.. Risk assessments are now in place. Staffing levels have been increased. An audit of day to day issues/complaints takes place and responses are recorded. Monthly service user meetings are held and all service users are encouraged to participate. The home has had a new boiler and all radiators and hot pipe work are now covered. Service users have chosen new colours for the redecoration that is imminent and should be completed by the end of March. A seven seater people carrier is on order to facilitate more outings. Suez Road (128) DS0000015168.V276969.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. Suez Road (128) DS0000015168.V276969.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 Suez Road (128) DS0000015168.V276969.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 Service users have all the information they need regarding living at Suez Road. EVIDENCE: An informative service user guide and statement of purpose is in place and available to the service users and their representatives. Suez Road (128) DS0000015168.V276969.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, 8, 9,10 Service users live as independent a life style as their disability will allow and are fully involved in all aspects of running the home as they are able. Confidentiality within the house is paramount but cannot be guaranteed outside of it. EVIDENCE: All care plans have been reviewed with the involvement of the service users. Regular service user meetings are held where all service users are given the opportunity to air their views. They are currently involved in planning holidays and have chosen the colours for redecoration and that of their new vehicle. Risk assessments are I place for all aspects of the service users lives. Service users are encouraged to maintain and develop independence. The home does not currently share the confidentiality police with partnership agencies such as employers or day services. This was a requirement at the last inspection and has not yet been met. It should be noted that the manager was on compassionate leave between the last inspection and this but any further failure to meet this requirement will result in enforcement action being taken. Suez Road (128) DS0000015168.V276969.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): N/A All these standards were inspected and met or exceeded at the last inspection. EVIDENCE: These standards were not inspected Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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, 21 The home has appropriate safeguards in place with regard to medication. Service users wishes with regard to ageing illness and death are known. EVIDENCE: The home has a monitored dose system of medication with a named member of staff taking lead responsibility.. Only one service user has any input into having their own medication and this is on a daily basis for when they are away from the home. It is planned to provide each bedroom with medication cupboards and staff will support the service user in taking their medication. It is not intended to give the service user free access to the own medication at this stage. A care plan is in place to assure that service users preferences for care during ageing illness and death are known and respected Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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, 23 Service users views are known and responded to. Service users are protected from abuse and harm. EVIDENCE: A complaint book is in place for service users to record any grumbles or concerns they have. This is checked regularly and the outcomes recorded. This is in addition to the formal; complaint procedure. All staff have had Protection Of Vulnerable Adults training and the organisations recruitment procedures ensures all appropriate checks are conducted before any new staff are appointed. Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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, 25, 26, 27 The home is of a domestic appearance and comfortably furnished. The interior of the home is safe but the garden is still in need of attention. 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 the one prior to that. This is however now planned and the service users have been involved in selecting the colours. 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. This was noted at the last inspection however the service users have written to “Ground Force” asking if they would consider planning and creating a new garden as part of the 25th anniversary celebrations. The inspector will maintain contact regarding this. If it is not an option then Granta Housing Society must take appropriate action. Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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): 31, 35, 36 Staff have clearly defined roles and benefit from a regular training programme and regular supervision. EVIDENCE: All staff have appropriate job descriptions and contracts of employment. Staffing levels have been increased to ensure both the physical, mental and social care needs of the service users can be met. Granta Housing Society has a training department that ensures all staff receive the training they need. Most staff have NVQ level 2 or higher. There is a key worker system in place. All staff have regular formal supervision sessions including bank or agency staff. Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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): 38, 39, 41, 42, 43 Service users benefit from an available manager who is sensitive to their needs. There is a regular quality assurance monitoring tool in use and all records are kept as required. Policies and procedures ensure the service users well being is maintained. EVIDENCE: The manager is open and responsive to all her service users needs. She tries to ensure not only the most verbal have their say as has been the case in the past. The home has regular quality assurance inspection using the Quartz QA tool. All records are kept as required and are available for inspection. Health and safety requirements are met and regularly monitored. The manager is supported by a senior staff team and an area manager. Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 X 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 3 26 3 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X 3 3 X 3 3 3 Suez Road (128) DS0000015168.V276969.R01.S.doc Version 5.1 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 YA10 Regulation 12(4(a)) Requirement The registered person must ensure all partnership agencies giving services to the service users have a copy of the homes confidentiality policy. It should be noted that this requirement is outstanding from the last inspection and failure to take action to meet it will result in enforcement action. Timescale for action 30/03/06 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 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.V276969.R01.S.doc Version 5.1 Page 18 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
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