The Care Quality Commission
  • Care Home
  • Care home

Archived: Fen Road

Overall: Good read more about inspection ratings

71 -73 Fen Road, Chesterton, Cambridge, Cambridgeshire, CB4 1UN (01223) 425634

Provided and run by:
Metropolitan Housing Trust Limited

Important: The provider of this service changed. See new profile
Important: The provider of this service changed - see old profile

All Inspections

4 May 2016

During a routine inspection

Fen Road is registered to provide accommodation and nursing care for up to 10 people. There were eight people with a learning disability using the service at the time of the inspection. People were accommodated in two bungalows in single occupancy rooms.

This unannounced inspection took place on 4 and 5 May 2016.

At the last comprehensive inspection on 30 October and 2 November 2015 this provider was placed into special measures by CQC. A breach of ten legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• providing care that was appropriate, safe and met people’s needs,

• treating people with dignity and respect,

• ensuring that the requirements of the Mental Capacity Act 2005 were met,

• safe management of people’s medicines,

• maintaining the premises,

• assessment and monitoring of the service,

• ensuring staff were competent to meet peoples assessed needs,

• having a robust recruitment procedure in place that was being followed.

During this inspection we found that there was sufficient improvement to take the provider out of special measures. We found that the provider had followed their plan which told us that the action required to make the required improvement would be completed by 10 April 2016.

There was a registered manager at the time of the inspection. However they were no longer working in the home. A new manager had recently been appointed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was acting in accordance with the requirements of the MCA including the DoLS. The provider was able to demonstrate how they supported people to make decisions about their care. Where people were unable to do so, there were records showing that decisions were being taken in their best interests. DoLS applications had been submitted to the appropriate authority. This meant that people did not have restrictions placed on them without the correct procedures being followed.

Staff were aware of the procedures to follow if they were concerned that anyone had suffered any harm. Risk assessments had been completed and staff were aware of how to reduce risks to people’s health and safety. Procedures were being followed so that any accidents or incidents were dealt with appropriately and action was being taken to prevent a reoccurrence.

Sufficient numbers of staff were in place to ensure that people were safe and received the care that they required. There were a number of staff vacancies but agency staff were being used so that there were enough staff on duty. Staff had completed training to ensure that they were able to meet people’s needs. Staff were supported and were receiving regular supervisions. There was a robust recruitment procedure to ensure that only the right staff were employed to work with people using the service.

Since our last inspection improvements had been made to ensure that medicines were stored, recorded and administered safely. Regular audits were being undertaken to check that this was the case.

The buildings and facilities had been maintained to an appropriate standard and equipment and furniture had replaced where needed.

People were receiving a balanced diet and people who had special dietary needs were receiving an appropriate diet. People received the support that they needed at mealtimes.

People had access to healthcare professionals when needed. When this had not been requested in a timely manner a full investigation had been conducted and action had been taken to prevent this from happening again.

People received personal care in private and their dignity was promoted. People were supported by staff in a kind and caring manner.

Care plan’s had improved and they contained all of the information that staff required to meet people’s needs in the way that they preferred. People and their relatives had been involved in updating and reviewing the information in the care plans.

The manager had carried out regular audits to assess what improvements needed to be made. The provider had carried out visits to the home to ensure that the action plans for improvements were being met.

30 October and 2 November 2015

During a routine inspection

Fen Road is registered to provide accommodation and nursing care for up to 10 people. There were 9 people with a learning disability living in the home at the time of the inspection. People were accommodated in two bungalows and all bedrooms were single rooms.

This unannounced inspection took place on 30 October and 2 November 2015.

At the time of the inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. The registered manager was not in the home during the inspection.

The system to monitor the quality of the care being provided and to drive improvement was not effective and this impacted on all areas of the service.

Risks had not always been managed to keep people as safe as possible. Risk assessments had not always been completed. This meant that staff did not have the information they required to ensure that people received safe care.

Accidents and incidents had not been managed effectively or reviewed to identify and address patterns or common themes. We could not be confident that people were receiving their medication as the prescriber had intended. Not all staff who administered medication had completed annual assessments of their competence. Current legislation was not being followed regarding the storage and recording of administration of medication. Medication audits were not being completed to identify any areas for improvement.

Action had not been taken in a timely manner to maintain, repair and replace equipment when necessary. Contingency plans had not been reviewed or updated so that staff knew what action to take in the event of an emergency.

Not all recruitment records were available. This meant that we could not be assured that staff had completed the necessary recruitment checks before being employed. We could not judge if the training provided to staff was sufficient to meet people’s needs. This was because staff training information was not available for all staff. Staff could not tell us when they had last received their training. Staff were not receiving regular supervisions.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was not acting in accordance with the requirements of the MCA including the DoLS. The provider could not demonstrate how they supported people to make decisions about their care and where they were unable to do so, there were no records showing that decisions were being taken in their best interests. This also meant that people were potentially being deprived of their liberty without the protection of the law.

People’s dignity, respect and privacy was not always maintained. People’s records were not held securely and confidential information was accessible to other people and visitors to the service.

Adequate food and drink was provided. However people were not always offered choices about what they would like to eat and drink.

Care plans did not contain all of the relevant information that staff required so that they knew how to meet people’s current needs. We could not be confident that people always received the care and support that they needed.

Staff were aware of the procedure to follow if they thought someone had been harmed in any way.

Some staff knew how to communicate with people in a way that made people happy.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found ten breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.