Inspection on 11/08/05 for Creative Support

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

Creative Support 10/05/07

Creative Support 03/05/06

Creative Support 09/12/05

Creative Support 08/03/05

Creative Support 20/12/04

Creative Support 26/03/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Creative Support 7 Amherst Road Fallowfield Manchester M14 6UG Lead Inspector Sue Jennings Unannounced 11 August 2005 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 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 Stationary 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. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Creative Support Address 7 Amherst Road Fallowfield Manchester M14 6UG 0161 256 4366 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Creative Support Ltd Responsible Individual - Ms Anna Lunts Miss Lisa Marie Croft CRH Care home PC Care home only 8 8 Category(ies) of MD Mental Disorder registration, with number of places Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users must be female only under pensionable age The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 08 March 2005 Brief Description of the Service: 7 Amherst Road is registered to provide accommodation and personal care for up to eight women. The aim of the service is to provide a high quality, individually focussed service to women with enduring mental health needs. The home is situated approximately five minutes walk from Withington and Ladybarn shopping areas and close to public transport links into both Manchester City Centre and Stockport town centre. A selection of shops, general practitioners surgeries and churches of various denominations are situated close by. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during a four-hour period on Thursday 11th August 2005. During the inspection, time was spent talking with the people who lived at the home, with staff on duty and the registered manager. In addition, a random sample of people’s files, records and other relevant documentation were examined. At the last inspection the home needed to work on some areas to make sure it met the National Minimum Standards (NMS). All of the improvements had been completed. In the last 12 months the CSCI has not received any complaints in relation to the home. The home had received 6 complaints, which had been recorded and appropriately investigated. A number of compliments had been received by the home. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: What has improved since the last inspection? The home has continued to make improvements to the facilities provided to people who use the service. The kitchen area has been re-painted since the last inspection. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 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. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 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 standard(s) 1 and 2 Prior to admission people who use the service are provided with information about the home and its services and their needs are assessed and identified. EVIDENCE: The home produced a Statement of Purpose, which was available for inspection. This document was written in plain English and contained sufficient information for people to make an informed decision about moving in. The document was translated onto audio tape for those people whose first language is not English. The manager stated that the organisation would have a translator go through the Statement of Purpose and the Service User Guide with any service user from a minority group as and when the need arose. The manager stated that they were thinking about translating the Statement of Purpose onto audio cassette. There was evidence to demonstrate that the home had obtained Care Management Assessment of need for each person admitted to the home. The home undertook a comprehensive in-house assessment of need for each person. The assessments were detailed and clear and identified the person’s priority needs and goals. There was evidence that specialist health assessments were undertaken. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 9 There was documentary evidence that people who use the service participated in the assessment of need and the formulation of support plans (care plan). The manager reported that people who were considering moving into the home were invited to visit prior to making the decision to move in. This was confirmed during the inspection when one person came to look around. People thinking of moving in were invited to spend a few hours in the home meeting other people who used the service and staff. The manager reported that all admissions to the home were planned and the home did not accept emergency admissions. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 10 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 standard(s) 6, 7 and 9 The home clearly identified people’s needs and goals and had identified situations and personal behaviours that may place them at risk. EVIDENCE: Each person has a comprehensive support plan developed from the assessments of need covering the individuals’ personal, social and healthcare needs. There was evidence to demonstrate that people’s right to make decisions had been respected. There was evidence to demonstrate that some people managed their own finances. Others had appointees from Social Services. The manager had information relating to advocacy services. Risk assessments were completed for each person. A random sample of support plans was inspected and risk assessments had been dated and regularly reviewed. There was evidence to show that people who use the service were involved in the planning of their support. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 11 However, risk assessments had not been agreed and signed by the person using the service and it was strongly recommended that the person using the service signed these documents. Policies and procedures to guide staff in the event of a person going missing had been implemented. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 15, 16 and 17 People living at the home had the opportunities and support to participate in appropriate activities within the home and in the local community and their rights and responsibilities were recognised. The home was able to show that people were encouraged to eat a healthy diet. EVIDENCE: People who use the service were provided with a Statement of Purpose, this detailed the support available in the areas of employment, education, training and religious observation. There was documentary evidence in support plans to show that people were encouraged to attend a variety of activities such as college, day centres and arts and craft sessions. Access to the ‘Breakthrough Project’, which provided opportunities to develop practical life skills was available to all people using the service. People’s support plans showed that they participated in local community facilities. These included trips to the theatre, community centres, day trips, Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 13 pub lunches and coffee mornings, trips to the cinema, the cyber café, leisure centre and libraries. There was evidence to show that people who use the service were able to maintain contact with family and friends and this was confirmed in discussions with people who use the service. One person who lived at the home said the staff were “brilliant, and there is always loads to do but I don’t want to take part”. People who use the service appeared to have a good rapport with staff and were able to access all areas of the home. People who use the service were seen to come and go freely during the inspection. There are two kitchens for people to prepare meals. Some people prepare their meals independently and staff provide support to others according to their assessed needs. Each person has a weekly meal allowance and is responsible for their individual food shopping. The support plans demonstrate that the home provides for the cultural dietary needs of people who use the service e.g. halal, diabetes and support plans contained guidelines in this area. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 14 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 standard(s) 18, 19 and 20 The home encourages and supports people who use the service to maintain their personal, emotional and healthcare needs. Overall the home’s medication system protected people although some amendments to the medication policy were suggested. EVIDENCE: People who use the service were encouraged and supported to maintain their personal care and encouraged to be as independent as possible. The support people need is set out in their support plan. If people required specialist support, aids or equipment then the home worked with the relevant healthcare specialists to provide this. The home used a key worker system to provide some consistency and continuity. Primary health care checks and their outcomes had been recorded in support plans. It was evident that the staff had developed good working relationships with health care professionals. Evidence was provided to demonstrate that people had access to the full range of community health services such as psychiatry, chiropody, dentists and opticians and staff provided people who use the service with information to Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 15 help them to understand their condition. All the people using the service were registered with the local general practitioner practice. The medication administration system was provided through a local pharmacist who also provided medication training. Records were maintained of all deliveries, returns and the administering of medication. The medication policy did not include a section relating to self-administration for people on leave from the home and it was strongly recommended that the home amend the medication policy accordingly. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 16 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 standard(s) 22 and 23 People who use the service are provided with the opportunity to raise their views and concerns and the home has the policies, procedures and systems in place to protect people from harm. There was a policy in place for the protection of vulnerable adults and staff had received training in what to do in the event of an allegation of abuse, thus ensuring the safety and well being of the people who use the service. EVIDENCE: The home had the required Adult Protection procedure including Whistle Blowing. The home also had copies of the Department of Health guidance document, ‘No Secrets’ and Manchester Multi-Agency document on the Protection Of Vulnerable Adults (POVA). Policies and procedures relating to money and financial affairs of people who use the service were in place and the home provided facilities for the safe keeping of money and valuables. The home had regularly informed the CSCI of any incident that affected the welfare of people including a POVA investigation, which was ongoing at the time of this inspection. There was evidence to show that appropriate action had been taken in line with both the home’s Adult Protection policy and procedures and the Manchester Multi-Agency Policy for the Protection of Vulnerable Adults. Staff members spoken to were aware of the action to be taken in the event of an allegation of abuse. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 17 The home kept a record of all complaints that included detail of the complaint, the investigation and outcomes. There were also a number of compliments about the service which had been received from people who used the service and their relatives. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 18 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 standard(s) 24 and 30 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home felt comfortable and homely and all areas were decorated to a high standard. Furnishings, fittings and equipment were of good quality and domestic in nature. All bedrooms were single and were comfortable and personalised. The home had a programme of routine maintenance and renewal of the fabric and decoration. The premises were accessible and people were observed to be moving freely around the home during the inspection. The home provides attractive, wellmaintained grounds, which are accessible to people living in the home. The home was clean, well maintained and free from offensive odours. Since the last inspection the kitchen area had been redecorated. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The numbers and skill mix of staff were sufficient to meet the needs of the people accommodated. The homes recruitment policies and procedures promoted the safety and wellbeing of the people using the service. EVIDENCE: Job descriptions were clearly defined and linked to achieving the individual goals of the people who use the service. Staff members participate in group interviews with group discussions and a practical skills task such as developing a support plan from a case study. Each member of staff had a detailed individual training and development plan, which also included certificates of achievement. All the staff members spoken to said that they had regular training sessions on care related topics. Staff members seemed enthusiastic about their training and understood it was an important part of their personal development. A random sample of staff files were examined during the inspection and found to contain two written references, evidence of Criminal Record Bureau checks, application forms, proof of identity, induction schedules, supervision and appraisal records and photographs of individual staff. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 20 The manager stated that those staff employed after the 26th July 2004 were checked against the Protection of Vulnerable Adults list prior to commencing employment. Staff had been given copies of the General Social Care Council Codes of Conduct for care workers and statements of terms and conditions of employment. There were no volunteers employed at the home at the time of the inspection. There was documentary evidence on staff files to show that staff were receiving recorded supervision which was being recorded. All staff had an appraisal following their three-month probationary period. Appraisals would then take place every six months. Staff members had been given copies of the home’s grievance and disciplinary procedures. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home had the policies, procedures and systems in place, which safeguards and protects people’s financial interests. The home was seen to promote the health, safety and welfare of the people who use the service and staff although there was one area of concern. EVIDENCE: The home had purchased a new tumble dryer. The new dryer was too large to sit on top of the washing machine and was placed next to the washer. This resulted in restricted access and created some risks to people using the laundry room. The manager stated that the organisation was considering extending the laundry room. A risk assessment had been carried out. There was evidence to demonstrate that regular maintenance and testing of the home’s equipment was carried out. Current test certificates were in place for the gas boiler, portable fire fighting equipment, fixed electrical installation, emergency lighting, the fire alarm and portable electrical appliances. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 22 The fire alarm was tested at prescribed intervals. People living at the home and the staff were aware of the procedure to be followed in the event of the fire alarms being activated. Records for periodical health and safety checks were current. Risk assessments and data sheets for the Control of Substances Hazardous to Health had been undertaken. Regulation 26 visits were carried out and the reports were submitted to the Commission for Social Care Inspection. The home’s registration certificate was displayed and the home had a current insurance certificate offering sufficient cover. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 23 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Creative Support Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 24 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 42 Regulation 13 Requirement Timescale for action 30.10.05 2. 9 15 3. 20 13 The restricted space in the laundry room on the ground floor posed a potential hazard to people who use the service and the room must be re-furbished to safely accommodate the washing machine and tumble dryer. People who use the service must 30.10.05 sign their risk assessments to indicate their involvement in the process. The home must arrange a review 30.10.05 of painkilling medications which were refused on a regular basis. 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. 2. Refer to Standard 20 20 Good Practice Recommendations It is strongly recommended that the medication policy be amended to include the homes policy and procedures for self-medication when people are on leave from the home. It is strongly recommended that the home keeps a list of those staff responsible for administering medication along with a sample of their signature and initials with the F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 25 Creative Support Medication Administration Records. 3. 4. Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Creative Support F55 F05 S21609 Amherst Road v243477 110805 stage 4.doc Version 1.40 Page 27 - 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!