Inspection on 12/05/06 for Creative Support

This inspection was carried out on 12th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creative Support 17/01/06

Creative Support 16/08/05

Creative Support 08/03/05

Creative Support 21/09/04

Creative Support 30/03/04

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

Tudor Bank Ltd

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

CARE HOME ADULTS 18-65 Creative Support 401 Wilmslow Road Fallowfield Manchester M20 4NB Lead Inspector Helen Dempster Key Unannounced Inspection 12th May 2006 1:00 Creative Support DS0000021610.V292675.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 Creative Support DS0000021610.V292675.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. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Creative Support Address 401 Wilmslow Road Fallowfield Manchester M20 4NB 0161 248 6070 0161 248 6070 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) Creative Support Ltd Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users are female and require care by reason of mental ill health (excluding learning disability and dementia). 6 of the service users are below pensionable age, 2 named service users are over 60 years of age. 17th January 2006 Date of last inspection Brief Description of the Service: 401 Wilmslow Rd is a care home, which provides care for up to eight women who suffer enduring mental ill health, emotional difficulties and who are vulnerable. The women who live at Wilmslow Rd prefer to be referred to as “residents”. The range of fees at the home are £373.54 to £427.12. The home is situated on the boundary of Withington and Fallowfield, close to public transport links to Manchester City Centre. Public transport links are also available to Stockport, Didsbury and Chorlton. A selection of shops, doctors surgeries and churches of various denominations are situated close by. The home is a large Victorian detached house, set in its own grounds with ample car parking to the front. The home is similar to some of the other residential houses on the street. The home does not have a sign outside to identify it as a care home to make sure that the residents live as normal a life as possible in the community. The accommodation is provided on three floors accessed via stairwells. All 8 residents have single bedrooms with en suite bathrooms. The home has plenty of communal space for the residents to use. This includes a lounge with adjoining conservatory, three kitchens (two of which have dining areas) and two laundry areas. Where possible, residents are supported to prepare their own meals in the 3 kitchens, but staff prepare some meals for some of the residents. The main dining area can seat all 8 women comfortably if they wanted to eat a meal together. The home is comfortably furnished. Ramped access is available for people who have impaired mobility. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by gathering lots of information about how well the home was meeting the National Minimum Standards. This included the manager filling in a questionnaire about the home, which gave information about the residents, the staff and the building. The inspection also included carrying out an unannounced visit to the home on 12th May 2006 from 1pm to 7pm. During this visit, lots of information about the way that the home was run was gathered and time was taken in talking with the residents and the staff team about the day-to-day care and what living at the home was like for the residents. Other information was also used to produce this report. This included reports about things and events affecting residents that the home had informed the Commission about. The main focus of the inspection process was to understand how the home was meeting the needs of the residents and how well the staff were themselves supported by the home to make sure that they had the skills, training and support to meet the needs of the residents. What the service does well: Residents are given lots of information about the home so they can decide if they want to stay there. There was also lots of information on notice boards about organisations that can help residents. The residents said that staff do explain things which they are not sure about. The home held good records about residents’ needs and any risks to them and how staff needed to support them. When anything changed, the staff made sure that the records were looked at again so the residents’ support plans told staff how to help each resident. This helped to keep residents safe and it respected their rights. Each resident has their own special member of staff who is called their “primary worker”. This person is the main carer for that resident. Residents were helped to budget so that they could manage some of their money. Residents were helped to go out to activities in the community. These included going to day centres, the cinema, coffee shops, the cyber café, libraries and local places of worship. Residents talked about a trip to Chester Zoo just before the inspection, which they said that they had enjoyed. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 6 Residents have a key to the front door and their own room and can come and go as they please. One resident said “staff help me when I need it”. She also said that she could go out when she likes. Residents said that they could see family and friends. Residents can go to bed and get up when they like and have meals when they like and staff helped residents to buy food and cook. Residents were helped by staff to go to medical appointments and the things the staff had to do to help residents with their health were written down. The way that staff helped residents to take their medication was also good. Residents said that they could make complaints at the home to the manager and staff and that “they do listen”. Staff are trained so they can protect residents from abuse and harm and the manager was very good at making sure that everyone understood what abuse was so that residents could be protected. The home was comfortable and homely, all residents had their own bedroom and en-suite bathroom and the gardens were looked after well. Residents were happy with the home. Residents said that the staff were good and that the manager was “kind”. The manager and staff were seen to be patient and respectful when helping residents. Staff were well trained and were supervised by the manager. The manager was good at checking that things that needed to be done were done and at organising meetings for staff and residents to discuss things happening at the home. The home protected peoples’ health and safety by doing regular safety checks, including fire safety checks. What has improved since the last inspection? What they could do better: Residents files, which had a lot of information in them, needed to be looked at to make sure that up to date information can be easily found by staff. People who make complaints need to be able to see all the information about their complaint, but not about other people’s complaints, so this information shouldn’t be kept in a hard backed book. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 7 Staff needed to give some residents more help with cleaning their room and the kitchens. The home needed to make sure that all the information that needs to be kept on the staff files is always there so that the manager is aware of important information about her staff. The home needed to find out the views of residents at the home and their relatives/friends and gather this information to help them to keep improving the way the home is run. 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 DS0000021610.V292675.R01.S.doc Version 5.1 Page 8 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 Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 9 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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information about the home and its services and their needs are assessed and identified. This allows them to be fully involved in the decision about moving into the home. EVIDENCE: The home has a Service User Guide/welcome pack, which was readily available to residents. This document was written in plain English and contained sufficient information for people to make an informed decision about moving in. Although it was a good source of information, it could be further improved by making it more simple and user friendly and by adding information about support to attend GP and hospital appointments and support to meet cultural and religious needs. A recommendation was made about this. The manager was reviewing this document at the time of inspection. Residents said that they had received information prior to admission and that anything that they had been unsure about was explained to them. It was also noted that notice boards at the home had a wide range of information, including information about other organisations and services, including the Benefits Agency, which was good for residents. All admissions to the home are planned and the home does not accept emergency admissions. The home uses an “offer letter” which makes clear to Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 10 the residents what the terms and conditions of living at the home are. In response to a requirement made at the last inspection, the residents had been informed, in writing, of financial contributions by all parties, including themselves. Copies of this information about the breakdown of fees and allowances was held on the residents’ files. The file of the most recent admission to the home, who was admitted just prior to the inspection, was case tracked. The assessments made by the placing authority and health authority were clear and detailed. The manager had visited this person in hospital and the information gathered at this visit, combined with the earlier professional assessment, formed a very detailed and clear statement of needs. This had enabled staff to complete a care plan so that they could meet this resident’s needs. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 11 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clearly identifying residents’ needs, goals and risks and consistently reviewing and updating these assessments in consultation with each resident protected residents from risk and respected their rights. EVIDENCE: The files of 3 residents were case tracked. This involved looking at all the information recorded about each of these 3 residents since they were admitted. Each of these 3 residents had a detailed and comprehensive support plan, which had been developed from the assessments of need. The support plan covered the residents’ personal, social and healthcare needs and was written in a way which showed that the residents had been involved in their care plan. A discussion took place with the manager about how bulky the files were due to the large volume of information which was both current and historical. It was recommended that residents’ file contents were reviewed to ensure that the essential up to date information is easily accessed by staff and that other information is archived to make the files more user friendly and to avoid any confusion for staff. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 12 The home allocates “primary workers” to be the main carer for an individual. The primary worker for one resident, who was the most recent admission to the home, was interviewed. She said that she read all the assessments about this resident before her admission, then she talked to the resident and asked her “what she needed help with”. The support plan was then compiled from information in the assessment and from the resident’s own view on her needs. This member of staff said that she then completed the “service user evaluation of involvement process”. This is a questionnaire which records how the resident felt about their involvement in the support plan. This level of involvement is good for residents because it makes sure that their views are taken into account. Detailed and clear risk assessments were in place, which covered a range of risks each resident could have based on their day-to-day life and behaviour. Other healthcare professionals had been involved as necessary in the development of support plans and risk assessments and support plans and risk assessments had been reviewed regularly. The consistent review of needs protected residents and any restrictions to a resident’s choice were based on risk assessments and were recorded on personal files. The residents’ notice boards had a wide range of information about organisations that could help them and about social events. The organisation was the corporate appointee for 5 of the residents. This meant that the organisation cashed the residents’ benefits and provided the residents with the personal allowance component of their benefits. Some residents managed their personal allowance money independently and one resident held her own bank account. Residents were supported to budget so that they could manage some of their money. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 13 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from support to participate in activities within the home and in the local community, having their rights and responsibilities recognised and, wherever possible, being encouraged to cook and eat their preferred food. EVIDENCE: Residents were provided with a Statement of Purpose which told them about the support available in the areas of employment, education, training and religious observation. None of the residents have a job. However, they were encouraged to attend a variety of activities such as college, day centres and arts and craft sessions. One resident enjoyed horse riding. Residents talked about a trip to Chester Zoo just before the inspection, which they said that they had enjoyed. Residents were also encouraged to use local community facilities including the cinema, coffee shops, the cyber café, libraries and local places of worship. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 14 The house is not identifiable as a care home and this affords the residents privacy. They have a key to the front door and their own room and can come and go as they please. One resident said “staff help me when I need it”. She also said that she could go out when she likes. Residents were able to maintain contact with family and friends and this was confirmed in discussions with residents who said that people could visit them at the home. Interactions between staff and residents were seen to be respectful and staff appeared to have a good rapport with residents who were able to access all areas of the home. Residents were encouraged to budget with their weekly meal allowance. However, some of the residents needs were great and they were not able to shop for food and cook their own meals independently. In these cases, staff assisted residents to pool their money to enable staff to buy food and cook meals for these residents from an agreed menu. One of these residents was a vegetarian and needed staff support to cook appropriate meals. The manager said that staff had obtained information from the library about low cholesterol diets for a resident who had a high level of blood cholesterol. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 15 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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported residents to maintain their personal, emotional and healthcare needs and the home’s medication system protected residents. EVIDENCE: Daily routines at the home including getting up, going to bed and mealtimes were flexible and residents had their chosen style of dress etc. Consistency and continuity of support for the residents was maintained through use of the “primary worker” system. The manager said that the home has a “matching process” for choosing the best primary worker for an individual resident, based on the individual resident’s personality and preferences and the impact of a staff member’s confidence and experience on meeting a resident’s needs. It was evident from the pre inspection questionnaire provided by the home and from talking to residents that all people living at the home were registered with a local general practitioners surgery and had regular access to other health care professionals including dentists, chiropodists and opticians. Residents also had access to appropriate screening for women, including breast screening and cervical smears. Each resident had a “primary health care monitoring sheet” which records the outcomes of all medical appointments and this record is audited each month. Prompt referrals had been made to relevant health care Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 16 professionals when a resident’s needs changed. Staff said that they supported residents to attend healthcare appointments and residents confirmed this. The home used a monitored dosage medication system and medication was stored in a locked cabinet in the office. The home was about to install lockable units in each tenant’s bedroom to store medication. The medication administration system was provided through a local pharmacist, who also provided medication training. Records were maintained of all medication received and returned to the pharmacy. Medication practice was good. This included holding copies of GP letters about medication with the medication records, having a description and drawing of each tablet to help staff to identify them, having clear and accurate medication administration records and using a “summary of work” which recorded changes in medication. The manager auditing medication practice every week, which protects residents from the potential of medication errors, maintained the level of accuracy. A requirement was made at the previous inspection about the need to find out the wishes of all residents in relation to terminal illness or death. This requirement had been addressed. The manager had recorded the details on file for some residents. She explained that the issue needed to be handled very sensitively for some residents and that discussions had to be planned when residents were “well”. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 17 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 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ concerns and complaints are investigated and the manager ensures that the home uses it’s policies, procedures and systems to ensure that residents are aware of their right not to be abused in any way and to protect residents from harm and abuse. EVIDENCE: Residents said that they could make complaints at the home to the manager and staff and that “they do listen”. The home kept a record of all complaints that included detail of the complaint, the investigation and outcomes. These records were held in a hard backed book. This would not allow a complainant to see the record of their complaint without breeching data protection and the confidentiality of others. It also meant that statements, letters etc could not be stored with the record of the complaint. It was recommended that this record be reviewed accordingly so that complainants can see all the information about their complaint. The local authority’s Protection Of Vulnerable Adults (POVA) procedure was readily available at the home. The home had regularly informed the CSCI of any incidents that affected the welfare of tenants. Staff members spoken to were aware of the action to be taken in the event of an allegation of abuse and all staff had received training in the protection of adults from abuse, which was covered in the induction procedure. The outcome of a referral to Manchester Social Services concerning the alleged abuse of one resident by another was discussed. The home had made the Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 18 referral appropriately and were continuing to consistently monitor the interactions between these 2 residents. The manager demonstrated a depth of understanding of the issue of abuse and the need to protect residents. In particular, this incident had led her to question residents’ understanding of what abuse was. She had spoken to residents individually and through a residents meeting to find out what their understanding of the issue of abuse was. The minutes of the meeting were seen and it was obvious that the issue had been handled sensitively. In the light of this, the home was felt to have exceeded this standard. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the premises was comfortable and homely, insufficient staff support to maintain hygiene could put residents’ health and wellbeing at risk. EVIDENCE: The home was comfortable and homely and all areas were decorated to an adequate standard. Furnishings, fittings and equipment were of an adequate standard. There is a ramp access into the building for people who have mobility difficulties or who use a wheelchair. One resident who has poor mobility said that when her mobility became poor and she wanted to stay at the home, staff gave her a ground floor bedroom and an adapted bathroom was also provided for her to meet her needs. She said that she was pleased about this. The home provides attractive, well-maintained grounds, which are accessible to people living in the home. Residents said that they had meals together in the large and homely main dining area. There is a ground floor smoking area for the residents to use. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 20 All the residents’ bedrooms are single and have an en suite bathroom. The bedrooms contained residents’ personal things, including pictures. Some areas of the home, including kitchen floors and worktops and some bedrooms were not clean. The need for staff to provide more support to residents to maintain hygiene was discussed with the manager and a senior manager. The manager agreed that some of the residents would benefit from more support to maintain hygiene. A requirement was made about this. At the previous inspection, it was recommended that an alarm clock suitable for a person who is hearing impaired should be provided to one resident. The alarm clock had been ordered. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 21 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, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home’s recruitment policies and procedures and staff access to training promoted the safety and wellbeing of the residents. However, staff files needed to consistently contain information which demonstrated that CRB clearance had been obtained and references taken. EVIDENCE: The residents spoken with knew who their primary worker was and who the manager was. Residents said that the staff were good and that the manager was “kind”. The manager and staffs’ contact with residents were seen to be patient and respectful. Three staff files were seen. Job descriptions were clear and detailed and records showed that staff had good access to a range of training. One member of staff’s file contained the record of the first week of their induction, which the staff member had just completed and the record of their first supervision session, completed by the manager. The manager explained that the staff have a 4 week induction at the home and an 8 day corporate induction at the organisation’s head office and that they receive supervision each week during their 4 week induction period. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 22 For 2 of the 3 files seen, references, proof of seeking CRB clearance and application forms were not on the file. The manager said that she was about to collect this information for the file of the most recently recruited member of staff from the head office. However, she was not aware that information was missing from the other file. A requirement was made to the effect that staff files are audited to make sure that all necessary information was on the file. One staff member had NVQ level 2. The organisation provides staff with NVQ training after they have passed their 3 month probationary period. Staff were receiving recorded supervision and staff had an appraisal following their threemonth probationary period. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 23 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager demonstrated good leadership skills and was consistently monitoring and reviewing practice to make sure that policies, procedures and systems at the home were used to ensure that residents were safeguarded and protected. EVIDENCE: At the time of inspection, the process for registration of the manager had almost been completed, following receipt of her Criminal Record Bureau check (CRB). The manager demonstrated a good knowledge of the residents’ needs and all contact between the manager, staff and residents were observed to be appropriate. There was also evidence in the records of the manager’s consistent audit of practice in the home. This is good for residents and staff. There were regular staff meetings held at the home and minutes were taken The home’s policies and procedures were discussed during the staff meetings Residents’ meetings were also held regularly and minutes of the meetings were taken. These meetings were used as an opportunity to discuss important Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 24 issues which affect residents, including abuse. (See concerns, complaints and protection for details). The home had a quality assurance monitoring system. However, this was corporate and did not include finding out the views of residents at the home and their relatives/friends. The need for the home to develop a quality assurance system, which involved residents and professionals, to audit the service was discussed. This is important, as it would allow the home to take account of the views of residents and their relatives/friends about how the home is run, what is good and what could be improved. A requirement was made about this. The pre inspection questionnaire described regular maintenance and testing of the home’s equipment, including the gas boiler, portable fire fighting equipment, fixed electrical installation, emergency lighting, the fire alarm and portable electrical appliances. The home had an environmental risk assessment, which is good for residents’ safety. 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. Regulation 26 visits were carried out and the reports were submitted to the Commission for Social Care Inspection so that the inspector was informed of issues at the home which affected the wellbeing of tenants. At the previous inspection, a requirement was made about the need to install a panic alarm in the office to ensure the safety of staff in an emergency. This had been requested by the manager who was awaiting fitting of the panic alarm. Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 25 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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 2 X X 3 x Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 26 No. 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 YA30 Regulation 16 Requirement The level of hygiene at the home must be improved. This includes staff supporting those tenants who need a higher level of support to maintain hygiene in their rooms and the kitchens. Staff files must be audited to ensure that they consistently contain the application form, 2 references and proof of CRB clearance. The home must review and develop their quality assurance system to provide a verifiable method, which involves residents, to audit the service and report on the findings. Timescale for action 15/06/06 2. YA34 18 15/06/06 3. YA39 24 15/08/06 Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 27 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 YA1 Good Practice Recommendations The Service User Guide should be made more simple and user friendly and should include more information about support to attend hospital and GP appointments and support to meet cultural and religious needs. It is recommended that residents’ file contents are reviewed to ensure that the essential up to date information is easily accessed by staff and that other information is archived to make the files more user friendly and to avoid any confusion for staff. It is strongly recommended that the record of complaints is reviewed so that complainants can see all the information about their complaint without breeching the confidentiality of others. 2. YA6 3. YA22 Creative Support DS0000021610.V292675.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection CSCI, Local office 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 DS0000021610.V292675.R01.S.doc Version 5.1 Page 29 - 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. 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