Inspection on 14/07/05 for Creative Support

This inspection was carried out on 14th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Creative Support 25/10/07

Creative Support 19/06/06

Creative Support 29/11/05

Creative Support 08/10/04

Creative Support 07/04/04

Creative Support 09/02/04

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 43 Station Road Crumpsall Manchester M8 5EB Lead Inspector Sue Jennings Unannounced 14 July 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 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Creative Support Address 43 Station Road Crumpsall Manchester M8 5EB 0161 740 2702 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 Limited Responsible Individual - Anna Lunts Sheila Reynolds - Newby Care home only (PC) 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) (5) of places Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: (1) The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 8 October 2004 Brief Description of the Service: Station Road is a care home providing 24-hour support and accommodation for up to five (5) people whose support needs relate to their mental health. The service forms part of the North Manchester Rehabilitation Scheme. The service is jointly-funded by Creative Support and the Manchester Mental Health and Social Care Trust (MMHSCT). The building is owned and maintained by St Vincents Housing Association. The home is situated in the Crumpsall area of North Manchester and is close to transport links, local shops and leisure facilities. The house is sited on a residential street and is similar in style to other houses in the immediate area. The homes phiosophy is based upon empowering people and ensuring that they are proactively involved in planning to meet their needs. Bedroom accommodation is provided on the first and second floors. All bedrooms are single and are fitted with wash hand basins. The home does not have a passenger lift and access to the first and second floors is via a central staircase. The home is therefore unable to offer a service to people with a high level of impaired mobility. Communal space is provided on the ground floor with two lounges and a large kitchen area. Laundry facilities and a games room are located in the basement. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, which took place over the course of 5 hours on Tuesday 14th July 2005. During the course of the inspection time was spent talking to the manager, two of the residents and a member of the nursing staff to find out their views of the home. Time was spent examining records, documents, the residents and staff files. A tour of the building was also conducted. Most of the requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. There had been no complaints received about the home since the last inspection. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well: Prospective residents are referred to the home flowing a multi-disciplinary assessment. The home’s décor, furniture and the facilities at the home are of a high standard. A variety of communal areas are available for residents including two lounges on the ground floor, a communal kitchen, laundry facilities and a games room in the basement. The atmosphere in the home was warm and welcoming. Staff were observed to be pleasant and courteous with residents. Staff were seen to have good interactions with residents and were observed dealing with residents individual needs. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 s21608 Station Road V238920 D140705 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 s21608 Station Road V238920 D140705 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, 2, 3 and 4 The home provided sufficient information to enable prospective users of the service to make an informed choice about the home. Each person moving into the home had a needs assessment and was able to visit the home prior to making a decision to move in. EVIDENCE: The home had produced a Statement of Purpose that contained clear and detailed information as required under Schedule 1 of the Care Home Regulations 2001. Each person was given a ‘Welcome Pack’ on admission. This was an individualised document containing all the information about Creative Support and the home. The home had a joint Admissions Policy and procedure, which set out the referral, allocations and introduction process One person spoken to stated that they were moving to another house within the project and had been to have a look at the bedroom. It was evident that the organisation encouraged people to view the home prior to making a decision about admission. Prospective residents would be fully involved in the admissions process. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 9 A range of pre-admission and ongoing assessment material was seen in resident’s files these included Care programme Approach assessments and Care Plans. The in-house assessments covered personal, social, emotional, mental health and general health needs and were clearly dated and signed by the assessor and the resident. There was evidence to show that residents and other relevant people had been fully involved in the pre-assessment process to ensure the service was able to meet their needs. Creative Support F55 F05 s21608 Station Road V238920 D140705 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 Residents were involved in planning their care and were encouraged in making decisions and choices within a risk assessment framework. EVIDENCE: A random sample of Care Plans was examined and seen to contain an introduction to the person. The resident’s identified goals for personal and healthcare support and for their future housing and occupational goals. Care plans included planned interventions and support and the desired outcome from the support offered were recorded. There was evidence to show that residents signed their Care Plans and review dates were agreed. The home used a key worker system where named staff would work in partnership with residents to develop and review the ongoing Care Plan. There was evidence to show that the Care Plan was reviewed on an ongoing basis determined by the needs of the individual resident. In addition the service Care Plan was reviewed during the Care Programme Approach (CPA) review process. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 11 There was evidence to show that residents were supported in the management of their personal finances and that this had been clearly recorded in the Care Plan. The manager reported that residents had access to Advocates to assist with managing finances these included an Appointee service via Creative Support, Hospital Advocates and Care Managers. There was evidence to show that any restrictions on choice were identified through the assessment process in partnership with the resident and were based on a risk assessment. There was evidence to show that risk assessments were reviewed approximately every six weeks. Creative Support and the Manchester Mental Health and Social Care Trust had developed a joint risk assessment/risk management and joint Missing Person Policies and procedures. Creative Support F55 F05 s21608 Station Road V238920 D140705 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 who use the service were encouraged to participate in leisure and community activities and to develop relationships with friends and family. EVIDENCE: There was evidence to show that people were involved in developing their computer skills. One resident spoken to said that they had achieved the ECGL award in computing and would like to pursue a career in computers. The manager said that one of the residents previously accommodated at the home had designed the front cover of the home’s Welcome Pack. The Statement of Purpose and Welcome Pack provided a range of information on local community facilities and activities. Evidence was seen that resident’s goals for finding employment had been identified and work was being undertaken to develop the resident’s skills to enable them to reach their goals. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 13 The manager reported that people were encouraged to participate in therapeutic work in the gardens at the cyber café in Manchester City Centre. There was evidence to show that residents made decisions regarding the inhouse and community based social and leisure activities they wanted to participate in. A full-time activities co-ordinator was employed to work with and support people to access a variety of appropriate leisure activities. The manager reported that the old office in the basement was being converted into a games room. People who use the service had been fully involved in the planning and decision making for this facility. Resident’s were encouraged and, where needed, supported to maintain regular contact with their families and friends this included weekend stays. Visitors were welcome to the home and people had the space for privacy. The daily routines of the home were flexible, based on the individual person’s needs, there were no set mealtimes and each person cooked their meals when they wanted them. Each resident had a bedroom and front door key. Mail was delivered to each resident unopened but support was offered if requested. The manager said that individual mailboxes were going to be installed in the games room so that people could check themselves if they had received mail. There was no restriction of movement around or in/out of the home. Each resident was responsible for cleaning their bedroom and had their own responsibilities for domestic tasks around the house. There was a housekeeper who occasionally prompted people with cleaning and laundry tasks. Each resident had their own food budget and they were supported and encouraged to take responsibility for the planning, shopping, and cooking of their own meals. The service supported and provided information to residents regarding a healthy nutritious diet and each person had their own storage space for food. One resident had a halal diet and was provided with separate microwave oven, crockery and cutlery equipment. Creative Support F55 F05 s21608 Station Road V238920 D140705 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 service worked with people and their representatives to record their goals and support needs in an individual plan. However, the medication recording systems did not fully protect the health, safety and welfare of the people who use the service EVIDENCE: The home did not provide personal care to any of the people accommodated. There was evidence to show that people had regular access to both specialist and general healthcare services based on their individual needs. Each person was encouraged and supported to take responsibility for their health needs. Relevant health monitoring was carried out on a regular basis and recorded. Evidence was seen through the Care Planning process and discussions with resident’s that the service offered the support and therapeutic input needed to help people to address their mental health needs. There were a number of gaps in recording on the Medication Administration Records (MAR). The manager reported that this was highlighted during the monthly audit of the medication systems. This issue raised serious concerns about the health and welfare of people who use the service. It was impossible to audit if medication had been administered where MAR sheets were not signed. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 15 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 The home had a complaints procedure that was known to people who use the service and they knew how to make a complaint. The home’s policies and procedures served to protect people from abuse. EVIDENCE: There was a joint Complaints Policy and procedure developed by the Manchester Mental Health and Social Care Trust and Creative Support, which been agreed and implemented. This included the role and contact details of the Commission for Social Care Inspection. There was evidence to show that people were aware of their rights to raise concerns and complaints. A record was kept of all concerns and complaints raised by people who use the service. The home had not received any complaints since the last inspection. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 16 Evidence was seen that the service had access to a clear and detailed in-house adult protection policy and used the Manchester Multi-Agency Adult Protection Procedures. Evidence was seen that staff had undertaken Adult Protection training. A joint policy and procedure for the management and monitoring of people’s personal finances developed by the Manchester Mental Health and Social Care Trust and Creative Support had been agreed and implemented. Each person had access to secure storage in their rooms for personal monies and valuables. The manager reported that some people received appropriate support to manage their personal finances. The Mental Health and Social care Trust and Creative Support had agreed and implemented a joint ‘Whistle blowing’ policy and procedure. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 17 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 and private accommodation is well equipped and personalised EVIDENCE: The premises were clean, well maintained and decorated. Evidence was seen of completed and ongoing redecoration and development of the premises to meet the needs of residents. The manager reported that a programme of redecoration was underway and people who use the service had been sampling paint colours for use in bedrooms and communal areas. The manager reported that CCTV cameras had been fitted to the front and the rear of the premises as a security measure these were seen during the inspection and did not appear to impinge on people’s privacy. At the time of inspection the premises were clean, hygienic and free from offensive odours. People were encouraged and supported to do their own laundry and there was a domestic washing machine and tumble dryer located in the laundry. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 18 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) 35 The numbers and skill mix of staff appeared sufficient to meet the needs of the people accommodated. EVIDENCE: Creative Support provides a team of staff that includes the registered manager, a senior support worker and an activities co-ordinator. Their role is to provide support to the people who use the service with social, leisure, occupational and current and future housing needs. The Manchester Mental Health and Social care Trust (MMHSCT) provides a team of registered mental health (RMN) nurses and support workers. Their role is to meet the mental health care and day-to-day support needs of the residents. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 19 There was evidence to show that all of the staff employed to work in the home had access to a range of ‘core’ and specialist training based on the needs of residents. An individual training and development record (Personal Development Plan) of the training had been developed for each member of staff. Copies of the certificates from training events were seen. One member of health staff spoken to stated that they were offered a variety of training and were currently undertaking an NVQ qualification. It was evident that training needs had been identified through the supervision process. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 20 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 systems and procedures in place, which safeguards and protects people and the home was seen to promote the health, safety and welfare of the people who use the service and staff. The home’s systems ensured that resident’s views of the service were obtained. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 21 EVIDENCE: The home used a quality assurance system in the form of anonymous questionnaires that could be discussed through meetings or through the oneto-one sessions with the person’s key worker. A random sample of the questionnaires was examined. Any issues raised were collated into a quarterly management report that was then developed into an annual business plan for the service. The Business Plan for 2005/06 was seen and contained clear aims and objectives for action in relation to the service and staff development. There was an opportunity for people who use the service to join an ‘Audit Group’ whose remit was to review and inspect the services offered by Creative Support. A senior manager carried out monthly inspections of the home and there was recorded evidence of any actions taken as a result of these visits. There was evidence to show that the home had Accident and Incident reporting and investigation policy and procedures. The Health and Safety Policy and procedures were seen. A fire risk assessment had been carried out on the 6th July 2005 and there was evidence to show that fire safety drills were carried out at prescribed intervals and that equipment, exits and lighting were maintained. Evidence was seen that gas and fixed electric appliances were serviced on an annual basis. The Portable Appliance Test was overdue and the manager must make arrangements for this to be carried out as soon as possible. There was a first aid box and risk assessments for safe working practices were seen. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 22 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 3 3 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 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Creative Support Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 23 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 20 Regulation 13 Requirement To ensure there are no unecessary risks to the health and safety of people who use this service the Medication Administration Record sheets (MAR) must be signed at the time of administration. The provider must arrange for a Portable Applicance Test to be carried out. Timescale for action 30.9.05 2. 42 13 30.9.05 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 Good Practice Recommendations No recommendations have been made as a result of this inspection. Creative Support F55 F05 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 24 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 s21608 Station Road V238920 D140705 Stage 4.doc Version 1.40 Page 25 - 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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