Inspection on 15/01/07 for Creative Support

This inspection was carried out on 15th January 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creative Support 05/12/05

Creative Support 29/06/05

Creative Support 26/10/04

Creative Support 08/06/04

Creative Support 20/02/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOME ADULTS 18-65 Creative Support 35 Coatham Road Redcar TS10 1SA Lead Inspector Val Daly Key Unannounced Inspection 15th January 2007 10:00 Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 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 DS0000000067.V326529.R01.S.doc Version 5.2 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 DS0000000067.V326529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creative Support Address 35 Coatham Road Redcar TS10 1SA 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) 01642 493500 01642 482990 Creative Support Ltd Miss Lucy Elizabeth Chapman Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Creative Support is a home for 12 adults between the ages of 18 -64. The home describes the house as a hostel and the residents are cared for in the home for up to 2 years. There are planned programmes of rehabilitation to prepare people to live independently. There is a team of mental health care professionals monitoring each persons well being. The house has 12 single bedrooms 6 of which are en-suite; a large communal lounge has a TV music system and a pool table. The fully equipped kitchen encourages residents to be assisted with cooking and cleaning. Staff supports the residents with household activities. The house is located close to the beach and the shops and the residents spend a lot of time out in the community. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by one inspector over two days. As a key inspection, all of the key standards were examined. A tour of the home took place, residents records were examined, records including accidents, complaints and menus were looked at and three residents, two members of staff and the manager were engaged in discussion about life at Creative Support. What the service does well: What has improved since the last inspection? What they could do better: The quality assurance needs to be extended to include the views of residents and staff. There are some communal areas, which require attention, the ground floor corridor, and a bathroom and shower room. The work surfaces in the kitchen are also worn and there are some areas where the surfaces have been cut through. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident’s care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each resident’s needs are met at the home and inappropriate admissions avoided. EVIDENCE: Two sets of residents care documentation were examined and they both contained a full detailed assessment of needs. A core assessment is also completed, containing the referral information. Prior to admission a transition/planning meeting takes place involving those people concerned in the care of the resident. Further assessments are carried out on a regular basis and include the resident and key worker. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. EVIDENCE: Residents are involved in their individual plans of care. The key worker carries out reviews and one to one discussions take place with the resident. Three residents spoken to during the inspection said that staff support them and make suggestions as to how they spend their days. The care records also include the resident’s weekly timetable. The key worker completes a summary report at the every month, which includes information on the resident’s health, medication, care needs and activities. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 10 Each resident has individual risk assessments depending on their needs and activities that they carry out. The risk assessments are detailed and include any trigger factors. However information is repetitive within the support plan and risk assessments. Reviews take place either six monthly or as the situation changes. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s rights are respected and routines in the home are flexible. Good contact is maintained between residents and their friends and relatives. EVIDENCE: The residents enjoy a range of activities both at home and in the local community. Daytime activities include, badminton, football, swimming, cinema, indoor bowls, local walks, and voluntary groups, attending college. There are board games in the home and scrabble is popular amongst the residents and staff. Pool competitions are held in the home, which are enjoyed by both those participating and watching. Some of the residents go out in the evening visiting friends or to the local pub. Staff organise a ‘theme’ night for the evening meal every month, for January it was for a ‘Burns Night’ There is also a special event every month which is chosen by the residents, for example, going to a show. A notice board in the main lounge displays the details of forthcoming events. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 12 It was noted that staff are respectful towards residents and are aware of their individual rights in their daily lives. Residents spoken to said ‘staff were really good’. One resident praised his key worker and felt that he received a lot of support. The menus showed that a variety of home cooked food is offered to the residents who eat from the home’s food. Many of the resident’s buy and cook there own food as part of their move towards semi or independent living. Staffs encourage healthy eating and look for low fat options. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good support from staff to ensure that their personal, physical and emotional needs are met. The home has procedures for storing and administering medication in place, however they are not always adhered to. EVIDENCE: The care plans examined detailed the personal support needed and given. All residents in the home have their own General Practitioner, some attend appointments on their own and others require an escort. Psychiatrists and Community Psychiatric Nurses also see residents when required. Each resident receives support from staff to the level that they choose and require. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 14 Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. However the medication records showed gaps where signatures or reasons for not giving medication should have been. Some of the residents are given their medication daily or weekly in dossettes to manage their own medication. This is supervised to ensure compliance of medication is taking place. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system, which residents can use if they are unhappy, have a grievance or dispute. Staffs have received training in adult protection to safeguard the residents fro abuse. EVIDENCE: The home has a complaints procedure and policy in place. However both the corporate and local policy requires re writing. Information regarding the Contacts and Commissioning Departments of Local Authorities needs to be included so complainants know they may contact them if they are not satisfied with the home’s response to their complaint. There had not been any complaints made to the home since the previous inspection. Staff work very closely with the residents and any concerns or grumbles are usually dealt with straight away. The home has an adult protection policy and procedure in place. Staffs training files were examined which showed that training in ‘No Secrets’, the protection of vulnerable adults had been completed and is part of the rolling programme for staff training. Two staff interviewed confirmed they had received the training. Information about adult protection is available to residents. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely and comfortable for the people who live there, some communal areas need re decorating. EVIDENCE: The home in the main was comfortable, safe and well maintained. However there are some communal areas, which require re decoration. The wallpaper and paintwork along the downstairs corridor is worn. The work surfaces in the kitchen are also worn and there are some areas where the surfaces have been cut through. The shower on the first floor needs re decorating and the tiles need re grouting. The bathroom needs redecorating, it was also odorous and required a thorough clean. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffs that are motivated, competent, approachable and trained support residents. Recruitment policies and procedures are robust. EVIDENCE: The home has a training plan in place and a matrix shows the training that has been completed and what is needed. Memos from Head Office are sent to the home offering places on various training courses. Staff interviewed described the training they had received and the many courses that are available following mandatory training, Advanced Mental Health, CPN legislation, Assertiveness, Management, Presentations, Supervision. Staff training files were examined which showed training had been carried out in Food Hygiene, ‘No Secrets’, Risk Assessments, First Aid and Fire Training. Each member of staff has a personal training plan. There are more than 80 of care staff have achieved NVQ level 2 or above. The home has recruitment policies and procedures in place. Three staff files examined showed that the home’s policies are being followed and all the required documentation was in place. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 18 The home has a formal supervision system in place with staff receiving supervision every eight weeks. The manager is available to carry out extra supervision sessions if needed. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager who is new in post has settled into her role with enthusiasm and has maintained the stability within the staff team. Residents are protected by the health and safety policies and procedures. EVIDENCE: The home undertakes an annual quality audit of the service they provide. In the past this has included a resident from another service speaking to residents, asking their views and reporting on them. Either this should be re commenced or an alternative way of seeking the residents’ views and also of the staff needs to be carried out. A senior member of staff also undertakes an annual audit of documentation used within the home. Monthly meetings both for residents and staff take place. An agenda is set for these meetings giving people the opportunity to add to it and minutes of the meetings are taken. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 20 The manager is also available to speak with residents and staff on a daily basis. Residents spoken to said that staff are always around in the home to offer advice and support. The home has health and safety policies and procedures in place. Training files showed that staff has received training in health and safety The manager has been in post for a few months and has submitted an application to the Commission to become the registered manager. Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 21 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 X 34 3 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 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X X 3 Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 22 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. 2. Standard YA20 YA30 Regulation 13. (2) 13. (3) Requirement There must be no gaps in the recording of medication. The bathroom requires a thorough clean. Timescale for action 28/02/07 28/02/07 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 YA22 YA24 Good Practice Recommendations The complaints policy needs re writing to include details of the local authorities contracts and commissioning department. There are some communal areas, which require re decoration. The wallpaper and paintwork along the downstairs corridor is worn. The work surfaces in the kitchen are also worn and there are some areas where the surfaces have been cut through. The shower on the first floor needs re decorating and the tiles need re grouting. The bathroom needs redecorating. The views of residents and staff need to be included in the quality assurance. 3. YA39 Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 23 Creative Support DS0000000067.V326529.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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