Inspection on 16/08/05 for Creative Support

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/05/06

Creative Support 17/01/06

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 Sue Jennings Unannounced 16 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Creative Support Address 401 Wilmslow Road Fallowfield Manchester M20 4NB 0161 248 6070 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Creative Support Ltd Responsible Individual - Ms Anna Lunts Miss Lisa Marie Croft CRH Care home PC Care home only 8 6 2 Category(ies) of MD Mental disorder registration, with number MD(E) Mental disorder of places Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 08 March 2005 Brief Description of the Service: The home provided accommodation for up to eight women who suffer enduring mental ill health, emotional difficulties and who are vulnerable. Accommodation is provided in a large Victorian house set in its own grounds with ample car parking to the front. 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. The accommodation is provided on three floors accessed via stairwells. Provision is made to accommodate eight people in single en-suite bedrooms. Communal space consists of a lounge with adjoining conservatory, three kitchens, one of which has a dining area and two laundries. The home is well maintained, bright and comfortably furnished. Ramped access is available for people who have impaired mobility. Creative Support F55 F05 s21610 creative support v244080 160805 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 four-hours on Tuesday 16th August 2005. During the course of the inspection time was spent talking to the manager and some of the residents to find out what it is like to live in the home. Time was spent examining records, documents, the residents and staff files. A tour of the building was also conducted. 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. The home had received three complaints since the last inspection. The Commission for Social Care Inspection had received a notification of concern regarding the work practices of a member of staff. 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: People who use the service are admitted to the home following a comprehensive assessment of their needs. The home’s décor, furniture and the facilities are of a good standard. There were a variety of communal areas available including a communal lounge leading to a conservatory and a small kitchen on each floor. There was a warm and welcoming atmosphere in the home. There were pieces of artwork undertaken by residents hung on the walls and the home displayed some very nice mosaic plaques and mirrors, which had been produced by a previous resident of the home. Staff were observed to be pleasant and courteous. Residents were seen to have good interactions with staff. The standard of cleanliness throughout the home was high. One resident said, “I have a lovely bedroom and its nice and clean” and “I have lots of space”. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 6 Staff at the home appeared to treat people with respect and dignity. The manager said that residents have choice with regard to their daily lives. 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 s21610 creative support v244080 160805 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 s21610 creative support v244080 160805 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) 2 People are only admitted to the home following a multi-disciplinary assessment of needs has been undertaken. EVIDENCE: People were admitted to the home following a multi-disciplinary assessment of their needs. The home undertook a comprehensive in-house assessment of need these were in place for each person and the support plans were developed from these assessments. A sample of support plans was examined they were seen to contain a Care Manager’s Assessments of needs. There was evidence that residents had been involved in their assessments of need and risk assessments. Assessments and reviews had been signed by the resident to indicate their agreement. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The home clearly identified people’s needs and goals and had identified situations and personal behaviours that may place them at risk. Although an area of risk was identified. EVIDENCE: A random sample of people’s files was examined and found to contain a photograph, support plans and risk assessments. There was evidence to demonstrate that people had been involved in the development of their support plans. Risk assessments were seen on resident’s files and it was evident that they had agreed and signed risk assessments and support plans. The support plans were comprehensive and there was documentary evidence to show that reviews of support plans were held on a regular basis. There was evidence to show that other healthcare professionals had, where necessary, been involved in the development of support plans. Any restrictions to resident’s choice were based on risk assessments and recorded on personal files. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 10 Individual risk assessments and risk management plans were in place for all risks identified throughout the assessment process. It was evident that risk assessments had been reviewed on a regular basis. There were some concerns regarding a recent incident where a resident left the building and the home’s policy and procedures had not been followed placing the resident’s personal safety at risk. There was documentary evidence to show that the incident had been thoroughly investigated and appropriate action taken following the investigation. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, and 17 The home provided a good environment for the people who live there with a wide range of activities. People were able to maintain contact with family and friends and were able to exercise choice and control over their lives. EVIDENCE: Each person was provided with a summary of the Statement of Purpose and Function on admission in the form of a ‘Welcome Pack’. The Statement of Purpose and Function detailed the support available in the areas of employment, education, training and religious observation. There was documentary evidence in support plans to show that people attended various community activities such as colleges, day centres and arts and craft sessions. There was artwork completed by a person who used to live at the home displayed in the hallway. People also had access to the ‘Breakthrough Project’, which provided opportunities to develop practical life skills. Support plans detailed the experiences of a person’s participation in local community facilities. These included trips to the cinema, theatre, community centres and libraries. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 12 The manager reported that people also attended the cyber café in Manchester. The people living at the home had just returned from a long weekend away at ‘Howetop’ in the Lake District close to Lake Widemere. People spoken to said they had “a lovely time, it was a really nice house and the rooms overlooked the Lake”. One resident said “it was a lovely weekend I would have liked to stay longer”. The manager reported that some people prepared their own meals, others required some assistance, mealtimes were flexible and people were given the choice of where and when they wanted to eat. People spoken to said “we cook our own meal about 1 or 2 times a week” and “we sometimes go out for a meal”. People were offered the opportunity to go out for a meal on a regular basis. Staff assist with the weekly shopping. People were seen to go out at various times during the inspection. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Overall people’s health and personal care needs were being met and the home’s medication administration systems protected people living at the home. EVIDENCE: Daily routines such as getting up, going to bed and mealtimes appeared to be flexible. Guidance and support regarding personal hygiene was available to people if required. There was evidence that people were being encouraged to express their individuality and personality as reflected in their chosen style of dress etc. Consistency and continuity of support for people was being maintained through use of a designated keyworker system. All people living at the home were registered with a local general practitioners surgery. Records provided evidence that people had regular access to dentists, chiropodists and opticians. Annual healthcare checks were up to date with specific outcomes recorded. Prompt referrals had been made to relevant health professionals according to the identified needs of the individual. The home used a monitored dosage medication system and medication was stored in a locking cabinet, which was secured to the wall. Residents prescribed Clozapine had their medication dispensed by the hospital and collected their Clozapine on a weekly basis. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 14 The medication system was not thoroughly examined and will therefore be fully inspected at the next inspection. Creative Support F55 F05 s21610 creative support v244080 160805 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 People who use the service knew the complaints procedure and the procedure had been used. There was a policy in place for the protection of vulnerable adults and most staff had received training in what to do in the event of an allegation of abuse, thus ensuring the safety and well being of the people using the service. EVIDENCE: The complaint procedure was available for all residents to use and some had followed this to raise their concerns and worries with the home. The Commission for Social Care Inspection had received one notification relating to poor care practices. This incident had been fully investigated and appropriate action taken to prevent a reoccurrence. The home had policies and procedures relating to abuse/protection of vulnerable adults, a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse and a ‘Whistle Blowing’ policy. The home had regularly informed the CSCI of any incident that affected the welfare of people including one POVA investigation. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: At the time of inspection the home was found to be clean, tidy and free from odour. The home appeared to be comfortable and well maintained. People spoken to stated that the home was “good it is nice and clean” one resident said the “conservatory is lovely”. The building was accessible and people were seen to move around freely during the inspection. Furniture, fittings and equipment were of good quality and domestic in nature. It was reported that the home had a planned programme of re-decoration, maintenance and renewal. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 17 One of the en-suite bathrooms had a bath seat and a grab rail fitted. One person said that they had been having difficulty getting out of the bath but these items had helped. The manager reported that they make a direct referral to social services for an assessment for aids and adaptations on an individual basis. The manager reported that there were plans to re-furbish the kitchen areas. Creative Support F55 F05 s21610 creative support v244080 160805 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) 34 and 35 The numbers and skill mix of staff were sufficient to meet the needs of the people accommodated. The home’s recruitment and selection procedures protected residents. EVIDENCE: The skill mix, experience and numbers of staff appeared to be appropriate to meet the needs of the people accommodated. Two staff were on duty at all times during the day and evening with a sleep-in and a waking night staff available during the night. The home had a training and development plan. Staff had access to the corporate training calendar and a new training booklet had been produced. The home also used staff meetings to share skills and experience. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 19 A random sample of staff files was inspected and found to contain a completed application form, two written references, proof of identification, a Criminal Records Bureau check and a photograph. Staff commenced in-house induction training on commencing employment and then after six-weeks attend an induction course at Creative Support’s head office. However, there was evidence that one member of staff had cancelled their induction on two occasions. The home must ensure that all staff undertake induction training within 6 weeks of commencing employment. There was evidence to show that regular recorded supervision sessions were being provided. Creative Support F55 F05 s21610 creative support v244080 160805 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) 37 None of the standards in this section were assessed during this inspection. Although it was noted that the new manager had not submitted an application for registration with the Commission for Social Care Inspection. EVIDENCE: A new manager had been appointed since the last inspection. The manager must submit an application for registration with the Commission for Social Care Inspection. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 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 x x 3 Standard No 31 32 33 34 35 36 Score x x x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Creative Support Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 22 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 9 Regulation 13 Requirement The home must ensure that unecessary risks to health and safety of people who use the service are identified and so far as is possible eliminated. All staff must receive training appropriate to the work they are to perform. This includes a structured induction programme. The manager must submit an application for registration with the Commission for Socail Care Inspection. Timescale for action 30.905 2. 35 18 30.10.05 3. 37 9 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 recommedations were made as a result of this inspection. Creative Support F55 F05 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 23 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 s21610 creative support v244080 160805 stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!