Inspection on 17/01/06 for Creative Support

This inspection was carried out on 17th January 2006.

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 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 12/05/06

Creative Support 16/08/05

Creative Support 08/03/05

Creative Support 21/09/04

Creative Support 30/03/04

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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 Judith Morton Unannounced Inspection 17th January 2006 11:00 Creative Support DS0000021610.V278078.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.V278078.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.V278078.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 Miss Lisa Marie Croft 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.V278078.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. 16th August 2005 Date of last inspection Brief Description of the Service: The home provides 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, two of which have dining areas and two laundries. The home is well maintained, bright and comfortably furnished. Ramped access is available for people who have impaired mobility. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of Wilmslow Road’s annual inspections. It was unannounced and took place over 4.5 hours. The standards that had not been checked on the last inspection were looked at. Four of the residents and three staff were spoken with. Two of the resident’s files and other records, such as minutes of staff and residents meetings etc were read. Two of the resident’s bedrooms were also visited. What the service does well: 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 DS0000021610.V278078.R01.S.doc Version 5.1 Page 6 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.V278078.R01.S.doc Version 5.1 Page 7 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, 3, 4, & 5. There is sufficient information for new residents to know what services are offered at Wilmslow Road. More detailed financial recording on the resident’s contracts would make sure they are fully aware of what they are signing their agreement for. EVIDENCE: On admission each resident was provided with a service user guide in the form of a ‘Welcome Pack’. It contained most of the information that would be important to a new resident moving in. However, it should include information on support offered to reviews, GP and hospital appointments. Also details on how cultural and religious needs would be met. (See recommendation 1) It was also a very long document that contained a lot of information from the statement of purpose. Residents would be more likely to read the full guide if it was produced more simply, with a brief summary of the statement of purpose and with information that would be immediately needed by new residents. (See recommendation 2) Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 8 Residents are offered an opportunity to sample the service before moving in. There was evidence in one new resident’s file that she had had a two-month introduction before moving in. In the first month she visited and sometimes stayed for a meal, in the second month she would occasionally stay overnight and then eventually moved in. Residents had a contract agreement on their file. They had signed this. However, Creative Support or Social Services contribution, or any financial contribution made by the resident, had not been included on the document. One file showed that the resident was in receipt of pension credit and mobility benefit, which would total around £140.00 per week, yet she was only receiving an allowance of £51.11 per week. On discussion with the manager it became clear that the resident was contributing the rest of her money towards her accommodation at Wilmslow Road. It should be clear to the resident exactly what she is paying towards and signing for at Wilmslow Road. (See requirement 1) Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 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 the following standard(s): 8 & 10 There is evidence to show that residents are consulted on all aspects of their life and things that affect them while living at Wilmslow Road. EVIDENCE: There were records of resident’s meetings, which showed clearly that they were being consulted about things that directly affect them. The minutes of the meetings showed that residents had made suggestions for alternative meal menus and also for monthly day trips. Other minutes showed that the residents had been consulted about where they would like to go on holiday. One resident said that she had chosen the colour of the paint for the walls, the curtains and carpet for her bedroom. The residents spoken with were aware that a file was held and that this included information about them. They also knew that their file was kept locked in the office and that they could ask to see it if they wanted. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 10 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): 11, 14, 15 & 16 Residents could participate in all daily activities if their emotional health allowed. Risk assessments would show the reasons for any restrictions to their participation. EVIDENCE: The residents were able to participate in daily activities dependant on their emotional health. On the day of inspection a number of residents were seen entering and leaving the property to go to the shops. One resident needed the support of staff to go out and they went to the local supermarket together. Some of the residents would cook their own meals while others relied on the support of staff to do this. The minutes of review meetings showed that the residents had made progress in a number of daily skills such as bathing, changing their clothes and tidying their room. One resident had made a New Year resolution to give up smoking and was being encouraged by staff to keep this. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 11 The visitor’s policy, which residents had a copy of in the welcome pack, showed that visitors were welcome at any time. However, it was recommended that visitors’ telephone before calling to make sure that the resident was at home and well enough, or willing to see them. Some of the residents choose to have a key to their room whilst others don’t lock their room. They were seen to freely move around the house and spend time in their own room or communal areas as they wished. There was a lockable draw in each of the bedrooms and each room also had an ensuite bathroom, allowing them privacy. The manager said that residents mail was recorded when it arrived and was then given to them unopened for them to read in private. If any resident had difficulty reading their post they would ask for the help of a member of staff who would read it to them in the privacy of their own room or in the office. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 12 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): 21 The staff would not know how to meet the residents’ wishes unless they are sought and recorded on their file. EVIDENCE: Two residents were subject to court of protection and their solicitors had sought details of their wishes in the event of terminal illness or death. These had been recorded on their individual plan. However, this information had not been asked of other residents and staff need to do this so that their wishes are known. (See requirement 2) Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 13 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): N/A Both of these standards had been checked and were met on the initial inspection. EVIDENCE: Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 14 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): 25, 26, 27, 28 & 29 There is sufficient personal and communal space for residents to choose where to spend their time and obtain privacy if they wish. EVIDENCE: Two residents bedrooms were visited during the inspection and two other residents spoke about their room. All of the residents were happy with their room and were particularly pleased with the ensuite bathroom. The residents were responsible for the general tidying and cleaning of their room but assistance or prompting from staff may also be needed. The residents were also responsible for choosing which clothes they would wear each day and for making sure their laundry was done. However, some residents also needed encouragement in these areas for it to be achieved successfully. This was recorded in their individual plan. One of the residents had a hearing difficulty. Her bedroom had been fitted with a red light fire alarm and vibrating alert. There had been a doorbell fitted which when pressed a light would flash above her door. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 15 The resident said she felt that all of her hearing needs were being met but would like an alarm clock as her own was broken. This was discussed with the manager who said she would enquire about an alarm clock specifically for people who were deaf. (See recommendation 3) There were a number of communal areas for the resident’s use. There was a lounge with two large sofas and a TV and a conservatory off this. The residents knew that the conservatory was the designated smoking area and were encouraged to use this when smoking within the house. There were also three kitchens, two that had a dining area. The residents were encouraged to become, or remain as independent as possible. One resident had difficulty getting in and out of the bath. A wall bar and powered, rise and fall bath seat had been provided to help with this and make sure she could remain independent in this area. There was a ramp access into the building for people who have mobility difficulties or who use a wheelchair. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 16 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): 31, 32, 33 & 36 The residents were being provided with a level of support, from competent staff, according to their assessed needs. EVIDENCE: The residents spoken with knew who their primary worker and co-worker was. They had been told this and also had the name of their primary and co-worker in their welcome pack. One member of staff had left Wilmslow Rd since the last inspection leaving one or two residents without a Primary worker. Other staff were taking the role of either primary worker or co-worker on a temporary basis for those residents. The residents also knew who the new manager was and throughout the inspection some residents spent individual time with her discussing things that were of concern to them. The residents’ reviews showed clearly that they were making progress in a variety of areas. This indicated that, for this to happen, the staff team was supporting them adequately. Additionally, the manager spoke of one member of staff who had left employment at Wilmslow Road, as she had not proved suitable during her probationary period. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 17 Staff had ‘in-house’ induction training on beginning employment and then after six-weeks attend an induction course at Creative Support’s head office. Staff were enrolled onto NVQ level 2 when they started working for Creative Support but would only begin the course once they had passed their 3 month probation interview. All staff were now receiving their induction training and formal, recorded supervision sessions were also provided. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 18 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): 38, 39, 40, 41, 42 & 43 The meetings held at Wilmslow Road would make sure that both staff and residents views could be expressed and that they could be kept fully informed of any changes in policies and procedures. EVIDENCE: The manager had recently attended a fit person interview with The Commission for Social Care Inspection and was awaiting the results of her Criminal Record Bureau check (CRB) before registration. There were regular staff meetings held at Wilmslow Rd. The minutes of the meetings showed that the manager gave clear direction to the staff that linked in with the aims of the home and the care standards. The policies and procedures were also discussed during the staff meeting as well as the Care Standards. The staff were asked to give a short presentation relating to their work, to the rest of the team. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 19 Residents meetings are also held regularly and minutes of the meetings are taken. The residents’ views and suggestions are clearly recorded but there didn’t appear to be any follow up or delegation of tasks to make sure the suggestions were followed through. It would be beneficial to know who will be responsible for what and by when so that it can be re-visited at the next meeting. There is a quality assurance questionnaire, which is completed by residents, professionals, visitors and staff. The findings of the questionnaires form a report on how people feel the company is functioning overall. It would be beneficial to those people completing the questionnaires and any prospective residents or their family, to be able to read a report specifically about how well the individual establishment they are interested in is functioning. The company should consider developing individual quality assurance feedback alongside the corporate report. (See recommendation 4) The manager had conducted a ‘survey’ of the house at Wilmslow Road in order to identify any areas that needed updating and any health and safety concerns. During the inspection one resident requested time with the manager, on her own, in the office. The resident became quite agitated and could be heard shouting. It became apparent to the inspector that should the member of staff need assistance there was no way of her requesting this. The company should consider installing a doorbell or alarm system in the office that could be used by staff in emergencies. Additionally, the office should be rearranged so that the staff member can sit near to the door rather than the resident, as happened in this case, making sure that the staff can leave the situation if the resident should become physically aggressive. (See recommendation 5) There were risk assessments held on all of the residents files which showed the level of support that the resident needed to achieve a task or activity safely. Any restriction on activities or tasks would be as a result of a risk assessment having identified a need for this. Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 20 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 X 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 2 X 3 3 3 3 3 3 Creative Support DS0000021610.V278078.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 YA5 Regulation 5 Requirement Details of financial contributions by all parties, including the resident must be included on the residents contract. The wishes of all residents, in relation to terminal illness or death, must be sought and recorded on their file. Timescale for action 01/04/06 2. YA21 3 01/04/06 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 3 4 5 Refer to Standard YA1 YA1 YA29 YA39 YA42 Good Practice Recommendations Information of support to attend reviews, GP and hospital appointments, and cultural and religious needs should be added to the welcome pack for residents. The Service User Guide should be made more simple and user friendly. An alarm clock suitable for a person who is hearing impaired should be provided to one resident. The company should consider developing individual quality assurance feedback alongside the corporate report. A panic alarm should be provided in the office and the office should be rearranged to ensure the safety of staff. DS0000021610.V278078.R01.S.doc Version 5.1 Page 22 Creative Support 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.V278078.R01.S.doc Version 5.1 Page 23 - 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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