Inspection on 25/10/07 for Creative Support

This inspection was carried out on 25th October 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creative Support 19/06/06

Creative Support 29/11/05

Creative Support 14/07/05

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 Steve O’Connor Unannounced Inspection 25 October 2007 1:45pm Creative Support DS0000021608.V342458.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 DS0000021608.V342458.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 DS0000021608.V342458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creative Support Address 43 Station Road Crumpsall Manchester M8 5EB 0161 795 2477 0161 795 2477 lisa.burke@creativesupport.org.uk 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 Lisa Burke Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2006 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. Creative Support and the Manchester Mental Health and Social Care Trust (MMHSCT) jointly fund the service. The building is owned and maintained by St Vincent’s 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 on a residential street and is similar in style to other houses in the immediate area. The homes philosophy focuses on empowering people and ensuring that they are proactively involved in the 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 DS0000021608.V342458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in June 2006. This information included the home completing a selfassessment form called an Annual Quality Assurance Assessment (AQAA) describing how they feel they have supported people in meeting the National Minimum Standards. Additional information included incidents notified to the CSCI and information provided through other people and agencies, including concerns and complaints. During the inspection site visit time was spent observing how staff work with people and talking to management and staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. In addition, as part of the inspection site visit the inspector was joined by a ‘Expert by Experience’. This is a person who does not work for the CSCI but has experience of mental health services. They were able to speak to three of the four people living at the home to gain their views on the service they received. From this they wrote a report on their experience and this was used as further evidence within the inspection report. The inspection report of June 2006 highlighted areas that the home needed to work on and improve. The home had addressed all the changes. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well: People were supported to stay well and healthy and to develop their skills so that they could move onto more independent living in the community. Since the previous inspection report eight people have been supported to move on to greater independence and a high majority of people have not had to return to hospital due to their mental health. Before people come to stay at the home a great deal of work would have been completed to make sure that their needs are known and that the service would be able to provide the support required. Staff from the home and other specialist providers would work with a person to build up a full picture of their personal, health and emotional needs and identify any areas of risk that could cause them or others potential harm. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 6 The management and staff team do share the same aims and objectives for the service and work well together to support people experiencing difficult times to maintain their health and to look forward to achieving greater independence. The staff team, as a whole, have a good combination of clinical and social skills and knowledge and have shown that they understand people’s needs. As part of the process of developing and maintaining their skills people were given the opportunity to explore with staff their own personal goals and ambitions and were then supported to find out and access the relevant services and facilities. People were very positive about the social, occupational and educational opportunities that they could participate in and that by having their own structured programme helped them maintain and improve their mental health. A lot of resources have gone into making the environment of the home attractive, clean, well-maintained and homely, showing a positive attitude to the people who live there. The furnishings and decoration of the communal and private areas was contemporary and of a very good standard. The layout of the building offered people choice and the chance for privacy if required. Staff had showed that they had listened to people and what they wanted from their environment and this was seen in the well-equipped games room. What has improved since the last inspection? What they could do better: To be able to keep people safe, all staff who work with them must be aware of how to protect vulnerable people and what to do in the event of an incident or allegation of adult protection. All the staff team must have the knowledge and awareness of what their role and responsibilities are in those situations. A number of recommendations were made through the report as suggestions for even further improvement to the service people receive. These include: • People’s involvement in developing their own care plans and reviews be DS0000021608.V342458.R01.S.doc Version 5.2 Page 7 Creative Support • • • • clearly evidenced and that the person centred approach to care planning is further developed to show how the person themselves wants to be supported. The management and staff team make themselves fully aware of the implications of the Mental Capacity Act 2005 and how it will impact on supporting people’s decision-making. People’s support needs in relation to medication be clearly recorded in sufficient detail and that the medication policies and procedures were reviewed in line with the Royal Pharmaceutical Society guidance ‘The Handling of Medicines in Social Care’ Personal development programmes for staff continue to be developed and offer staff the skills and knowledge they require to support people’s needs. The agenda for the tenants meetings be provided to people prior to the meeting so that they have the opportunity to respond to the issues raised in the meetings. 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 DS0000021608.V342458.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. 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. People’s needs were fully assessed and understood prior to them coming to live at the home. EVIDENCE: There continues to be an established admissions policy and procedure, which described the process for referrals, assessments and how prospective residents are introduced to the home. Referrals were made by a variety of professionals, including Social Workers and Community Psychiatric Nurses (CPNs). When the referral was received, a joint assessment was made by the Unit’s NHS Nurses and the Creative Support staff. Other assessment documents were also used to provide detailed information about a new resident. These include the Care Programme Approach, (CPA), assessments. Samples of these assessments were seen and they covered such issues as personal, social, emotional, mental health and general health needs. The information from the variety of sources was detailed, comprehensive and was moving towards a more person centred approach to identifying and recording people’s needs. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 10 People were as involved in the pre-admission process as possible and samples were seen where the person had signed the assessment and a “Licence Agreement” which detailed the terms and conditions of the stay at the home. Being fully involved in the pre-assessment process, and being well informed of the terms and conditions of stay, ensured that the resident was clear about how the service was able to meet their needs. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to meet their personal goals and to make relevant choices and decisions about their life. EVIDENCE: Both organisations allocated a member of staff as a keyworker where named staff would work in partnership with people to develop and review the care plans. From the records sampled it was seen that people have two care plans developed to identify and describe how their needs are to be met. One is developed by the MMHSCT staff and addresses a persons mental and general health and rehabilitation needs. The second is developed by Creative Support and focuses on a person’s housing, occupational, educational and leisure goals. However, these plans were seen by the staff team and management as being one as it was recognised that issues such as meaningful occupation and leisure, for example, can have an impact on people’s mental health. Assessments and care plans also included planned interventions and support Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 12 and what the desired outcome from the support offered was for the person. The level and detail of the information recorded was comprehensive with some very clear person centred goals based on a person’s wishes and personal goals. It is recommended that peoples’ involvement in developing their own care plans and reviews be clearly evidenced and that the person centred approach to care planning be further developed to show how the person themselves wants to be supported. Care Plans were being reviewed on an ongoing basis depending on people’s needs and health. This included formal reviews through the Care Programme Approach held every 3 months at the home, which involved the person and the staff who supported them. The aim of the support people receive was to help them to develop and/or regain the skills for more independent living with less support. People were encouraged to make their own decisions about their day-to-day life and routines as well as with major life decisions such as housing, employment and maintaining their mental health. People were able to access independent advocates to assist them with aspects of their support and decision making if this was needed. The staff team were asked about their understanding of the implications of the Mental Capacity Act 2005 for people they supported in relation to decisionmaking. It was surprising to find that the staff from the MMHSCT did not appear to have had any training or awareness raising in this important piece of legislation. It is recommended that the management and staff team make themselves fully aware of the implications of the Act and how it will impact on people’s decision-making. Evidence was seen of a range of risk assessment documentation relating to the impact of people’s mental health on their lives and the hazards they may face. The assessments and guidance was clear and detailed and reviewed on an ongoing basis. Any restrictions of choice would only be made as a result of a risk assessment. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People were encouraged and supported to participate in meaningful activities within the home and in the community to develop a lifestyle that meets their needs and maintains their emotional health. EVIDENCE: One of the aims of the home was to support people to develop and/or regain skills and knowledge that would allow them to become more independent. People, staff members and other professionals work together to find out what skills they need to develop and what other interests they have. From this work skills development programmes for rehabilitation were developed that involved support and nursing staff and looked at life skills such as budgeting, cooking, healthy eating, maintaining personal health, domestic skills and dealing with housing related issues. This move towards greater Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 14 independence was seen by people as an essential but, at times, uncomfortable process. In addition, people were supported and encouraged to look at their occupational, educational and leisure interests. People were provided with a range of information about these activities and supported by their keyworkers to take part. People accessed local education services, gym, drop-in services and made use of the local leisure facilities. These activities were seen as an important part of people’s therapy and rehabilitation and were based on individual needs and not set programmes of events that people had to fit into. Residents were encouraged and supported to maintain regular contact with their families and friends. Residents said that visitors were welcome to the home but that residents were expected to respect the needs and privacy of the other residents. Each person’s routine was based on their own choices and the activities that they took part in. Mealtimes were flexible and people had their own front door key so they could come and go as they wished. Each person had their own budget for buying food and were supported and encouraged to shop for, prepare and cook the meals of their choice. People were made aware about the importance of a healthy diet for their lifestyle and supported to maintain this. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal care, general and mental health needs were being supported. EVIDENCE: People’s personal care, general and mental health needs were clearly identified through the care planning system. The support and encouragement provided to meet these needs were reasonably detailed but could be more person centred focused (see recommendation from standard 6). People had good access to general and specialist health services when they needed it due to the close cooperation and links between the two organisations and the community mental health services. People commented that they thought the support they received to access health services was appropriate. People’s medication was stored in their own rooms. The support offered depended on the individual person. It was seen that one person self-medicated whilst others required more support and encouragement. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 16 Each person’s care plan did contain a record of the medication they took and could be used to record what actual support was given to that person. It was found that this information was not complete for people’s care plans and it was unclear whether staff were administering or just supporting a person with their medication. It is recommended that people’s support needs in relation to medication be clearly recorded in sufficient detail. It is also recommended that the medication policies and procedures be reviewed to ensure that they were in line with the Royal Pharmaceutical Society guidance ‘The Handling of Medicines in Social Care’. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and practices were in place to protect people and to allow people to express their concerns. EVIDENCE: People were given information on how to raise concerns and make a complaint when they first arrive at the home and have a copy available in the house. People felt that they were treated well by the staff team and stated that they felt there was no bullying or sense of harassment. All concerns and complaints and the actions taken in response to them were recorded. Any incident that affected the welfare or safety of a person or member of staff and any actions taken was also clearly recorded and audited by the management team. The Local Authority’s Protection Of Vulnerable Adults (POVA) procedure was readily available and managers were aware of how to make a referral under the Safeguarding procedures. Not all of the staff team had undertaken any recent training around the protection of adults and this has been addressed under the Staffing section of the report. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard and flexibility of the environment met people’s needs and the systems were in place to maintain their health and welfare. EVIDENCE: The home was clean, well decorated and maintained. The decoration, furniture and fittings of the communal areas and bedrooms were modern and of a good quality. There was a relaxed and homely atmosphere. People can personalise their bedrooms and bring in their own items to make the room more personal. People had the choice to spend time in several communal areas as well as the privacy of their own rooms. This gave the home greater flexibility and met people’s needs. Since the last inspection the bathrooms have been fully refurbished and were of a high standard. One bathroom had a large shower that people preferred to a bath. The garden was well maintained and had a new decking area. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 19 In response to people’s views a room in the basement was now an activity room with a range of entertainment equipment as well as a computer with Internet access. Laundry facilities were available and people were supported to take responsibility for their own laundry. Infection control and health and safety training for staff was given and was ongoing. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 20 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): 32,33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by a staff team that had the knowledge and skills required to meet their needs. EVIDENCE: Creative Support provides a team of staff that includes the registered manager and 3 support workers. 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 with a clinical manager, registered mental health (RMN) nurses and support workers. In addition, people have access to other specialist health staff such as an Occupational Therapist and a Pyhciatric Consultant. Their role is to meet people’s mental health care and rehabilitation needs including developing/maintaining independence skills. People commented that the staff team were responsive to their needs and good relationships had been developed. Overall their experience of living at the home was seen as a positive one. This was evidenced through talking to Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 21 various members of the staff team who were able to clearly describe their role and how they all worked together with people to support them towards more independent living. This was helped by the relevant keyworkers meeting together on a regular basis to assess how the support was progressing. It was however noted that the MMHSCT and Creative Support staff had separate staff meetings. It was recommended that the full staff team had opportunities to meet together as one team to enable greater cooperation and understanding and to ensure that service aims and goals were shared. The staff team who work with the people at the home had a range of vocational qualifications. Of the non-nursing staff all but one person has achieved at least the NVQ level 2 or above. Both organisations have an established and clear recruitment procedure that requires all the necessary checks to ensure that staff were safe to work with vulnerable people. As an example of good practice a member of each organisations sits on the other organisations interview panel and people who use Creative Support’s services take part in different aspects of their recruitment process. A list of Criminal Record Bureau numbers was being maintained to show that all staff had the required certificate. At the time of the site visit one staff member from the MMHSCT was still awaiting a disclosure certificate. Both organisations had an annual programme of training events that develop staff skills and that set out a range of core training events that members of staff have to attend. All team members can be nominated to attend any of the training events provided by both organisations. Both organisations have a personal development programme for each staff member. These programmes set out key targets and core training and skills that staff required and wished to develop. It was seen that the Creative Support programme was well established and showed clear evidence of the range of Induction and further training events that staff had attended. The MMHSCT programme had only recently been implemented and was still in the process of delivering the training that staff required. Staff training records showed that the majority of the MMHSCT had not undertaken the core training. It is recommended that the personal development programmes for staff continue to develop and offer them the skills and knowledge thay require to support people’s needs. It was noted that many of the staff team had not attended any form of adult protection awareness raising or training. It is important to ensure that staff have this knowledge. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 22 The vocational NVQ, Creative Support’s Induction programme and the recently implemented Trust training programme have elements of assessing the competence of staff in their understanding and implementation of training. It is recommended that a system of assessing the competence of staff in applying the skills and knowledge they have gained from training be developed and implemented to clearly evidence that staff have the skills to meet people’s needs. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems and practices were in place to seek peoples and others views of the quality of the service. The policies and practices were in place to ensure people lived in a safe environment. EVIDENCE: The manager had been in post since December 2006 and had become the registered manager for the home in September 2007. They currently hold an NVQ level 4 in Care and were undertaking the Registered Manager’s Award. In addition, they were a qualified assessor for the NVQ vocational qualification. The MMHSCT staff, who are based at the home and who work with people living at the home, are line managed by a clinical manager based at the home. At the time of the inspection the registered manager was not available. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 24 However, the clinical manager described how they worked together in meeting the aims of the service as a whole. The service had a well established system of quality assurance. On a monthly basis a senior manager fromCreative Support would undertake an unannounced visit and look at how the serivce was supporting people. Their findings would be recorded. In addition, the organisation undertook an annual quality assurance audit. The last audit was in March 2007 and involved not only senior management but also independent assessors. From this audit a set of recommendations were made in a formal report and a plan of action was developed to address those recommendations. Questionnaires are also used to try to seek the views of other agencies about the quality of the serivce. People were supported and encouraged to express their views of the service. Regular meetings were held where people had the opportunity to talk about their concerns or any issues that they wanted to raise. People did make the comments that they often only found out the agenca for the meeting on the day and so did not have the chance to think about what they wanted to say. It is recommended that the agenda for the meetings be provided to people prior to the meeting so that they have the opportunity to respond to the issues raised in the meetings. A full series of health and safety checks were undertaken to ensure that people and staff live and work in a safe environment. All gas and electric appliances had been serviced and legionella testing was carried out. The AQAA, provided by the home, set out the dates when equipment had last been serviced. The fire checks and risk assessment were up-to-date and regular checks were being made and recorded. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 2 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 4 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 4 X X 3 X Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 19 Requirement To ensure that all members of staff know their roles and responsibilities in protecting people from harm they must be provided with the relevant information and training. Timescale for action 30/12/07 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. Refer to Standard YA6 Good Practice Recommendations It is recommended that people’s involvement in developing their own care plans and reviews be clearly evidence and that the person centred approach to care planning is further developed to show how the person themselves wants to be supported. It is recommended that the management and staff team make themselves fully aware of the implications of the Mental Capacity Act 2005 and how it will impact on people’s decision-making. It is recommended that people’s support needs in relation to medication be clearly recorded in sufficient detail. DS0000021608.V342458.R01.S.doc Version 5.2 Page 27 2. YA7 3 YA20 Creative Support 4 YA33 It is also recommended that the medication policies and procedures be reviewed to ensure that they were in line with the Royal Pharmaceutical Society guidance ‘The Handling of Medicines in Social Care’. It was recommended that the full staff team had opportunities to meet together as one team to enable greater cooperation and understanding and to ensure that service aims and goals were shared. It is recommended that the personal development programmes for staff continue to develop and offer staff the skills and knowledge they require to support people’s needs. It is recommended that a system of assessing the competence of staff in applying the skills and knowledge they have gained from training be developed and implemented to clearly evidence that staff have the skills to meet people’s needs. 5 YA35 6 YA39 It is recommended that the agenda for the meetings be provided to people prior to the meeting so that they have the opportunity to respond to the issues raised in the meetings. Creative Support DS0000021608.V342458.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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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