Inspection on 03/05/06 for Creative Support

This inspection was carried out on 3rd May 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creative Support 10/05/07

Creative Support 09/12/05

Creative Support 11/08/05

Creative Support 08/03/05

Creative Support 20/12/04

Creative Support 26/03/04

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

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 7 Amherst Road Fallowfield Manchester M14 6UG Lead Inspector Helen Dempster KeyUnannounced Inspection 3rd May 2006 2:00 Creative Support DS0000021609.V292664.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 DS0000021609.V292664.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 DS0000021609.V292664.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Creative Support Address 7 Amherst Road Fallowfield Manchester M14 6UG 0161 256 4366 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 Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be female only under pensionable age The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th December 2005 Date of last inspection Brief Description of the Service: 7 Amherst Road is a care home, which provides care for up to eight women with mental health needs. The women who live at Amherst Road prefer to be referred to as “tenants”. The range of fees at the home are £399.43 to £427.33. The home is a large detached property, which is similar to other residential houses on the street. The home does not have a sign outside to identify it as a care home to make sure that the tenants live as normal a life as possible in the community. All the tenants have a single room with en suite facilities. There are 3 kitchens, where tenants are supported to prepare their own meals. There are dining areas in each kitchen, but none of these areas could seat all 8 women comfortably if they wanted to eat a meal together. The home has one attractive and comfortable lounge area and tenants therefore tend to receive visitors in their own rooms. The home is situated approximately five minutes walk from Withington and Ladybarn shopping areas and is close to public transport links into both Manchester City Centre and Stockport Town Centre. A selection of shops, doctors surgeries and churches of various denominations are situated close by. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by gathering lots of information about how well the home was meeting the National Minimum Standards. This included a senior care worker filling in a questionnaire about the home, which gave information about the tenants, the staff and the building. The inspection also included carrying out an unannounced site visit to the home on 3rd May 2006 from 2pm to 8pm. During this visit, lots of information about the way that the home was run was gathered and time was taken in talking with the tenants and the staff team about the day-to-day care and what living at the home was like for the tenants. Other information was also used to produce this report. This included reports about things and events affecting tenants that the home had informed the Commission about. The main focus of the inspection process was to understand how the home was meeting the needs of the tenants and how well the staff were themselves supported by the home to make sure that they had the skills, training and support to meet the needs of the tenants. What the service does well: People who are thinking about living at the home are given lots of information about the home, which can be written in a different language if their first language is not English. This means that they can choose whether they want to live there. Before anybody is admitted to the home, a member of staff visits them to find out about their needs and how they want to be supported. The tenants living at the home said that anything that they had been unsure about was explained to them and that they had been asked “a lot of questions” about what they wanted and needed. This is good for the tenants. The staff helped tenants to take part in activities at the home and in the local community. When they first go to live there they are given information about how they could be helped with employment, education, training and their religion. Tenants have a key to the front door of the home and their own room and can come and go as they please. One tenant said that she likes living at the home because she feels supported but can also do what she wants, when she wants. Tenants can see their family and friends. One tenant said the staff were “very good” and that she was encouraged to keep in touch with her family who do not live in England. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 6 Each tenant has a member of staff who is responsible for helping them. One tenant talked about her “special” member of staff. She said that this member of staff wrote things down in a record about her. She said that she was “ok” with this because it helped the staff to help her. Tenants’ concerns and complaints are investigated and the home has procedures which protect people from harm and abuse, including staff having training about protecting people from abuse. The home was comfortable and homely and had attractive gardens, which tenants can use. All the tenants’ bedrooms are single and have an en suite bathroom and tenants can have their own things in their room. When the home recruits staff, they are careful to make all the necessary checks, including police checks and getting references. Tenants take part in the interviews of staff and one tenant said that the people “want your opinion”. This tenant said that the staff were “very nice” and that you “couldn’t get any better than here”. Staff had lots of good training, which helped them to understand the tenants’ problems and how to help them. The home makes regular safety checks, including fire safety checks, which protects tenants. What has improved since the last inspection? What they could do better: Although the home assessed and recorded information about tenants’ needs and any risks to them, they did not always review these needs and risks with each tenant. This could put the tenants at risk of harm. Staff found it hard to follow all the information about tenants to help them to support the tenants because there was too much out of date information on the files. There was no information about advocacy at the home, which meant that tenants may not be sure about where to go if they wanted any independent advice. The records of medication given to tenants by staff were not completed properly which could put tenants at risk. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 7 The laundry area at the home is very small and could not be used by more than one tenant at any one time, the dining area in the kitchen was not big enough to comfortably seat the 8 tenants and the smoking area is in bedrooms or outside. Some parts of the home, including the kitchens and some bedrooms, were not clean and staff needed to help and support tenants to keep these areas clean. The fridges and freezers in kitchens needed repair or replacement because freezer baskets were broken and sharp edges could injury somebody. Freezers were also so full that the doors were not closing properly and this could result in the food being defrosted which could cause stomach upsets. The home had not had a manager for almost a year and this meant that staff had not had the leadership and guidance they needed to keep standards up at the home. The home needed to do a survey of the views of tenants and their relatives/friends about how the home is run, what is good and what could be improved. The home needed to review the assessment of the risk of fire at the home because of changes in the risks. This is important so that tenants are safe. 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 DS0000021609.V292664.R01.S.doc Version 5.1 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 DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants are provided with information about the home and its services and their needs are assessed and identified. This allows them to be fully involved in the decision about moving into the home. EVIDENCE: The home has a Statement of Purpose, which was readily available to tenants. This document was written in plain English and contained sufficient information for people to make an informed decision about moving in. The senior manager stated that the document would be translated for those people whose first language is not English. The senior manager added that the organisation was considering translating the Statement of Purpose onto audio cassette. Tenants, including those whose first language was not English, confirmed that they had received a range of information prior to admission and that anything that they had been unsure about was explained to them. The senior manager said that all admissions to the home were planned and that the home did not accept emergency admissions. The home uses an “offer letter” which makes clear to the tenants what the terms and conditions of living at the home are. The tenants confirmed that they had received this letter. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 10 The records of 3 tenants were case tracked. This involved looking at all records about these individuals, from the time just prior to admission to the present time. Each of these tenants had been referred by a local authority and they all had a care management assessment of need. The home had also completed a detailed and comprehensive in-house assessment of need for each tenant and specialist health assessments had been undertaken where necessary. Tenants said that they had been involved in their assessment of needs by being asked “a lot of questions” about what they wanted and needed. The tenants were able to recall visiting the home before they were admitted. The senior manager said that these visits can be for a meal, but not for an overnight stay. The senior manager also stated that placements are monitored to see if they are working for that tenant, but also to look at the impact on the other tenants. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. While the home clearly identified people’s needs, goals and risks, failure to consistently review and update these assessments in consultation with each tenant and record the outcomes, may place the tenants at risk. EVIDENCE: Each tenant had a support plan, which had been developed from the assessments of need. The support plan covered the tenants’ personal, social and healthcare needs and was written in a way which showed that the tenants had been involved in their care plan. At the time of the visit, the tenants’ files were very bulky and it was very difficult to access information about the current needs of tenants due to information, which was no longer current, being left on the file. It was recommended that all out of date information is archived. One member of staff said that the large volume of information, much of which was out of date, made it very difficult for staff to have a clear picture of the tenants’ needs. The senior manager said that she felt that the continuity of records had “fallen behind” due to the high turnover of staff and lack of a manager. The senior Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 12 manager and senior support worker had completed an audit of the tenants’ files and this had shown up some serious shortfalls in the review and updating of support plans and other information about tenants. The policy of the organisation is to review support plans every three months. For one tenant the “holistic assessment” had not been reviewed since June 2003. The senior manager stated that “staff can’t provide the correct level of support for the individual when the support plans are not updated”. Risk assessments were completed for each person. However, like support plans, these had not been reviewed and updated regularly and did not therefore reflect the tenants’ current needs which could result in the risks not being minimised. This included one tenant whose risk assessment concerned “self injury and injury to others”. This risk assessment had not been updated since June 2005. Due to the high level of needs of the tenants and the lack of a manager to guide and support staff to provide continuity of care to the tenants, these shortfalls in record keeping could put tenants at risk. A requirement was made concerning the need to consistently review and update tenants’ files as their needs change so that their needs are met appropriately. In some instances, people’s right to make decisions had been respected. However, while most of the tenants managed some of their money independently, the senior manager stated that the organisation’s supported housing officer was the corporate appointee for 7 of the 8 tenants’ benefits. Furthermore, there was no information about advocacy readily available at the home and a recommendation was made accordingly. The management of money was clearly a problem for some of the tenants who had difficulty in funding all the things they wanted, including cigarettes. Policies and procedures to guide staff in the event of a person going missing had been implemented. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants benefited from support to participate in activities within the home and in the local community, having their rights and responsibilities recognised and being encouraged to eat their preferred food. EVIDENCE: Tenants were provided with a Statement of Purpose which told them about the support available in the areas of employment, education, training and religious observation. Tenants were encouraged to attend a variety of activities such as college, day centres and arts and craft sessions. One tenant, who was talented at art, showed the inspector some of the ceramics she had made, including a dream catcher. Tenants were also encouraged to use local community facilities including the cinema, the cyber café, the leisure centre, libraries and local places of worship. None of the tenants had a job, although one tenant did some voluntary work in a café. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 14 The house is not identifiable as a care home and this affords the tenants privacy. They have a key to the front door and their own room and can come and go as they please. One tenant said that she likes living at the home because she feels supported but can also do what she wants, when she wants. There was evidence to show that tenants were able to maintain contact with family and friends and this was confirmed in discussions with tenants. One tenant said the staff were “very good” and that she was encouraged to keep in touch with her family who do not live in England. One tenant said that she had a “boyfriend” who visited her at the home. She said that she stays with him sometimes because one of the rules of the home is not to have visitors staying overnight. The staff stressed the need for a balance between rights and responsibilities when so many people live at the home. Interactions between staff and tenants were seen to be respectful and staff appeared to have a good rapport with tenants who were able to access all areas of the home. Each tenant has a weekly meal allowance and is responsible for their individual food shopping. There are two kitchens for people to prepare meals. Some people prepare their meals independently and staff provide support to others One tenant cooked a pakora and curry sauce for the inspector to taste. She said that staff help her to shop in Rusholme where she buys ”Halal meat, vegetables and spices”. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home encouraged and supported tenants to maintain their personal, emotional and healthcare needs. However, the home’s medication system did not fully protect tenants. EVIDENCE: The home used a key worker system in an attempt to provide some consistency and continuity. One tenant talked about her “special” member of staff. She said that this member of staff wrote things down in a record about her. She said that she was “ok” with this because it helped the staff to help her. The inspector witnessed one key worker supporting a tenant whose first language was not English. The member of staff communicated with this tenant in Urdu, which the tenant preferred. The key worker system was good for the tenants but it had been disrupted by a high staff turnover. It was evident from the pre inspection questionnaire provided by the home and from talking to tenants that tenants had access to the full range of community health services such as psychiatry, chiropody, dentists and opticians. Staff said that they supported tenants to attend healthcare appointments. All the tenants were registered with a local general practitioner. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 16 The medication administration system was provided through a local pharmacist, who also provided medication training. Records were maintained of all medication received and returned to the pharmacy. The home was about to install lockable units in each tenant’s bedroom to store medication. Some tenants took their own medication when they stayed out with family or friends. Some things about medication practice were good. This included having a description and drawing of each tablet to help staff to identify them and using a “summary of work” which recorded changes in medication. However, medication administration records were not completed properly. In particular, for one tenant, 7 of the prescribed medications did not have a record which showed whether they had been administered or not. The senior manager said that she was concerned about this. A requirement was made because this practice could put residents at risk. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Tenants’ concerns and complaints are investigated and the home has the policies, procedures and systems in place to protect people from harm and abuse. EVIDENCE: Tenants said that they could make complaints at the home. At the time of the visit, a tenant discussed the outcome of her recent complaint with the senior manager. The home kept a record of all complaints that included detail of the complaint, the investigation and outcomes. These records were held a hard backed book. This would not allow a complainant to see the record of their complaint without breeching data protection and the confidentiality of others. It also meant that statements, letters etc could not be stored with the record of the complaint. It was recommended that this record is reviewed accordingly so that complainants can see all the information about their complaint. The local authority’s Protection Of Vulnerable Adults (POVA) procedure was readily available at the home. The home had regularly informed the CSCI of any incidents that affected the welfare of tenants. Staff members spoken to were aware of the action to be taken in the event of an allegation of abuse. All staff had received training in the protection of adults from abuse, which was covered in the induction procedure. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A lack of staff support to maintain hygiene and a lack of adequate freezer facilities to store food safely could put tenants’ health and wellbeing at risk. EVIDENCE: The home was comfortable and homely and all areas were decorated to an adequate standard. Furnishings, fittings and equipment were of an adequate standard. The premises is not suitable for physically disabled people as there are steep stairs and there is no passenger list. The home provides attractive, well-maintained grounds, which are accessible to people living in the home. Some aspects of the building were not ideal. This included the laundry area which was very small and could not be used by more than one tenant at any one time. The tenants said that they sometimes had meals together. However, the dining area in the kitchen was not big enough to comfortably seat the 8 tenants. The senior manager said that the organisation planned to extend the main kitchen. Five of the 8 women are smokers, yet they had to go outside to smoke or to smoke in their bedrooms, as there is no agreed smoking area in the building. Communal areas were smoke free and risk assessments were in place concerning the risks from smoking. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 19 All the tenants’ bedrooms are single and have an en suite bathroom. Three of the tenants took the inspector to see their bedrooms. The bedrooms contained their personal things, including pictures and art work. One tenant had a television tuned in to Asian channels. This tenant said that this was very important to her because of her religious needs and her enjoyment of programmes in her first language. Areas of the home, including the kitchens and some bedrooms were not clean. One tenant seemed anxious about whether her bedroom was clean. The need for staff to provide more support to tenants to maintain hygiene was discussed with staff. This was particularly important in kitchens, which had dirty floors and worktops. The fridges and freezers in kitchens were also in need of repair/replacement because freezer baskets were broken and sharp edges could result in injury. Freezers were also so full that the doors were not closing properly and this could result in the food being defrosted which could cause stomach upsets. Requirements were made about these issues. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment policies and procedures and staff access to training promoted the safety and wellbeing of the tenants. EVIDENCE: The organisation has a recruitment and selection procedure which includes completing an application, obtaining criminal records bureau clearance, obtaining 2 appropriate references and taking part in an individual and group interview. One tenant talked about her experience of assessing staff at group interviews. She said that when she does this she “watches” and “makes notes” and that the people “want your opinion”. This tenant said that the staff were “very nice” and that you “couldn’t get any better than here”. Three staff files were seen. Job descriptions were clear and detailed and records showed that staff had good access to a range of training. One member of staff talked about her induction and the training she had attended. She said that training on “modular mental health” and “hearing voices” was particularly good as it helped her to understand some of the particular problems of the tenants appraisal records and photographs of individual staff. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 21 One staff member had NVQ level 3.The home was working towards the staff having a minimum of NVQ level 2 by enrolling 2 staff on NVQ level 2 and one member of staff on NVQ level 3. Staff were receiving recorded supervision and staff had an appraisal following their three-month probationary period. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 22 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): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home had the policies, procedures and systems in place to safeguard and protect tenants, the lack of a manager at the home for some time had led to a lack of leadership and guidance of staff and also to slippage in some standards at the home. This had the potential to put tenants at risk. EVIDENCE: The former registered manager left the home in June 2005. The organisation had not yet managed to recruit to the post. The senior manager present during the inspection acknowledged that not having a manager was having a negative impact on the home and that some things, including reviewing support plans, had slipped. The senior manager said that the organisation was committed to recruiting a manager as soon as possible. At the time of the visit, the senior manager discussed the need for staff to have leadership. It was evident from talking to staff, and from observing interactions between staff, that the staff teamwork was suffering through the Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 23 lack of leadership. A requirement was made that the organisation must review management arrangements at the home to provide leadership, support and guidance to staff. The organisation has also been required to submit to the Commission an application for registration of a manager. The home had a quality assurance monitoring system. However, this was corporate and did not include finding out the views of tenants at the home and their relatives/friends. The senior manager said that this had fallen down because of not having a home manager. The need for the home to develop a quality assurance system, which involved tenants and professionals, to audit the service was discussed. This is important, as it would allow the home to take account of the views of tenants and their relatives/friends about how the home is run, what is good and what could be improved. A requirement was made about this. The pre inspection questionnaire described regular maintenance and testing of the home’s equipment, including the gas boiler, portable fire fighting equipment, fixed electrical installation, emergency lighting, the fire alarm and portable electrical appliances. The home had reviewed the environmental risk assessment just before the inspection, which is good for tenants’ safety. However, the fire risk assessment had not been reviewed since January 2005. A tenant who smoked in her top floor room had been admitted since this time and the risk assessment needed to be reviewed to take account of this new risk and of any other changes in the risk from fire. A requirement was made about this. The fire alarm was tested at prescribed intervals. People living at the home and the staff were aware of the procedure to be followed in the event of the fire alarms being activated. Regulation 26 visits were carried out and the reports were submitted to the Commission for Social Care Inspection so that the inspector was informed of issues at the home which affected the wellbeing of tenants. The home had a current insurance certificate offering sufficient cover. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 24 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 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 1 X 2 X X 2 x Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 25 Yes. 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 YA6 Regulation 15 Requirement Tenants’ support plans and risk assessments must be consistently reviewed and updated as their needs change so that their needs are met appropriately. The records of administration of tenants’ medication must be maintained so that it is possible to see a clear audit trail of medication prescribed to tenants to ensure their safety. Loose and cracked tiling to the work surfaces in the independent kitchen must be repaired/replaced. (Previous timescale of 28/02/06 not met). Adequate freezer facilities must be provided so that food can be stored safely. The level of hygiene at the home must be improved. This includes: Staff supporting those tenants who need a higher level of support to maintain hygiene in their rooms. Staff ensuring that the kitchen is clean enough to prepare food. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 26 Timescale for action 15/06/06 2. YA20 13(2) 02/06/06 3. YA24 16 15/06/06 4. 5. YA24 YA30 16 16 15/06/06 15/06/06 6. YA37 8 7. 8. YA37 YA39 8 24 9. YA42 23 The organisation must review management arrangements at the home to provide leadership, support and guidance to staff. The organisation must submit to the Commission an application for registration of a manager. The home must review and develop their quality assurance system to provide a verifiable method, which involves residents, to audit the service and report on the findings. The home must review the fire risk assessment to take into account known changes in the risk from fire. 15/06/06 30/07/06 15/08/06 15/06/06 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. Refer to Standard YA6 YA7 YA22 Good Practice Recommendations It is strongly recommended that all out of date information on tenants’ files is archived to avoid any confusion for staff. It is strongly recommended that tenants are given information about, and access to, advocacy services. It is strongly recommended that the record of complaints is reviewed so that complainants can see all the information about their complaint without breeching the confidentiality of others. Creative Support DS0000021609.V292664.R01.S.doc Version 5.1 Page 27 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 DS0000021609.V292664.R01.S.doc Version 5.1 Page 28 - 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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