CARE HOME ADULTS 18-65
Creative Support 7 Sidney Road Blackley Manchester M9 8AT Lead Inspector
Steve O`Connor Unannounced Inspection 8th November 2005 12:00 Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 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 DS0000021607.V266144.R01.S.doc Version 5.0 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 DS0000021607.V266144.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Creative Support Address 7 Sidney Road Blackley Manchester M9 8AT 0161 205 7314 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 Mary Carter Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home is registered for a maximum of seven (7) service users in the category of MD (Mental disorder, excluding learning disability or dementia) of either sex. Three (3) named service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age) may be accommodated within the overall number of registered places. Two of the seven places are situated in 19 Allen Roberts Close, which backs onto 7 Sidney Road. These two places are for service users moving towards independent living. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 17th May 2005 4. Date of last inspection Brief Description of the Service: The home is managed by Creative Support and is based at 7 Sidney Road and 19 Alan Roberts Close (neighbouring properties) that operate as a single scheme offering 24 hour care and accommodation to five people in the core house (Sidney Road) and two in the cluster house (Alan Roberts Close). The primary needs of the people living at the home relate to their long-term mental health. The scheme is situated in the Blackley area of North Manchester, within close proximity to public transport, shops, parks, churches and a local market. Both properties are sited on residential streets. There is parking available at both properties and each has a well-maintained rear garden. In Sidney Road bedroom accommodation is spread over the three floors. All bedrooms are single with hand washbasins and the ground floor bedroom has an en-suite bathroom. Communal space is provided in both properties along with kitchen and laundry facilities. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 8th November 2005. During the inspection, time was spent observing how staff worked with people, talking to the manager and examining records, people’s files and other documents. At the previous inspection the home had been asked to make some changes and improvements to certain areas so that they met the required standards. The home had worked hard and had addressed all the requirements made of them. No complaints about the service had been received by the CSCI. As this inspection focused on specific standards and issues that were raised during the previous inspection in May 2005, this report should be read together with the previous and future reports to gain a fuller picture of how the service is meeting the needs of the people living there. What the service does well:
The home has continued to show that it is supporting people to maintain as much of their independence as possible and has worked with one person to support and encourage them in planning to move to less supported accommodation. This has involved working with other agencies, services and the person’s family to identify the support and accommodation that worked best for that person. The areas of work that were identified in the last report continue to be done well in meeting people’s needs. At the last inspection the main house had all the bedrooms and communal areas redecorated. The decoration programme has continued with the other property and further decoration of the main house. The home provides people with a very relaxed and homely environment and was committed to maintaining this high standard. The home has continued to work with people to identify and support them to take part in activities that they enjoy. The home would support people, either as a group or just one person, to go out and enjoy a greater range of activity such as day trips, walks, holidays and use the facilities that were available in the local community. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The medication administration records must be maintained accurately at all times and any mistakes in recording must be acknowledged through a crossed single line and the initials of the person All staff who administer medication must receive the required training and be deemed competent, by the home, to do so. Each individual staff’s Personal Development Plan (PDP) must be reviewed to ensure that the document is completed correctly and accurately. All staff must participate in moving and handling of people and food hygiene training before carrying out these tasks without supervision. It is recommended that the risk assessment and action plan for a named person be reviewed and this is reflected in the person’s care plan and support. It is recommended that a daily record is maintained of all the meals people have and the alternative choices taken. It is recommended that the hands on procedures for supporting people’s continence needs and the safe handling of soiled items be updated to reflect current good practice guidance and action taken to ensure that staff are aware of the procedures. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 7 It is recommended that the frequency of undertaking the management be reviewed to ensure that the manager has the capacity to carry out the process and gather the information required. 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 DS0000021607.V266144.R01.S.doc Version 5.0 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 DS0000021607.V266144.R01.S.doc Version 5.0 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): EVIDENCE: These standards were assessed at the previous inspection. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 10 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 and 9 People’s changing needs had been identified and recorded in their individual care plan. The home continued to support people to take risks and make informed decisions. EVIDENCE: The home had further developed the care planning process that included a full social history and people’s goals and needs. The review process now included the progress and changes made to a person’s care plan as needs changed. Each care plan had an evaluation of the person’s primary goals and had recorded changes to the support they need. The home had responded to an event that affected the wellbeing and independence of a person by undertaking a full risk assessment. Advice and ideas had been sought from other agencies in how to address the issue and an action plan had been developed setting out the support the person needed. Although the person was being supported to access the community the activity records did not show evidence that the agreed action plan was being carried out. It is recommended that the risk assessment and action plan be reviewed and this is reflected in the person’s care plan and support.
Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home supports and offers people a healthy and balanced diet. EVIDENCE: Mealtimes were part of the structured routine of the house but were also flexible to allow people to take their meals when they wished. Food stores were sufficient with a range of fresh fruit and vegetables and not a reliance on processed foods. People’s food likes and dislikes had been identified and were fully consulted over the menu choices. Although there was a planned menu the home did not record the actual meals people had. It is recommended that a daily record is maintained of all the meals people have and the alternative choices taken. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 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): 18, 19 and 20 The home supported and encouraged people to maintain their personal and healthcare needs. The medication administration systems did not fully protect people. EVIDENCE: The home continued to support people to maintain their personal, general and mental healthcare. The medication records were seen and found that there were some errors. Some medication administering had not been signed. Some signatures could not be read and mistakes had been penned over so the original entry could not be seen. A local pharmacist provided the medication training. Three of the current staff team had not received this training and no staff had undertaken accredited medication training. A number of requirements were made accordingly. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 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): 23 The home had the policies, procedures and systems in place to protect people from abuse. EVIDENCE: The manager stated that almost all the staff team had attended Adult Protection training or were booked onto a training event. The staff induction programme includes a dedicated module to adult protection issues. This action met the requirement issued at the previous inspection. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 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): 30 The home was clean, hygienic and had the systems to protect people’s health and wellbeing. EVIDENCE: There had been an increase in staff having to handle and wash clothes and linen etc that had been soiled with urine due to a person’s continence problems. The issue of cross infection had been raised with the staff team and they had been provided with the necessary equipment to handle soiled items safety. The procedure for handling soiled items has been past onto staff but it was found that the procedures required updating to ensure that they meet recommended guidance. It is recommended that the hands on procedures for supporting people’s continence needs and the safe handling of soiled items be updated to reflect current good practice guidance and action taken to ensure that staff are aware of the procedures. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 15 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): 33, 34 and 35 The home has the systems in place to recruit suitable staff who generally have the skills required to meet people’s needs. However, the training systems do not show fully that all staff are receiving the required training. EVIDENCE: Through evidence found over the last two inspections by talking with people with staff and observing them working the home has shown that it has a staff team with a high level of skills, enthusiasm and the values to work with people in a positive and respectful way. The home had undertaken a review of people’s support needs during the night and had decided to maintain the current level of support. This addresses the recommendation made at the previous inspection. A review of the use of part-time staffing positions had been reviewed and the staff team now consisted mostly of full-time positions. This allows the manager greater flexibility in meeting people’s needs. This addresses the recommendation made at the previous inspection. The handover process for the night staff has been updated to ensure that all daily logs are read and more detail in included in the nighttime recording. This action met the requirement issued at the previous inspection.
Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 16 The staff files contained a copy of the staff member’s application form and two references. The manager had instructed the staff to provide the other documentation required and around half the staff had done so. The main organisation, Creative Support, has a system where Criminal Record Bureau (CRB) certificate details were checked by the personal department, recorded and the relevant information sent to the home. Creative Support has a set 8-day induction programme that all new staff have to participate. In addition Creative Support have a comprehensive in-house training programme. Each member of staff has a Personal Development Plan (PDP) that logs the training undertaken and identifies training needs, including NVQ qualification. Training needs are regularly discussed during supervision and through an ongoing training audit process. Staff are encouraged to identify their own training needs and to apply for the relevant training events provided by Creative Support and other external providers. Some examples of the PDP’s were seen and the following was found. There appeared to be some confusion over the recording of training events participated in and those planned. For example, the date of the event and the duration of the event. The PDP allows for comments on whether the staff member has achieved the right level of competence from the training they have undertaken. These sections were not completed and so could not confirm whether the staff was competent or not. The manager confirmed that staff had participated in First Aid training but this was not recorded in the PDP seen. Staff supported some people with their personal care and also cooked meals. It was noted that not all staff had moving and handling people or food hygiene training. One staff, who had started in May 2005, was booked onto a moving and handling event in March 2006. It was noted that a training event was offered on a monthly basis. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 17 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): 39 and 42 The home has the policies, procedures and systems in place to protect people’s safety and welfare and implemented the systems required to gather people’s views of the home. EVIDENCE: The home has a structured programme of health and safety and environmental audits to ensure they provide a safe place for people and staff to work in. In addition, a senior manager undertakes monthly checks as part of their regulation 26 responsibilities under the Care Homes Regulations 2001. Records of house meeting are taken of the issues people raised about the dayto-day running of the home. Creative Support were also introducing a new quality assurance system called the Management Review. This was to be undertaken, by the manager, on a monthly basis and would include people’s views on the service as well as consultation with families, carers, other relevant agencies and the staff team. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 18 Whilst the introduction of such as quality assurance system would provide the means of gathering important information, the process was to be undertaken on a monthly basis, which would require a high commitment of time from the manager. It is recommended that the frequency of undertaking the management be reviewed to ensure that the manager has the capacity to carry out the process and gather the information required. Fire logs were seen and the required checks were being made and fire equipment serviced annually. All gas and electrical equipment was being serviced on an annual basis. All COSHH standards are being adhered to, accident books are maintained and all accidents and incidents effecting the people’s welfare and safety are being recorded. Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Creative Support Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000021607.V266144.R01.S.doc Version 5.0 Page 20 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 YA20 Regulation 13 Requirement The medication administration records must be maintained accurately at all times. 1. All medication administered must be signed for at the time. 2. All signatures must be legible. 3. Any mistakes in recording must be acknowledged through a crossed single line and the initials of the person. All staff that administer medication must receive the required training and be deemed competent, by the home, to do so. Each individual staff’s PDP must be reviewed to ensure. 1. That completed and planned training events are clearly and accurately recorded in the PDP. 2. That use is made of the PDP section that requires comments, from the manager/senior person, as to the competence of the staff resulting from the training event.
Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 21 Timescale for action 30/11/05 2 YA20 13 01/03/06 3 YA35 18 30/12/05 3. That all training undertaken by staff was clearly recorded in the PCP. 4 YA35 18 All staff must participate in moving and handling of people and food hygiene training before carrying out these tasks without supervision. 01/03/06 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 YA9 YA17 YA30 Good Practice Recommendations It is recommended that the risk assessment and action plan be reviewed and this is reflected in the person’s care plan and support. It is recommended that a daily record is maintained of all the meals people have and the alternative choices taken. It is recommended that the hands on procedures for supporting people’s continence needs and the safe handling of soiled items be updated to reflect current good practice guidance and action taken to ensure that staff are aware of the procedures. It is recommended that the frequency of undertaking the management be reviewed to ensure that the manager has the capacity to carry out the process and gather the information required. 4 YA39 Creative Support DS0000021607.V266144.R01.S.doc Version 5.0 Page 22 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
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