This inspection was carried out on 9th December 2005.
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 2 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Creative Support 7 Amherst Road Fallowfield Manchester M14 6UG Lead Inspector
Sarah Oldham Unannounced Inspection 9th December 2005 10.30 Creative Support DS0000021609.V269671.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 DS0000021609.V269671.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 DS0000021609.V269671.R01.S.doc Version 5.0 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.V269671.R01.S.doc Version 5.0 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. 11th August 2005 Date of last inspection Brief Description of the Service: 7 Amherst Road is registered to provide accommodation and personal care for up to eight women. The aim of the service is to provide a high quality, individually focussed service to women with enduring mental health needs. The home is situated approximately five minutes walk from Withington and Ladybarn shopping areas and close to public transport links into both Manchester City Centre and Stockport town centre. A selection of shops, general practitioners surgeries and churches of various denominations are situated close by. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a three-hour period on Friday 9 December 2005. During the inspection time was spent talking with some of the people who lived at the home, with staff on duty and the service manager. Due to the promotion of the previous manager the home did not have a manager who was registered with the Commission for Social Care Inspection (CSCI) although a manager had been appointed and an application to CSCI was being submitted. In addition to the above a sample of residents files, records and other documentation was examined. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the residents. What the service does well: What has improved since the last inspection?
The home had developed a draft medication policy and procedure to address the issue of self-medication when people were on leave from the home. Medication sheets had been signed and records maintained of when a person had refused their medication or it was not required. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 6 The laundry room had been rearranged to ensure that the washing machine and tumble dryer fitted in the limited space available. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made regarding these standards. EVIDENCE: These standards were not assessed at this inspection. The key standards were assessed at the previous inspection and there were no requirements made. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 & 10 The home had the systems in place to allow people to participate in the dayto-day running of the home. All information was stored securely. EVIDENCE: People were given the opportunity to be involved in the day-to-day running of the home to ensure that the home reflected their needs and on going development. Regular house meetings took place and offered the opportunity for people to discuss and be involved with any changes within the home. The company that runs the home provide training to enable people to be involved in the recruitment and selection of staff and also to be involved in forums that addressed policy changes and further development of the company. At the present time no one had wanted to take this opportunity up however, it was raised on a regular basis at house meetings. One person spoken to said that she enjoyed living at the home and felt that her opinion was listened to. At the time of the inspection preparation was being undertaken for the Christmas period and staff were observed to be
Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 10 actively seeking the views and wishes of the residents with planning for this period. The home also undertook service users questionnaires as part of the company’s quality assurance checks. Information regarding residents was maintained securely in accordance with the Data Protection Act 1998. Staff were aware of the confidentiality policy and procedure. Creative Support DS0000021609.V269671.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): 11 People living at the home had the opportunity and support to increase and maintain skills for their personal development. EVIDENCE: The people who use the service were supported to develop independent living skills. Clear care plans detailed how these targets would be achieved and these had been developed in conjunction with the individual. One person spoken to said that at first she had felt that she was not able to do things for herself very well but that staff had “helped me with doing things for myself”. Care plans demonstrated that there was a multi agency involvement to ensure that people had access to appropriate specialist support and intervention to further support their personal development. Creative Support DS0000021609.V269671.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 & 20 The home encourages and supports people to maintain their personal, emotional and healthcare needs. However, the systems for medication administration do not fully protect people EVIDENCE: People were encouraged and supported to maintain their personal care and to be as independent as possible. Their needs were clearly recorded in their care and support plan. One person spoken to said that she had “come a long way” with the support of the staff and her key worker who “were nice and help me and I can talk to them”. Health care needs were recorded on the care plan and details of health checks were recorded. Some of the records had not been completed on the appropriate sheets due to some confusion. There needed to be a clear audit trail that cross-referenced with the daily record sheets. At the previous inspection the medication policy did not include a section relating to self-administration for people on leave from the home. This policy had been revised and a draft policy had been completed that addressed this.
Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 13 Records of medication administered via community nurses must be recorded and cross referenced with daily report logs to ensure a clear audit trail is maintained Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 14 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): No judgement was made regarding these standards. EVIDENCE: These standards were not assessed at this inspection. The key standards were assessed at the previous inspection and there were no requirements made. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 15 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, 27& 30 The home had the systems and facilities to maintain the cleanliness and hygiene of the home. However, the environment was not fully safe and could pose a risk to the people living there. EVIDENCE: The home was comfortable and homely and all areas were decorated to a high standard. It was clean, well maintained and free from offensive odours. The service manager said that all the bedrooms were single and that people were encouraged to personalise them. One person said that she liked her bedroom and it was “nice to buy things for my room”. The home had a programme of routine maintenance and renewal of the fabric and decoration The independent kitchen area was clean and well equipped. However, the tiled work surface had cracked and some tiles were broken. This could present a risk to the people living there. The laundry area was compact and although the washing machine and tumble dryer were in place there was little room spare in this area. The service
Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 16 manager said that there were plans to extend the building to increase the living room, kitchen and laundry room although this was only at the early stages of discussion and was aware that the CSCI would need to be informed of development plans if the company wished to proceed with these. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 17 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 Staff had the skills and appropriate training to meet their needs supported residents. EVIDENCE: Staff at the home had the appropriate training and qualities to meet people’s support needs. The home had a clear induction programme and ongoing programme of training and development for staff. This included NVQ training at levels 2 and 3. Staff were observed to interact well with people and a good rapport was evident. The home had a key worker system in place and staff had developed good clear working relationships with other professionals to ensure that people’s needs were met appropriately. Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 People living in the home benefit from having a manager with the management skills to provide a quality service. EVIDENCE: At the time of the inspection the home had a new manager who was in the process of submitting an application to the CSCI to be the registered manager. The manager had experience of working within the home in a supervisory capacity and had been supported in her role by the service manager who had previously been the registered manager for the home. Policies and procedures were in place. People had written terms and conditions and a copy of these were maintained on their individual files. Creative Support DS0000021609.V269671.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 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X 3 X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X X X CONDUCT AND MANAGEMENT OF THE HOME X 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 3 X X X X X X DS0000021609.V269671.R01.S.doc Version 5.0 Page 20 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 YA24 Regulation 16 Requirement Timescale for action 28/02/06 2. YA20 13 Loose and cracked tiling to the work surfaces in the independent kitchen must be repaired/replaced. Records of medication received 28/02/06 via community nurses must be recorded and cross referenced with daily report logs to ensure a clear audit trail is maintained RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Creative Support DS0000021609.V269671.R01.S.doc Version 5.0 Page 21 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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