Inspection on 01/11/06 for Creedy Court

This inspection was carried out on 1st November 2006.

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

Creedy Court 04/01/06

Creedy Court 10/01/05

Creedy Court 12/07/04

Creedy Court 10/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Creedy Court Shobrooke Crediton Devon EX17 1AD Lead Inspector Dee McEvoy Key Unannounced 1 November 2006 09:30 st Creedy Court DS0000021920.V299449.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 Creedy Court DS0000021920.V299449.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. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creedy Court Address Shobrooke Crediton Devon EX17 1AD 01363 773182 01363 775822 info@autismcare.co.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) Ms Penelope Debra O`Sullivan Mrs Mary O`Sullivan James Leslie Moore Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Creedy Court is situated near the village of Shobrooke and approximately two miles from Crediton. It is registered to provide care for up to 17 adults who have Autism, Asperger’s Syndrome and learning disability. The buildings are arranged around a courtyard, which has a central lawn surrounded by a wide path. There is also a well-maintained garden area to the rear of the home that backs onto open fields. There is off road parking to the side of the building. Accommodation at the home is divided into two separate units, (Eastleigh and Westleigh) each with its own lounge, dining area and kitchen. Eastleigh is an eleven-bedded unit for people with autism, challenging behaviour and learning disability. Westleigh is a six-bedded unit for people with Asperger’s Syndrome and learning disability and supports people who are able to live more independently. All bedrooms are for single occupancy only. There is a large day services area for the use of residents, including a pottery room, a massage room and a snoozelem. The home has a mini-bus and two ‘house cars’ and offers transport to residents for appointments and other trips and outings. The fees for care range from £1,500 per week upwards depending on individual needs. Additional costs, not covered in the fees, include transport, which is charged per mile, hairdressing and personal items such as toiletries and newspapers. Current information about the service is available to prospective residents. CSCI reports are available on request. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over of the course of two days. During the inspection the inspectors saw or spoke with most residents around the home. Four residents were case tracked, which helps us to understand the experiences of people using the service. A number of residents do not have the capacity to communicate fully and the inspectors spent a considerable time observing the care and attention given to residents by staff. Several weeks before the inspection confidential surveys were sent to residents to find out about their views on life at the home, 6 were returned to the inspector. 12 staff surveys were returned to the Commission ensuring that that their views were also heard. CSCI surveys were also received from five relatives and 10 health and social care professionals. Additional information was gained from a questionnaire completed by the home prior to the inspection. The inspector also toured the premises with a resident and a sample number of records were inspected which included care plans, medication records/procedures, staff recruitment files, service and maintenance certificates and fire safety records. What the service does well: When residents were asked what the home does well comments included, “Everything is good”, “Staff understand me completely” and “There’s lots to do here”. The majority of relatives and all heath and social care professionals were satisfied with the overall care provided to residents, comments included, “Very professional staff” and “Creedy Court offers a high standard of care”. Good information in a suitable format has been produced about the home ensuring that potential residents can make an informed choice about where to live. The home obtains valuable information about residents prior to them moving so as to ensure needs can be met. Good care planning and delivery takes into account residents’ needs, risks and wishes, which ensures that individual health and social care needs are met. Residents are enabled to take control over their lives and are supported to make choices. The home encourages a range of activities and education opportunities and residents are supported to fulfil their potential. An excellent staff team support residents. Staff provide high quality care and are able to communicate well with residents. Staff are well trained, skilled and Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 6 experienced and are motivated to provide a good service. One resident said of staff, “People care about us”. Feedback from residents, staff, relatives and professionals indicated that the overall management of the home is good. The management team are experienced and approachable and residents and staff expressed confidence in them. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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 Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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): 1&2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information about the home is available for prospective residents, which enables them to make an informed choice before moving into the home. Residents benefit from a good admission and assessment process, which ensures that the home can meet their needs. EVIDENCE: Five of the six residents responding with surveys confirmed that they had received enough information about the home before moving in so they could decide if it was the right place for them. One resident said they couldn’t remember about the information given, another said the manager had visited them with photos. Where possible residents and relatives are encouraged to visit and spend time at the home before making a decision to move. The statement of purpose is comprehensive and produced in a form that residents can understand. It is freely available and one resident showed their copy to the inspector. As part of case tracking, four residents’ care files were looked at; preadmission assessments are completed by the referring professional, usually a social worker, and the home completes a comprehensive assessment which includes input from the manager, team leaders and other health professionals such as psychiatrists, psychologists and speech and language therapist. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 9 Assessments looked at demonstrated that all needs were covered in the areas of mental and physical health, and personal and social care needs. All staff responding with surveys said they were not asked to care for people outside of their area of expertise. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individual care plans are good and reflect the residents’ needs ensuring that staff have the information they need in order to meet the needs of the residents. Resident’s rights and independence are respected and promoted; residents are encouraged to undertake an independent lifestyle, with staff assistance when needed. EVIDENCE: Residents spoken with were generally happy with the care; one told the inspector “I have the help I need”, another said, “I am happy here”. Five residents responding with surveys said they “usually” received the care and support they needed, one said they “always” receive the support required. Most relatives and all health and social care professionals indicated they were satisfied with the overall care provided, comments from professionals included, “Offers a high standard of care” and “Very pleased with the care”. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 11 Care plans were good; they were detailed and gave a clear picture of the residents’ needs and preferences, ensuring that staff were aware of individual needs and goals. It was particularly good to see personal histories and life stories, which gives a sense of who the person is and their life experiences. Some residents were able to confirm that they are involved in the development and review of their care plans. Staff demonstrated an excellent knowledge of residents’ care plans, needs and individual characters. The home operates a key worker system, which means that designated staff are responsible for ensuring that specific needs are met and helps to provide continuity of care. All residents spoken with were able to identify their key worker and it was obvious that positive relationships had been developed between residents and staff. One resident said about their key worker “We can talk”. During the inspection staff were observed to consult with residents about what they would like to do and what they would like to eat. One resident told the inspector how their key worker was helping to secure supported voluntary work, something the resident was very keen to do. Another resident was excited about the plans being made with their key worker to visit a local holiday park, as requested. One resident wished to attend church and this was being arranged with the key worker. The inspector observed staff listening to residents and responding to their requests in a sensitive way. The majority of residents felt that staff listened and acted on what they said. One resident told the inspector they were always consulted and supported with choices but also recognised where restrictions were in place and why. In order to ensure that decisions are made in the best interests of the residents’ the manager and staff involve relatives, care managers and other professionals when residents are unable to communicate fully. One example is the sensitive way the home has consulted about the final wishes of one resident. One relative responding to the CSCI survey felt they would like to be more involved in decision making. This was discussed with the manager, who was aware that some difficulties did exist but was keen to improve the situation. Risks to residents are carefully identified and clear guidelines for reducing and managing behavioural, situational and environmental risks are available to staff. Any restrictions or limitations on choice or freedom for residents are discussed, recorded and reviewed. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 12 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 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Links with the local community are good; supporting and enhancing residents’ social and educational opportunities as well as offering appropriate job opportunities. In the main residents are supported in maintaining good relationships with relatives. The meals and mealtimes offer flexibility, choice and variety to residents. EVIDENCE: Opportunities are provided to develop life skills and encourage residents to participate in local community activities. A number of residents attend local colleges to undertake courses to develop daily living skills such as cooking, IT and horticulture, one resident said, “I love cooking”, another described college as “enjoyable”. One resident is supported to maintain employment and another resident is currently being assisted to find an appropriate work placement. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 13 Many residents said they enjoyed the activities arranged by the home. Four residents responding to CSCI surveys said there were “always” activities they could take part in, one wrote, “Activities I do are good”; for two residents this was true “sometimes”. The home has drama, music, art and pottery therapists who visit and work with groups of residents in separate ‘day’ facilities. During the afternoon the inspector joined a group of five residents for a music therapy session; all residents participating appeared to enjoy the session. On the second day of the inspection several residents were enjoying an aromatherapy massage, the therapist visits regularly for this popular session. Residents are not charged for any of these activities. On the day of the inspection a number of residents went off to play skittles in the morning; it was an enjoyable event by all accounts. Later in the day residents and staff were heard making arrangements to visit a local firework display for those interested. Other residents are supported and encouraged to use public transport independently and pursue hobbies and interests outside the home. One resident produces a newsletter for the home and resources and materials such as a computer, as available to support this. Residents in Westleigh plan and go away on holiday; several had just returned from a week in Cornwall. Residents were keen to tell the inspector how much they had enjoyed their time. The residents in Eastleigh are more likely to go away on an individual basis with staff or out for days. It is very much geared to their individual needs and how they react to certain situations. The cost of the holidays is partially met by the home. Several residents spoke about the friendships developed at the home and confirmed that visitors are encouraged and contact with family and friends is supported. The home will provide transport and staff to escort residents on home visits, in some cases travelling long distances. The home will also provide financial assistance for relatives with travelling and accommodation costs. Four of the five relatives responding with CSCI surveys said they felt welcome in the home at any time, one said that the staff were “friendly”. One relative contacted CSCI in order to assist with re-establishing contact with the home and their relative. The home responded in a positive way to ensure that contact will be maintained. Residents in Westleigh are involved in planning, preparing and cooking meals; the inspector had lunch with a number of residents who had prepared their own preferred meal. Residents told the inspector about their own speciality, which they prepare, and share with the other residents. In Eastleigh the meals are prepared in the main kitchen. The cook showed a good knowledge of individual preferences and needs and records kept showed a varied and balanced diet was provided. The majority of residents said they liked the meals at the home, comments included, “The food is good” and “The cook makes great dinners”. Residents said they were offered a choice of foods, one said, “They will always give you something different”. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and their health care needs are well met. The systems for the management and administration of medications are generally good. EVIDENCE: Residents spoken with were happy with the care they received overall. Care plans detail the level of support required by residents in respect of personal care and staff are sensitive to individual needs. Preferences regarding the gender of carer and how residents wish their needs to be met are recorded. Staff had a caring and respectful manner when talking about residents and when communicating with them. Residents responded well to staff and appeared relaxed and happy in their company. Many residents appeared completely at ease expressing their preferences. Care plans clearly described individuals’ health care needs and showed that changing needs were monitored. Specialist health professionals have been regularly consulted where necessary, such as psychiatrist, speech and language therapist, dietician and dentist. All residents responding to surveys Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 15 and those spoken with during the inspection said they “always” receive the medical support they need. All health and social care professionals were happy with the overall care provided by the home and felt that the home demonstrated a clear understanding of residents’ needs. Professionals felt the home communicated well and worked in partnership with them. Comments included, “Excellent quality service”, “An excellent resource” and “I am very pleased with the care provided”. Two G.Ps responding to CSCI surveys were happy that residents’ medication was managed appropriately by the home. The system for managing medicines is generally good; the home uses a monitored dosage system and pre-printed medicine administration records from a local pharmacy. Medication administration records were found to be accurate and up to date; when a variable dose is prescribed the actual dose administered is recorded. Staff administering medication have received the appropriate training. Some staff have received additional training to administer invasive medicines however the guidelines developed with health professionals for this procedure were not available during the inspection. The inspector was told that they might have been inadvertently transferred with a previous resident. All medicines were stored securely. The home has good internal auditing processes to ensure that all stock is correct. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 16 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assured that their complaints will be listened to and their safety and welfare is fully protected. EVIDENCE: Five residents responding with CSCI surveys and those spoken with during the inspection knew who to speak with if they were not happy; residents felt that staff listened and acted on what they said. The manager and pre-inspection questionnaire confirmed that no complaints had been received by the home in the past 12 months. One of the five relatives responding to the survey said that they had made a complaint in the past. None of the 10 health and social care professionals have dealt with any complaints about the service. Staff spoken with had received adult protection training and demonstrated a good knowledge of adult protection issues; induction records showed that adult protection was core training for all staff. The home uses the gentle teaching and calm and safe approach when dealing with challenging or difficult behaviour and situations. Staff spoken with could describe strategies used to manage or diffuse difficult situations. The inspector observed staff relating to residents in a positive, sensitive and calm way. Physical restraint is rarely used. A number of residents handle their own financial affairs and the manager acts as appointee for four residents. Individual bank accounts have been set up and a good record of transactions is kept. Receipts were available and monies held on behalf of the two accounts looked at tallied exactly. It was noted that two Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 17 signatures are not always obtained for each transaction, which is good practice and improves accountability. Creedy Court DS0000021920.V299449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is safe, clean, well maintained and generally homely. EVIDENCE: Creedy Court is a detached property arranged on lower and ground floor levels around a pleasant courtyard. There are separate facilities within the courtyard that provide space for activities such as pottery, art and therapy sessions. The home also has a Snoezelen room, which offers a relaxation area for residents. The home is accessible to current residents but may not be suitable for people with mobility problems due to the stairs. There are two units within the home Eastleigh and Westleigh. Each unit has it’s own communal space, including lounge and dining areas. The communal space on Westleigh is particularly bright and homely, with comfortable spaces for residents to enjoy. The provider and manager agreed that the dining area in Eastleigh could be more comfortable and pleasant as at present it is rather functional and dreary. The home has an on-going programme of maintenance and refurbishment to ensure the environment remains comfortable and safe. There are plans to Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 19 refurbish a bathroom on Westleigh, which is needed, and the carpets in communal areas in Eastleigh are being replaced, as they are now worn and illfitting in places; the inspector was told this was to happen within two weeks of the inspection and shown carpet samples. The ceiling in the kitchen on Westleigh has sustained damage from a leak and needs to be repaired to maintain a good level of food hygiene; the manager said that this was in hand. All bedrooms are single occupancy and those visited by the inspector were personalised and comfortable and reflected individual tastes. The home has been creative with some furnishings and fittings to ensure that bedrooms are personalise and comfortable but also sustain minimal damage from residents, who maybe destructive. It was noted that one mattress needed to be replaced; this was discussed with the providers and manager. The majority of residents responding with surveys said that the home was “Always” clean and fresh. Residents are involved in light domestic duties where they are able, one wrote, “Cleaning is good”. On the day of the inspection the home was clean and free from offensive odours. Hand washing and drying facilities were available in bathrooms and toilets and gloves and aprons are used when necessary ensuring infection control is maintained. On Westleigh there is a separate washing machine which residents are encouraged to use with staff support. There is an additional laundry for all other washing, which is situated in the courtyard away from areas where food is stored, prepared or eaten. Creedy Court DS0000021920.V299449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by appropriately qualified and supervised staff. Robust recruitment practices ensure that residents are protected. EVIDENCE: Residents spoke highly of the staff describing them as friendly, kind and helpful. They told the inspector that staff listen to them and understood their needs, one said, “They know what to do if I am having a bad day”, another wrote, “Staff are always at hand”. The staff team is stable and all staff responding to CSCI surveys felt they have the support needed to do their job well. During the inspection eight staff members were spoken with, including the manager and deputy. Staff spoken with were knowledgeable and motivated; one said, “I love my job”, another said, “We have a good team”. Comments on surveys included, “It is a privilege to work here” and “The staff group have a lot of experience”. Staff appear to have a high level of job satisfaction, which helps to make the atmosphere at Creedy Court a happy one for residents. Staffing levels appear to meet individual needs at present. The majority of residents surveyed felt that staff were “always” available when needed, two Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 21 said “sometimes”. During the inspection staff had time to give one to one attention to residents, for example one resident went shopping with their key worker and another was escorted for a medical appointment. A number of other residents were accompanied on their skittle trip. Staff spoken with felt that they had enough time to meet residents needs. Three staff recruitment files showed that the home’s recruitment practices are safe and protect residents; references, identity checks and Criminal Records Bureau checks (CRB) had been obtained for all staff. Staff surveys confirmed this. The home supports the training and development needs of staff to ensure they have the skills to meet residents’ complex needs. 57 of staff have achieved a nationally recognised qualification in care (NVQ 2 or above), which exceeds the standard expected. All staff have received a good range of training that helps them to understand and meet residents’ needs; training includes, mandatory health & safety, protection of vulnerable adults and safe administration of medicines. Specialist training undertaken by staff includes, gentle teaching, safe and calm, epilepsy and effective communication. Staff requiring extra support with learning are encouraged and nurtured to achieve their potential. The home provides excellent supervision for staff; records showed that the manager and deputy provide internal staff supervision and externally a qualified counsellor provides supervision for staff, which is paid for by the home. Supervision enables managers to brief staff and monitor their development and performance, and offers staff an opportunity to give direct feedback about their work and training needs. All staff responding with surveys and those spoken with felt valued and supported. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents, relatives and staff benefit from the experienced, friendly and open management at the home. The systems for resident consultation are good, with evidence that indicates that residents’ views are sought and acted upon. Overall residents’ safety and welfare are protected by good health and safety practices and procedures. EVIDENCE: Residents and staff spoke highly of the manager and the deputy, one resident said, ”The managers are great around here”. The inspector was told that the managers and providers were approachable and responsive. The manager has the necessary experience and is working towards the required qualifications; the deputy manager has attained the Registered Managers’ Award and has a Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 23 great deal of experience. Health and social care professionals indicated that the home was well managed. The home has established quality assurance systems to review, develop and improve the home, and ensure that residents, relatives and professionals ‘have their say’. Surveys sent to residents are in a format they can understand and a key worker or advocate assists them where necessary. The inspector was shown a number of responses from residents’ questionnaires completed earlier in the year; these showed a high level of satisfaction. Satisfaction surveys are currently with relatives and professionals. Once a full audit has been completed the management team compile a report with outcomes and points for action. Health and safety is generally well managed. Records showed and staff confirmed that they receive the necessary mandatory training such as moving and handling, food hygiene and general health and safety to ensure practice is safe. Training records showed that two staff needed first aid up-dates; the manager was aware that up-dates were overdue but assured the inspector that a qualified first aider was on duty at all times. Since the last inspection a fire warden has been appointed and trained to ensure that fire safety is maintained. All staff have received fire safety training and residents are also involved in fire drills and evacuations, three residents spoken with confirmed that they knew what to do should the fire alarm sound. Thermostatic valves deliver water at a safe temperature and radiators in communal areas have been covered to prevent accident and harm to residents. Window restrictors have been fitted to first floor windows to reduce the risk of falls for residents. The pre-inspection questionnaire showed maintenance of equipment, water, gas and electrical systems was up-to-date. Accidents, incidents and injuries are recorded at the home but the home has not informed the commission of these events and must do so. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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 4 2 4 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 4 X 3 X X 2 X Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 25 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 YA42 Regulation 37 (1) Requirement The registered person shall give notice to the Commission without delay of the occurrence of – (c) any serious injury to a service user; (d) serious illness of a service user at a care home at which nursing is not provided; (e) any event in the care home which adversely affects the wellbeing or safety of any service user Timescale for action 27/12/06 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. Refer to Standard YA20 Good Practice Recommendations It is recommended that agreed guidelines be made available for staff administering invasive medication. DS0000021920.V299449.R01.S.doc Version 5.2 Page 26 Creedy Court 2. 3. YA23 YA24 4. YA42 It is recommended that two signatures be obtained when dealing with residents’ personal finances. It is recommended that 1. The mattress identified during the inspection be replace 2. The kitchen ceiling in Westleigh be repaired 3. The dining area in Eastleigh be reviewed to ensure that it provides a pleasant and comfortable environment for residents to enjoy meals. It is recommended that staff receive regular first aid updates as needed. Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Creedy Court DS0000021920.V299449.R01.S.doc Version 5.2 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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