Inspection on 04/01/06 for Creedy Court

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Creedy Court 01/11/06

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 Susan Lyons Unannounced Inspection 10:30 4 January 2006 th Creedy Court DS0000021920.V268772.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 Creedy Court DS0000021920.V268772.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. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 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.V268772.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 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 a 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 lounges and kitchen. All bedrooms are for single occupancy only. There is a large day services area for the use of service users, including a pottery room, a massage room and a snoozelem. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place during the morning. As it was still holiday time the majority off the residents were all at home and able to meet with the inspector, if they wished. Much of the information gained at the inspection was from residents. Residents living on Westleigh were able to tell the inspector about the home and about their activities. It was more difficult to obtain information from the residents on Eastleigh as many of the residents are not able to talk. Therefore information had to be gained by observation and talking to staff. There was a nice relaxed atmosphere within the home. At the time of the inspection decorators were at the home redecorating many of the areas. Many of the core standards were assessed on the previous inspection therefore the report for that inspection should be read as well as this one. What the service does well: What has improved since the last inspection? Since the last inspection records identified as missing in relation to staff have been obtained and the fire alarms have been tested regularly. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 6 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.V268772.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 Creedy Court DS0000021920.V268772.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): 3 Generally all residents’ needs are being met at the home, however attention needs to be given to a specific concern for one resident. EVIDENCE: This standard was not looked at in detail, however one resident told the inspector that they were disturbed at night by the noise made by another resident. This was discussed with the manager. Creedy Court DS0000021920.V268772.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): 6&7 Resident are confident that they are involved in the care planning process and that their wishes and choices are respected. EVIDENCE: Care plans were looked at in detail at the last inspection. However residents confirmed that they are involved in the completion of their own care plans. Through discussion with residents on both units it was evidenced that they are able to make choices about their own lives with the support of the staff. Residents described activities, which they have decided not to do, and new ones they are hoping to pursue. Residents confirmed that they have been able to choose furniture for their own room as well as for communal rooms and also the colour scheme. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 10 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): 16 & 17 Resident’s privacy is respected and they benefit from meals which they enjoy and may help to prepare. EVIDENCE: Residents in Westleigh confirmed that they are able to have a key to their own bedroom door but do not have a key to the front door. Residents said that their mail is given to them unopened although one resident said in the past his had been opened by a member of staff, since he complained about this it had not happened again. There is a separate lounge in Westleigh for residents to use when smoking. One resident said that all the staff except one member knocks on the door before entering. The resident asked the inspector to speak to the manager about this. The manager spoke to the member of staff before the inspector left the premises. In Westleigh the residents help prepare some of the meals. In Eastleigh the meals are prepared in the main kitchen. Staff said that if residents want to do some cooking then they would take the ingredients etc. into the unit for residents to be involved. The cook confirmed that residents come to the hatch or door of the kitchen to tell her if they dislike anything on the menu and they are then able to have an alternative. The menu is displayed on a board in the kitchen. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 11 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): These core standards were assessed on 19th July2005 inspection. EVIDENCE: Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 12 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): These core standards were assessed on 19th July2005 inspection. EVIDENCE: Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 13 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 Residents benefit from a clean home with suitable facilities to maintain hygiene standards. EVIDENCE: On Westleigh there is a separate washing machine which residents are encouraged to use with staff support if it is required. There is an additional laundry for all other washing. On the day of the inspection the home was clean and there were no unpleasant odours. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 14 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 Residents are supported by suitably qualified staff. EVIDENCE: Currently the home has eight members of staff with NVQ 3 and 4 with NVQ 2. there are a further 6 members of staff who are due to either complete level 2 or 3 by the end of January. The home has therefore exceeded the standard of 50 of their staff trained to a minimum of level 2 NVQ. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 15 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): 42 The safety of residents may be compromised by not all staff having specific training. EVIDENCE: A requirement was made in relation to fire safety training following the last two inspections. One member of night staff had not received fire safety training for over twelve months at this inspection. The inspector was informed that the member of staff has not attended when fire safety training has been provided. An immediate requirement notice was issued in respect of this. It was noted that a further two members of staff had not received any fire safety training during the last ten months. Creedy Court DS0000021920.V268772.R01.S.doc Version 5.0 Page 16 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 2 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X 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 3 17 Standard No 31 32 33 34 35 36 Score X 4 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Creedy Court Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X 1 X DS0000021920.V268772.R01.S.doc Version 5.0 Page 17 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 YA42 Regulation Requirement Timescale for action 07/01/06 23 (4) (c ) You must ensure that all staff (d) receive fire safety training twice in a twelve-month period. ( Timescale of 20-8-05 not met) 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 YA3 Good Practice Recommendations It is recommended that you look at ways in which all residents’ needs in relation to noise are met. 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