Care Home: Creedy Court

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What the care home does well Everyone has a care plan and staff are aware of people`s needs and how best to meet them.There are plenty of staff available and they are well trained.There are lots of things to do and lots of choices are available.The home is clean and fresh and environmental risks are minimised. What has improved since the last inspection? The home now lets us know about anything that happens at the home that is out of the ordinary. What the care home could do better: The home needs to make care plans a bit smaller and they need to be more clear about what staff have to do for people, so that everyone always gets the help they need.All creams need to have the date they are first used written on them, so that they are not used for too long.All staff need to have training in POVA (Protection of Vulnerable Adults) matters so that they can recognise and report bad practice and keep people safe.All required information must be obtained before staff start work at the home, so that the home is sure they are suitable to work with vulnerable people. Key inspection report Care homes for adults (18-65 years) Name: Address: Creedy Court Creedy Court Shobrooke Crediton Devon EX17 1AD The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sue Dewis Date: 1 3 0 8 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 37 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 37 Information about the care home Name of care home: Address: Creedy Court Creedy Court Shobrooke Crediton Devon EX17 1AD 01363773182 01363775822 creedycourt@autismcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Ms Penelope Debra O`Sullivan,Mrs Mary O`Sullivan care home 17 Number of places (if applicable): Under 65 Over 65 17 0 learning disability Additional conditions: Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 37 A bit about the care home Creedy Court is situated near the village of Shoebrooke and approximately two miles from Crediton. It is registered to provide care for up to 17 adults who have Autism, Aspergers Syndrome or a learning disability. The home is arranged around a courtyard and there is also a garden to the rear of the home that backs onto open fields. There is off road parking to the side of the building. Care Homes for Adults (18-65 years) Page 5 of 37 The home is divided into two separate units, (Eastleigh and Westleigh) each with its own lounge, dining area and kitchen. Eastleigh is for people who are less able. People who live in Westleigh are more independent. Everyone has their own bedroom. There is a large day services area, including a pottery room, a massage room and a snoozelem. Care Homes for Adults (18-65 years) Page 6 of 37 The home has a mini-bus and two house cars. The fees for care range from 1300 2200 pounds per week upwards depending on peoples needs. CQC reports are available on request from the manager. Care Homes for Adults (18-65 years) Page 7 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 8 of 37 How we did our inspection: This is what the inspector did when they were at the care home This unannounced visit took place over 8 hours and 2 days in July and August 2009. The home completed and returned an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. Care Homes for Adults (18-65 years) Page 9 of 37 Although only one inspector undertook this visit, throughout the report there will be reference to what we found and what we were told. This is because the report is written on behalf of the Care Quality Commission. During the visit we looked at the care of 3 people very carefully. We sent questionnaires out to some people living at the home, some social care professionals and some staff. We had responses from 4 people living at the home, 3 social care professionals and 2 staff. Care Homes for Adults (18-65 years) Page 10 of 37 During the visit we spoke with people living at the home and watched how staff and people living at the got on together. We also spoke with 3 staff, the manager and the deputy manager. We also looked at the communal areas of the building and a some records including medications, care plans and staff files. There has been a concern raised recently about the privacy and dignity of one individual. This matter was addressed through the Safeguarding Adults process and the home has put measures in place to ensure the issue does not happen again. Care Homes for Adults (18-65 years) Page 11 of 37 What the care home does well Everyone has a care plan and staff are aware of peoples needs and how best to meet them. There are plenty of staff available and they are well trained. Care Homes for Adults (18-65 years) Page 12 of 37 There are lots of things to do and lots of choices are available. The home is clean and fresh and environmental risks are minimised. What has got better from the last inspection Care Homes for Adults (18-65 years) Page 13 of 37 The home now lets us know about anything that happens at the home that is out of the ordinary. What the care home could do better The home needs to make care plans a bit smaller and they need to be more clear about what staff have to do for people, so that everyone always gets the help they need. Care Homes for Adults (18-65 years) Page 14 of 37 All creams need to have the date they are first used written on them, so that they are not used for too long. All staff need to have training in POVA (Protection of Vulnerable Adults) matters so that they can recognise and report bad practice and keep people safe. All required information must be obtained before staff start work at the home, so that the home is sure they are suitable to work with vulnerable people. Care Homes for Adults (18-65 years) Page 15 of 37 If you want to read the full report of our inspection please ask the person in charge of the care home. If you want to speak to the inspector please contact Sue Dewis CQC South West Citygate Gallowgate Newcastle upon Tyne NE1 4PA 03000 616161 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 16 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 17 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good assessment and admission process in place, which means that people thinking of moving into the home can be sure that their needs will be met. Evidence: There have been no new admissions to the home since 2006. The manager and deputy explained what the admission process would be following any referral. They told us that they would put an information pack together for the individuals first visit. This would contain the brochure and Statement of Purpose for the home. Following a look around the home staff would chat to the individual and would make a verbal assessment of the person. A thorough assessment would be completed over a period of time while the individual got to know the home and the home learned about them. Three of the four people who returned surveys said that they had received enough information about the home before they had moved in. The fourth said they didnt remember. Page 18 of 37 Care Homes for Adults (18-65 years) Evidence: The three files that were looked at contained detailed pre-admission assessments and covered areas of mental and physical health as well as personal and social care needs. Care Homes for Adults (18-65 years) Page 19 of 37 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are detailed, but provide staff with limited clear information how the needs of individuals are to be met. People can be assured that risks to their personal safety will be properly identified and managed. Evidence: The plans of care for three individuals were looked at in some detail. They are divided into two sections - the main file and one for the use of staff. They were quite well organised and contained a detailed assessment of the individuals abilities. However, they are very large and contain much information that is not needed by staff on a day to day basis. The size of the care plans also mean that it is difficult to find the information specific to meeting the needs of individuals. One persons file contained a My Life My Plan booklet that gives staff good detailed information on their likes and dislikes. The care plans do provide staff with some direction as to how to meet the needs of individuals. However, this is not always specific and tends to be staff to monitor or staff to action. This lack of specific directions to staff could lead to inconsistent care being provided. Care Homes for Adults (18-65 years) Page 20 of 37 Evidence: We received several comments on survey forms from staff and social care professionals about care plans. One staff felt that Once a care plan has been implemented it should be stuck to, and should not allow for different shift leaders to interpret as they wish. A social care professional said It could provide clear written aims and goals for clients development. One care professional commented on their survey form that they felt the particular mix of people with profound learning difficulties and Aspergers Syndrome was problematic and that the home struggles with meeting their diverse needs. There was evidence on two care plans on the individuals method of communication. One person had a set of communication cards and a member of staff told us how these were used. Another persons care plan detailed how staff would know if the person (who communicated non-verbally) agreed or disagreed with what they were being asked to do or were being offered. Staff spoken with had a good knowledge of peoples needs and associated risks and were able to describe in detail the care needed by individuals. Staff told us that they found the care plans useful and that they helped in ensuring that the care they provided was good quality. The home operates a key worker system, which means that designated staff are responsible for ensuring that the individuals needs are met and helps to provide continuity of care. Any hazards within the home or with individuals are assessed and any action needed to reduce risks to people is recorded. This ensures staff have the information they require to keep people safe and staff were able to demonstrate a good awareness of individual risks. Care Homes for Adults (18-65 years) Page 21 of 37 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Creedy Court are able to take part in activities that suit their needs and wishes and they are supported to access the local community and maintain contacts with family and friends. Evidence: Opportunities are provided by the home to enable people to develop life skills and encourage them to participate in local community activities. A number of individuals attend local colleges to undertake courses to develop daily living skills. One person attends Grannys Meadow where people are able to participate in horticultural activities such as potting seeds. People also go out with staff on environmental studies with some people going out in wheelchairs. People help to keep the countryside tidy and learn about their environment at the same time. There are a number of activities available within the home such as aromatherapy and arts and crafts. We saw people enjoying arts and crafts and saw many of their paintings and pottery that they had made. People also enjoy time spent at Georges Bar which is a Care Homes for Adults (18-65 years) Page 22 of 37 Evidence: room where individuals can relax together, there is also a disco and tuck shop here. It is run by someone living at the home and gives them confidence and helps promote independence. There are also opportunities for dance and movement therapy and people can use the well equipped snoozelem. There are meetings for people who live at the home every two weeks which are minuted. Here people are encouraged to discuss anything they want to and in particular things they would like to see improved at the home. All four of the people living at the home who returned surveys said that they could do what they wanted to during the day, evening and weekends. The home has recently purchased a flat in Crediton that people can use to help increase their independence. People can go to this flat and spend the day learning daily living skills such as cooking, budgeting and cleaning. The flat can also be used for people just to have some time alone away from the home with their key worker. However, when asked What the service could do better one care professional commented on their survey form Promote supported/independent living. The home also has a yearly fun day each August when friends and family are invited to the home. Several people spoke about the friendships they have developed at the home and the manager and staff confirmed that visitors are encouraged and contact with family and friends is supported. The manager also told us that the home will provide transport and staff to escort people on home visits, in some cases traveling long distances. People living in Westleigh are involved in planning, preparing and cooking meals for each other and some people are doing a GNVQ in catering. In Eastleigh meals are prepared in the main kitchen. One professional commented on their survey form that the home could improve the access to the kitchen so that people can see and be involved in food preparation. Menus are prepared by the cook who has a good knowledge of individual preferences and needs and menus show a varied and balanced diet is provided. People told us that they enjoyed the meals at the home and one person wrote on their survey form that the home cooks nice food. Care Homes for Adults (18-65 years) Page 23 of 37 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Creedy Court are supported in their personal and health care needs in a way that suits them. Systems for the administration of medicines are well managed. Evidence: The three care plans looked at showed that health care issues were clearly identified and any specific issues were followed up. Information about visits from and to health care professionals had been recorded in individual care plans, showing clear evidence that people are supported to maintain access to specialist medical services. These included dentists, GPs, psychiatrists and physiotherapists. Everyone at the home has a complex and diverse need, which staff try to understand and deal with. Staff demonstrated a good knowledge of peoples needs and preferences and gave examples of how key words can alter peoples frame of mind. Staff were also able to tell us how they enabled people to choose how they receive their care and support. All of the people seen during this visit were treated with respect by the staff and their right to privacy was upheld. Personal care, when needed, was offered in a discreet manner and we heard staff speaking to people in a friendly, enabling manner. However, there has been a concern raised recently about the privacy and dignity of one individual. The home has put measures in place to ensure that this type of incident will not reoccur. Care Homes for Adults (18-65 years) Page 24 of 37 Evidence: The home uses a monitored dosage system for the administration of medication and all staff who administer medicines receive appropriate training. We saw that the home stores medication in a secure manner and has in place a good system to record the receipt of medicines into the home. The application of topical cream is recorded on the MAR (Medication Administration Record). However, the date the container was opened was not recorded. This date needs to be recorded so that the cream is not used for longer than one month after it was opened. Care Homes for Adults (18-65 years) Page 25 of 37 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples views are listened to and acted upon, and adequate procedures are in place to ensure that people are protected from abuse. Evidence: There is a simple complaints procedure available to people in an easy read format. We were told by the manager and deputy that people would be supported to raise any concerns they may have and there is a form within the complaints procedure for people to complete with staff. The manager told us that many individuals were able to voice any concerns they may have, and that for those who were unable to do this, key workers are able to recognise any changes in behaviour that may indicate the person is unhappy and would look to see if they could identify the causes. A complaints file is kept, this showed no complaints had been received since our last visit. One concerns was raised with the Commission which was dealt with through the Safeguarding Adults process. People who returned survey forms indicated that they knew who to contact if they were unhappy, this was usually their key worker or the manager. Some of these forms were completed with help. Peoples finances are well managed and good records of all transactions are maintained. Records show, and one staff told us that they had received training in Protection Of Care Homes for Adults (18-65 years) Page 26 of 37 Evidence: Vulnerable Adults (POVA) issues. Two of the three staff that we spoke with could not remember having received any POVA training. Two staff that we spoke with were able to discuss different forms of abuse and said that they would report any suspicions they had to the manager. They were also able to tell us who they would report any concerns to, outside of the home, if necessary. However, the third person could not tell us about any POVA issues. This is concerning as all staff should be able to recognise abuse in order to keep people safe. Care Homes for Adults (18-65 years) Page 27 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a pleasant, comfortable and safe environment for those living in, working at and visiting the home. Evidence: Creedy Court is a large 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 Snoozelen room, which offers people a relaxation area. There is another relaxation room that people use for discos and which has a bar area. The home is accessible to people currently living at the home, 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 its own communal space, including lounge and dining areas. The communal space on Westleigh is bright and homely, with comfortable spaces for people to enjoy. The dining area in Eastleigh was being refurbished on the second day of our visit. The home has an on-going programme of maintenance and refurbishment to ensure the environment remains comfortable and safe. However, some areas of the home need work to make them more homely and comfortable. All bedrooms are for single occupancy only and those seen by us were personalised and comfortable and reflected individual tastes. Care Homes for Adults (18-65 years) Page 28 of 37 Evidence: The home has been creative with some furnishings, fittings and cleaning routines to ensure that bedrooms are personal and comfortable but also minimise any damage or risks to the individual. Three people who completed surveys said that the home was usually clean and fresh with the fourth feeling this was always the case. People are encouraged to take part in light domestic duties where they are able. On the day of the visit the home was clean and free from offensive odours. Hand washing and drying facilities were available in bathrooms and toilets. On Westleigh there is a separate washing machine which individuals 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. Staff confirmed that disposable gloves and aprons were available to them in order to minimise the risk of cross infection. They also confirmed and records show that they have received training in this area. Care Homes for Adults (18-65 years) Page 29 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A wide range of training is provided and the numbers and skill mix of staff on duty are sufficient to meet the needs of people currently living at the home. People are generally protected by recruitment procedures that ensure people who may be unsuitable to work with vulnerable people are not employed at the home. Evidence: On the day of the visit there were 6 care staff the manager and deputy on duty, as well as three non care staff. There are 2 staff awake and one person asleep at the home each night. Individuals spoke highly of the staff, describing them as friendly, kind and helpful. The staff team is generally stable though there have been new staff recruited recently. Staff responding to CQC surveys felt they usually or sometimes have the support needed to do their job well. During the inspection three staff members were spoken with, including the manager and deputy. Staff spoken with were knowledgeable and motivated. Comments on surveys included, the staff try to the best of their abilities to help and assist the service users where needed. Staff appear to have a high level of job satisfaction, which helps to make the atmosphere at Creedy Court a happy one for everyone. Care Homes for Adults (18-65 years) Page 30 of 37 Evidence: Staffing levels appear to meet individual needs at present. During the visit staff had time to give 1:1 attention to people and staff spoken with felt that they had enough time to meet peoples needs. However, one professional commented on their survey form that the home struggles to provide their client with 1:1 support. Staff told us and evidence confirmed that they have received a variety of training, including First Aid, Infection Control and the Protection of Vulnerable Adults (POVA). However, not all staff have received training in POVA issues. Staff have also received a variety of service specific training including Autism Awareness and Managing Challenging Behaviour. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that 19 staff have achieved NVQ level 2 or above. Staff spoken with demonstrated a good awareness and understanding of peoples needs. People who we spoke with said that staff were very good to them and helped them whenever they needed it. The files of three staff were looked at, one contained all the required information including satisfactory CRB (Criminal Records Bureau) checks, full employment history, 2 written references and proof of identity. However, one file contained only one written reference and the other contained none. No one should start work at the home until satisfactory references have been obtained to ensure they are suitable to work with vulnerable people. The home provides regular supervision for staff and records showed that the manager and deputy provide internal staff supervision. An external qualified counsellor also 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. Care Homes for Adults (18-65 years) Page 31 of 37 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of people who live and work in the home. Evidence: The manager, James Moore has the necessary experience to manage a care home and is working towards the required qualifications. He is supported in his role by a deputy and an administrative assistant. Surveys received from care professionals indicated that they felt the home was well managed. Staff that we spoke with felt that they were supported to do a good job, but one person commented on their survey form that the home should Listen to ideas from staff who actually work the floor. All staff carry large bunches of keys and walkie talkies which give the home a rather institutional feel. The manager told us that they are introducing a card entry system for staff and people living at the home to reduce the need for large bunches of keys. We were told that originally walkie talkies were introduced for emergency situations, but their use had increased and they were now used for staff to routinely communicate with each other. We were told that the use of these devices would be looked at. Care Homes for Adults (18-65 years) Page 32 of 37 Evidence: The manager told us that there was no-one living at the home that is subject to a deprivation of liberty authorisation. We saw no evidence to show that anyone living at the home is having their liberty deprived without an authorisation. The home has established a quality assurance system to review, develop and improve the care provided by the home, and ensure that everyone connected with the home has their say. However, no report has been produced this year, so as yet, people are aware of the result of the consultation. The owners regularly visit the home. However, in line with Regulation 26 of The Care Standards Act 2000, the Responsible Individual (the representative of the company owning the home) must carry out monthly quality audits covering all aspects of the provision of the service, to ensure that standards are maintained. A report must be produced following this visit and a copy kept at the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Creedy Court complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, fire precautions, health and safety checks and risk assessments. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. Although the AQAA was returned to us when we asked for it, the information supplied was limited. The AQAA should be fully completed in detail so that we can use it to make a judgement about the quality of care provided by the home. So that the risk of burning from hot surfaces is minimised, radiators within the home have been covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows and all taps are fitted with thermostats to minimise the risk of people being scalded. Care Homes for Adults (18-65 years) Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 37 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 6 6 20 You are recommended to make care plan information more accessible to staff. You are recommended to ensure directions to staff on how to meet peoples needs are more specific. You are recommended to ensure that the date is recorded on topical creams, when they are opened. This is so they are not used for more than one month. Staff should not start work at the home until all the required information has been obtained. This is to ensure no-one is employed at the home who is unsuitable to work with vulnerable people. All staff should receive training in POVA issues to ensure they can recognise and report bad practice and ensure people are kept safe. The Responsible Individual for the company must write a 4 34 5 35 6 39 Care Homes for Adults (18-65 years) Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations monthly report on the conduct of the home, a copy of which should be kept at the home. Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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