Inspection on 29/08/07 for Manchester Learning Disability Partnership

This inspection was carried out on 29th August 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manchester Learning Disability... 22/09/06

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Manchester Learning Disability Partnership Short Breaks Service 228 Ryebank Road Chorlton Manchester M21 9LU Lead Inspector Steve O’Connor Unannounced Inspection 29 August 2007 3:00 Manchester Learning Disability Partnership DS0000065167.V342126.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 Manchester Learning Disability Partnership DS0000065167.V342126.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. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manchester Learning Disability Partnership Address Short Breaks Service 228 Ryebank Road Chorlton Manchester M21 9LU 0161 881 8108 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) Manchester Physical Disability Service Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home provides accommodation and care on a respite basis for a maximum of four adults aged between 18 and 65 years old whose primary need for care is by reason of learning disability. The organisation must, at all times, employ a suitably qualified and experienced manager. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. 22nd September 2006 Date of last inspection Brief Description of the Service: Ryebank Road is a care home that provides 24-hour accommodation and support for up to four adults with learning disabilities, and associated disabilities, for short breaks that give carers/families a break from their care role. The building is a normal domestic dwelling set on a residential area in the south of Manchester with good access to local shops and amenities. The building is accessible for wheelchair users with tracking hoists fitted throughout the ground floor. The ground floor has a kitchen, lounge and dining room, and one bedroom with toilet and shower facilities. The remaining 3 bedrooms and bathroom facilities are located on the 1st floor with office space on the 2nd floor. There is an enclosed garden to the rear of the building. The weekly fees charged at time of this inspection were approximately £13.50 per evening. The home gives a copy of this inspection reports to people, families and professional on request. A copy of the home’s Statement of Purpose and Service User’s Guide is always made available to read at the home. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in September 2006. This information includes an Action Plan sent in response to that inspection report, an Annual Quality Assurance Assessment (AQAA) completed by the home and returned to the CSCI in August 2007, survey questionnaires sent to the people who use the short-break service, incidents notified to the CSCI by the home and information provided through other people and agencies, including any concerns and complaints. As part of the inspection process the Short-Break service office was visited on the 24 August to talk to the Team Manager (who is not the registered manager) and to view relevant files, documents and records. An unannounced site visit was made to the home on the 29 August 2007. The opportunity was taken to talk to people who were staying at the home, the staff on duty and assess relevant documentation. In addition, a tour of the premises was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how many visits the CSCI needs to carry out with the home. What the service does well: Comments received from families and carers of people who use the service were generally very positive about the standard of service people received. The help and support provided by the staff team was highlighted and was summarised by a parent when they stated that, ‘the staff are very friendly and helpful and always willing to help and listen.’ During the site visit the interaction between people and the staff on duty was seen to be very positive and understanding. There was lots of joking and friendly banter between people that made the atmosphere of the home welcoming and homely. The home is part of the Manchester Learning Disability Partnership (MLDP). This is a joint social and health service made up of social and healthcare professionals. Therefore, either before a person uses the service or if needs change the home can work with specialist providers such as Speech and Language Therapists to develop clear guidance on how to help a person eat safely, or an Occupational Therapist to make sure that any support with a persons mobility or moving and handling are carried out in the right way. If a person needs support to cope with some behaviour that could be challenging, then psychologists and other clinical professionals will develop clear guidance on how to reduce and cope with this behaviour. Around 35 people and their families and carers use the home to have a short break. People have their individual needs and ways that they prefer and have Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 6 to be supported, especially with their personal and healthcare. Each person has their own personal care checklist and guidance that explains how they themselves wish to be supported. A few examples seen explained whether the person preferred a shower or bath, what shampoos or other personal hygiene products they used. The guidance read as if the people were telling you themselves the best way to help them. The home continues to place a high emphasis on providing its staff team with the skills, knowledge and training they required supporting people in the right way. They have access to the Manchester City Council Adult Social Care department’s training programme and team as well as the training resources available within the MLDP, especially in relation to health needs. If specific specialist training was required then the home will find that from other relevant professions and training providers. What has improved since the last inspection? What they could do better: At the time of the inspection the management structure of the Short-Break service and the home did not yet include having a registered manager who had key accountable operation management responsibility. A proposal from the Short-Break service had been agreed with the CSCI as to a new structure but this had not yet been put in place. Plans were ongoing to implement this structure. An important part of a person’s stay at the home is that they are able to take part in social and leisure activities, particularly in the community. A survey of the service sent to families and carers of people who use the service was Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 7 conducted in December 2006. One of the issues raised through the survey was that they would like people to have more activities in the community. Comments made on the questionnaires returned to the CSCI also raised this issue when a parent stated, ‘sometimes he goes out during the evening. There could be a bit more and to different places and activities.’ From the records of support seen in the home it was not always very clear what activities, if any, some people had been offered or supported to take part in. 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. The summary of this inspection report can be made available in other formats on request. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to them being offered a service. EVIDENCE: There is an established referral and introduction programme for all new people who want to use the short-break service at the home. This involved the Care Management Team completing a detailed referral form and comprehensive assessments of needs. If required, specialist health providers would contribute to the assessment of need and provide guidance and training for staff to be able to fully meet people’s health needs. Samples of completed Community Care and specialist health assessments were seen. The period of introduction would vary depending on the individual person. The home would provide people with information about the service and offer as many tea visits and overnight stays necessary for them and their carers to make an informed decision about using the service or not. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs and support had been identified through their care plan. The home supports people to make decisions and choices unless agreed through the care plan. Risks to people’s health and wellbeing are assessed and supported by the home. EVIDENCE: From the information gathered through the assessment the home worked with people and their carers to develop an individual care plan of their needs and the support they require to help them. Samples of care plans were seen and found that they contained a brief personal history of the person and then a range of information relating to the person’s individual personal, healthcare, social and emotional needs. There was some good health information such as epilepsy care plans and detailed eating and drinking guidance that had been produced by specialist health providers. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 11 The care plan also included a detailed personal routine of how the person wanted to be supported. This was person centred focused and read as if the person was telling you how they wanted to be helped. Although the care plans contained a good range of information, from discussions with staff on duty, it was found that staff had a much more in-depth and personal knowledge and awareness of people’s needs that were not fully reflected in the individual care plan. It is recommended that the person centred focus of the care plans continue and that the knowledge and awareness of how people are supported was fully reflected in the individuals care plan. The previous inspection report highlighted some areas of improvement that were needed with the care planning process. One area was in how people’s care plans were reviewed and updated to make sure that they reflected changes in people’s needs and support. Examples were seen where additional information had been added to care plans to reflect changing needs. It is recommended that the home continue to develop the person centred approach to supporting people and working with them to identify what is important to them how they want to be helped. The home had also introduced a new reviewing system where people and their carers were contacted before the person came for their stay to check whether their had been any changes or other information that the home needed to be aware of. In addition to this ongoing review process, people’s care plans and support were formally reviewed by the home and by the relevant Care Management team on an annual basis. Examples of these reviews were seen in people’s care plans. The home works with the person and their family and other relevant people to find out what the person likes and does not like in terms of diet, activities, environments and communication. Through this they try to offer people dayto-day choices and decisions that reflect their needs. Restrictions of choice are only made to safeguard the person and only as a result of a full risk assessment. Identified risks had been assessed and detailed instructions were available so that staff knew what they had to do to keep people safe. Examples of risk assessments included moving and handling, medication, finances and healthcare. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s lifestyle and choices whilst staying at the home were generally based as much on their normal routines and needs as possible. EVIDENCE: As people only stay for short periods of time the home tries to make sure that the person keeps to their normal routines of activities such as attending a day centre or education classes. Occasionally this is not possible due to problems with accessing community transport or during those times when a person’s normal activities were not provided such as during college breaks. Individual care plans do highlight the activities that people enjoy taking part in both at home and in the community. However, it was found that the amount and type of activities, especially in the community, that people participate in can be very limited. It appeared, from talking to staff on duty, that factors such as access to transport, levels of personal support, the perceived Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 13 unsuitability of local entertainment and leisure venues and the amount of personal spending money a person has all impacted on the staff’s decisions of what activities to offer people. During the site visit people were spending time drawing, watching the television and sitting in the dining room. However, from the records sampled there appeared very little variety in evening social and leisure activities and two of the five questionnaires returned by people’s families also highlighted that they would like more and varied activities offered to people. The home must look at the factors that may limit people’s opportunities to participate in valued community activities and to try to seek ways to minimise those factors and so offer people more and varied choices. The home tries to maintain the routines that people have developed at their own homes in terms of the day services and other activities that they would normally take part in. This is reflected within the home where peoples’ routines are based on the activities they attend and their own personal preferences. Visitors are welcome to come to the home at reasonable times but the home provides a short break away from people’s carers/family and so visits would not happen on a regular basis. Mealtimes are usually taken together with staff providing any assistance required. As the home provides a service for over 30 people choice of meals has to remain flexible and is dependent on the dietary needs of the people staying at the home at the time. Information on people’s food likes and dislikes is used to decide the choice of meals and the home encourages a healthy balanced diet with the availability of fresh fruit, vegetable and ingredients. The majority of all meals are home cooked and people are also offered a take-away choice once a week. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs were understood and supported by the home. EVIDENCE: Each person who comes to stay at the home has their own personal care checklist and support guidance. This sets out clearly the skills the person has and what help they need to maintain their personal care. If people’s needs change or staff are aware of new information this was added to the personal care plan. People’s healthcare needs are identified prior to them coming to stay at the home. Health needs and the support needed to meet them are clearly identified and the input from the relevant healthcare services had been gained. Specific skills needed to support people’s healthcare needs were provided to the staff team where required. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 15 Each person has a medication profile that lists all current medication. Changes to the medication regime have to be notified to the home prior to the person’s stay. If the medication that arrives with the person is different from that listed then the home will contact the relevant prescribing doctor to confirm the changes. All medication that comes with the person is recorded on a MAR sheet. The Medication Administration Record (MAR) sheets seen were accurate in recording the dosage of medication given. MAR sheets are regularly audited by the management team and the medication is checked and recorded by staff each time they change a shift. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate policies, procedures and systems are in place that encourage people and or their carers to express their concerns and worries and for their protection. EVIDENCE: The home forms part of the Manchester Learning Disability Partnership (MLDP) Short Break service and as such links into the formal Manchester City Council Adult Social Care department’s complaint procedures. This is a clear and established complaints process that people and/or their carers/families can access. Information about how to make a complaint has been made available to people and their carers. The home also has its own informal complaints process where people and carers can contact the staff or management team to discuss issues that they are not happy with or concerns that they have. The home will try to resolve any concerns directly or may require the attention of the management team. Examples of records were seen where people had raised concerns about the service and the home had acted to remedy those concerns. The home follows the Manchester Multi-Agency Adult Protection Procedures. The staff team have access to a rolling programme of adult protection training and are aware of the procedures to follow. Staff on duty understood and were able to describe clearly the procedures to follow in the event of an allegation or incident affecting people. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 17 As people only stay at the home for a short time a specific system of recording people’s monies and spending has been developed. The system should show clearly what has been spent on what and how much was returned home with the person. Examples of financial records were seen and found to be accurate. Staff check the money balances every day and the finance sheets are audited on a regular basis by the team coordinator. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises meets people’s needs and provides a safe environment. EVIDENCE: A tour of the premises found that the home was clean and generally well maintained. The house was owned by a Housing Association who were responsible for the maintenance and safety of the building. The house was furnished in a modern style with good quality furniture, fixtures and fittings. As people only stay at the home for a short-time bedrooms were generally decorated and furnished in a simple and minimal style. People were encouraged to bring their personal items with them. One bedroom was located on the ground floor and was adapted to support people with physical limitations. The room was fitted with overhead tracking and a raising and falling bed. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 19 The communal areas were adequate for people’s needs but the only lounge in the house would be difficult to accommodate six people all at once or if people used wheelchairs. The decoration of the house was adequate with some areas starting to show signs of wear and tear such as bathroom floors and loose tiling and some carpets in communal areas. It is recommended that a review of the premises be undertaken to establish the decoration and refurbishment needs of the home and to develop a plan of action to improve the standard of the premises and environment. Laundry facilities were domestic machines and located in the kitchen. Staff had access to the aids and equipment required to handle soiled linen and clothes safely and to minimise cross infection. Staff spoken to on duty were aware of the risk of contamination and cross infection and the safe working practices to follow to maintain people’s health. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from having an effective and competent staff team who have the skills and knowledge required to support their needs. The home’s recruitment practices and procedures ensure that staff are safe to work with vulnerable people. EVIDENCE: The staff team consists of a Co-ordinator, who oversees the day-to-day running of the home and six support staff. The number of staff on duty depends on people’s daily routines such as whether they attend a day service. There will always be at least one member of staff on duty if people were in the home. During the mornings, late afternoon/evenings and weekends there are two staff on duty and a sleep-in cover every day. To cover staff days off, holidays and sickness the home employs agency workers from either the MLDP’s own bank or private agency staff. The MLDP Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 21 bank staff cover the majority of hours and several of the staff team work for this bank and so this provides for better consistency of staffing. According to the information provided by the home in the Annual Quality Assurance Assessment (AQAA) all but one of the staff team have gained at least the NVQ level 2 or above. New members of staff had access to a structured staff induction programme that is based on the Learning Disability Award Framework and meets the requirements of the Skills for Care Induction modules. Each year the MLDP Short Break service develops its own training needs plan that is submitted to the Manchester City Council Adult Social care training department. They then commission and provide a range of training events that staff can be nominated for. Training can also be provided from within the MLDP especially in relation to people’s health and behavioural needs. Staff spoken to at the home described a range of training events that they had attended over the last 12 months and included moving and handling, infection control and food hygiene. A record of staff attending training events was maintained and used to establish staff training and refresher needs. However, it was found that samples of the training records seen were not up-to-date to reflect the training that staff had participated in. It is recommended that the home ensure that the systems for recording staff training is accurately maintained. The need for staff to show their competence in implementing the training they have participated in was an issue that the home’s management were aware of. It is recommended that a system for assessing staff competence in how they implement the skills and knowledge gained through participating in training events is developed. An established clear and rigorous recruitment and selection procedure was in place. This included face-to-face interviews of which one person who used the service would be invited to sit on the interview panel. Also, two written references and CRB/POVA checks were completed before an appointment was confirmed. Manchester Learning Disability Partnership DS0000065167.V342126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to seek people’s views of the service and to ensure the health and safety of people staying at the home. EVIDENCE: Currently the home’s management structure has an Assistant Network Manager (Co-ordinator) who has day-to-day responsibility for the safe running of the home. They are also responsible for another home in the Short Break service. They are responsible for supervising the staff team and to ensure that standards of care are being maintained. They do this through allocating a large proportion of their time at the home working and spending time with people and monitoring the homes recording and operational systems. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 23 They are line managed by the Team Manager who has responsibilities for the Short Break and other services within the MLDP. The service had been in discussion and negotiations with the CSCI for over a year as to who was to be the registered manager. The Short-Break service put forward a proposal and this was agreed by the CSCI. However, at the time of the site visit a named manager had not yet applied to become the registered manager. A manager must be appointed who is fit to manage the service as the registered manager. The home gathers information about the service it provides in several ways. On an informal basis the home listens to people and their carers about their experiences of the service. The care management and in-house reviews looks at the support individuals receive and the home also organises regular meetings with people and their carers to discuss their experiences. The home does have a formal quality assurance process but had not been undertaken since before the last inspection report of September 2006. In December 2006 the MLDP Short-Break service did carry out a survey with the families and carers of people who use the service to find out what parts of the service people were satisfied/not satisfied with. It is recommended that the quality assurance programme be undertaken and to include a quantifiable analysis of the information gathered to provide a year on year measure of the quality of the service. Information provided by the home, in the AQAA, stated that it had the required health and safety policies and procedures and the gas, electricity and moving and handling equipment had been serviced. Fire risk assessment was seen dated 24/11/05. It is recommended that the fire risk assessment is reviewed on an annual basis in line with health and safety guidance. The fire log was seen and was being maintained, temperatures of water sources and fridges/freezers were being maintained. Manchester Learning Disability Partnership DS0000065167.V342126.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 X 2 3 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 3 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA12 YA13 Regulation 16 (2) (m)(n) Requirement The factors that limit people’s opportunities to participate in valued community activities must be minimise so as to offer people more and varied choices. A manager must be appointed who is fit to manage the service as the registered manager. Timescale for action 01/11/07 2 YA37 9 (1) 01/11/07 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 YA6 Good Practice Recommendations It is recommended that the home continue to develop the person centred approach to supporting people and working with them to identify what is important to them how they want to be helped. It is recommended that the staff’s knowledge and awareness of how people are supported was fully reflected in the individuals care plan. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 26 2 YA24 It is recommended that a review of the premises be undertaken to establish the decoration and refurbishment needs of the home and to develop a plan of action to improve the standard of the premises and environment. It is recommended that the home ensure that the systems for recording staff training is accurately maintained. It is recommended that a system for assessing staff competence in how they implement the skills and knowledge gained through participating in training events is developed. 3 YA35 4 YA39 5 YA42 It is recommended that the quality assurance programme be undertaken and to include a quantifiable analysis of the information gathered to provide a year on year measure of the quality of the service. It is recommended that the fire risk assessment is reviewed on an annual basis in line with health and safety guidance. Manchester Learning Disability Partnership DS0000065167.V342126.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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