CARE HOME ADULTS 18-65
Outreach, 162 Bury Old Road 162 Bury Old Road Crumpsall Manchester M7 4QY Lead Inspector
Steve O`Connor Unannounced Inspection 14 February 2006
th Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 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 Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 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. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Outreach, 162 Bury Old Road Address 162 Bury Old Road Crumpsall Manchester M7 4QY 0161 740 0471 0161 740 5678 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) Outreach Community & Residential Services Maretta Bernadette Anne Patten Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: The Outreach home at 162 Bury Old Road is a residential care home providing 24-hour accommodation and support to 7 service users with a learning disability. One bedroom is available for respite care. The home is situated in the North of Manchester close to local shops, amenities and public transport links. It is a Victorian terrace building situated on a busy residential street and is of the same size and character as surrounding houses. There is a small car park to the rear adjacent to a well-maintained garden. Accommodation is provided over three floors and a basement area. Six single bedrooms with wash-hand basins are situated on the first and second floors. There is also a self-contained flat on the first floor. Communal space consists of two lounge areas, a dining room and kitchen. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 14th February 2006. Time was spent talking with the manager and observing how staff worked with people. In addition people’s files and other documents were inspected. The previous inspection identified a number of areas of work that the home needed to improve upon. The majority of these have been addressed and now meet the required standards. The CSCI had not received any concerns or complaints about the home since the last inspection. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well:
Of the standards assessed during this inspection the home does well in the following areas. Helping and supporting vulnerable people to make their own choices and decisions in the areas that affect their lives is very difficult and needs to be balanced with protecting and keeping people safe from harm. The home encourages and supports people to be as independent as possible and to take up new opportunities and experiences. Several people have gone on overseas holiday or participated in social, leisure and educational activities for the first time. One person was given the training and opportunity to be apart of the selection panel for new staff. The home is very aware that the dilemma between protecting and encouraging vulnerable people does affect the way they support people and so have asked for help from independent advocates to work with and speak up on behalf of people who may find it difficult to speak fully for themselves. Being able to keep close links with family, friends and to make new relationships is an important area in people’s lives. The home supports and encourages those with families and friends to keep that contact going and to involve them as much as possible in people’s lives. The home is aware of how forming personal relationships is a right that all the people they support have. The home will seek help and guidance and will offer help and guidance to people who may need it to achieve this. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 6 Everyone has the right to raise their concerns and worries and know that they will be taken serious and listened to. The home has provided people with information and support that allows them to raise their concerns, even when it is a complaint about the home itself. In one example, it was seen that the organisation and the home took a person’s complaint very seriously and acted on her worries and concerns. Every home needs a manager who provides the leadership and support to maintain high standards of care and support. The home’s manager has the skills and values that are needed to support vulnerable people in a positive and safe environment. They are open and honest about the issues they face and the challenges in supporting people to fulfil their potential. What has improved since the last inspection? What they could do better:
The accurate recording of the administration of medication is important in making sure that people remain healthy and safe. The home has to make sure that the person who administers medication signs the Medication Administration Record sheets correctly and at the time that the medication is given. It was not clear whether all the bank/agency staff that the home uses has had the correct level of training in the administration of medication. The home were required to show proof that all bank/agency staff have received the right medication training.
Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 7 Whilst the home appeared clean and decorated in a homely nature, it was found that several of the carpets in the basement area and some furniture was starting to look tired and worn. The home must provide an action plan (with timescales) to the CSCI for the maintenance, replacement and renewal of the flooring and furniture of the home. Providing staff with the necessary training and making sure that the staff maintain those skills through up-dated and refresher training is important to make sure that people’s support needs are being met correctly. Staff training records showed that the staff team had undertaken various training events and programmes. However, the records did not make it clear that staff had received up-dated and refresher training in areas such as first aid, food hygiene, adult protection etc. The home was required to undertake a full audit of the training undertaken by staff to ensure that they have access to the required refresher training. Making sure that people are as safe as possible from accidents such as the outbreak of fire is an essential responsibility of the home. As part of this responsibility they are required to make certain visual checks on fire equipment, lighting, alarms and escapes at regular intervals recommended by the local fire authority. These intervals for checks were not being maintained by the home and they were required to improve. 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. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 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 Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made for these standards. EVIDENCE: The core standard was assessed at the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home supports people to make choices and decisions that impact on their lives. EVIDENCE: The home actively supports people to make their own choices and decisions. Any restriction of choice would be based on the outcome of a risk assessment. The home have supported people to access independent advocates. Where possible people control and manage their own finances as much as they can and are supported where needed in relation to their benefits. The previous inspection required the home to review its risk assessment process in light of an incident that affected a person whilst they were holiday. The risk assessment systems had been reviewed and updated accordingly. The remaining core standards were assessed during the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 People are supported to maintain appropriate relationships. EVIDENCE: The recommendation to develop and record a menu of meaningful and valued activities that they enjoy and wish to try was being worked on. The home supports people to maintain family relationships and friendships. Families and friends are encouraged to visit and some people visit their relatives. People can use both private and communal rooms for their visits. The home supported two people through a relationship and provided support, guidance and information to help them make informed choices. The remaining core standards were assessed during the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home does not have all the systems in place to ensure the safe administration of medication. EVIDENCE: The medication administration system was seen and found that generally the system operated well. However, it was noted that some of the MAR were not fully signed and the PRN medication record was incorrectly filled in. It was explained that this was due to the person being a ‘bank worker’ and so not familiar with the home’s systems. The medication administration systems MAR and PRN medication recording must be accurate at all times. All bank staff that administers medication must have had the necessary training. The remaining core standards were assessed at the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home encourages and supports people to raise their concerns and complaints. EVIDENCE: The home has provided people with a clear complaint procedure and encourages people to raise their concerns and complaints. Evidence was seen of a person at the home using the formal complaints system and the main organisation treated the complaint seriously and fully. The recommendation that the home’s policy and procedures for managing physical intervention be based on the British Institute of Learning Disability (BILD) guidance was being looked at. The remaining core standard was assessed at the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 14 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 The home was clean and had the systems in place to maintain hygiene standards. EVIDENCE: The previous inspection report highlighted the deterioration of the carpet in the lounge. It was seen that the carpet had been cleaned. The basement lounge and stair carpet was beginning to show signs of wear and staining. Some of the chairs in the basement lounge were also beginning to show signs of wear. The registered provider must provide an action plan (with timescales) for the maintenance, replacement and renewal of the flooring and furniture of the home. The recommendation that the home consider whether the use of florescent lighting creates the environment the home wants to achieve has been considered and felt that it would have to be the people living at the home who make this decision and bear the costs. At the time of inspection people did not require hands on personal care that required infection control practices. The kitchen contained clear information on safe food handling practices and staff had received training in food hygiene.
Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 15 Laundry facilities are domestic in nature and are situated in a secure storage area. The other core standard was assessed during the previous inspection. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 16 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): 35 and 36 The home provides staff with the required supervision. However, not all the training systems are in place to ensure that staff have all the training required to support people. EVIDENCE: The previous inspection report highlighted how the use of bank and agency staff meant that the home was not benefiting from a consistent and stable staff team. Although the numbers of permanent staff has remained the same the bank staff used were consistent. The home still had to use staff who were not familiar with the service on occasion and this issue has been raised in relation to the administration of medication standard. The previous inspection report raised concerns about the authenticity of references and the legal documents required to allow people to work for the home. The home stated that all relevant references now required either authorisation or a telephone follow up. The documentation relating to work and residents’ permits had been checked to ensure that all records were up-to-date and authentic. Each member of staff has a training profile/record. This records the skills and qualification that the person comes to the job with, what core training they require to undertake as part of their induction and any further training needs. Those training events participated in were also recorded. However, the records
Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 17 were not kept up-to-date and it was unclear whether staff had undertaken refresher core training. The home must undertake a full audit of the training undertaken by staff to ensure that they have access to the required refresher training. In September 2006 a new compulsory induction programme, set by the national organisation responsible for setting the content and quality of training in the social care sector (Skills for Care), will have to provided to all social care workers. The home must ensure that its current induction programme meets the standards set by the Skills for Care Induction modules. It is recommended that the home develop a system for evidencing the competence of staff arising from any training event they participate in. Staff have received regular and ongoing supervision approximately every 6 weeks. Full records of the supervision are maintained. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People benefit from a well run home that has the systems in place to listen to their views about the service they receive. However, the systems for fire health and safety do not fully protect people living at the home. EVIDENCE: The manager of the home has the qualifications and skills to run the home. They are open and honest about the issues they face and the challenges in supporting people to fulfil their potential. The manager has the skills and the values to support this aim and has been successful in supporting people to take on new activities and responsibilities. The main organisation (Outreach) has introduced a new quality assurance audit for all its services. The home has completed the audit and this included seeking people’s views and those of relatives and relevant care managers. The home also supports people in house meetings and a manager from another service undertakes Regulation 26 visits/inspections. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 19 It was noted that the quality assurance process did not actually result in any action plan for improvement and was more of an audit than a measurement of quality. It is recommended that the home develops an action plan from the quality assurance process that sets out how the service wants/needs to improve over the next 12 month period. The fire log was seen and found that the checks were not being made in accordance to the guidance from the local fire authority. A fire risk assessment was completed in September 2005. The home must undertake the visual checks relating to the fire protection systems based on the guidance from the local fire authority. Evidence was seen of electrical, gas and fire equipment being serviced on an annual basis. Safe working practices and environmental risk assessments had been completed. Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 20 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 X 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 3 X X 2 X Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 21 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 YA20 Regulation 13 Requirement a) The medication administration systems MAR and PRN medication recording must be accurate at all times. b) All bank/agency staff that administers medication must have had the necessary training. The registered provider must provide the CSCI with evidence to collaborate this. a) The carpet in the basement lounge was stained and needed replacing. b) The registered provider must provide an action plan (with timescales) to the CSCI for the maintenance, replacement and renewal of the flooring and furniture of the home. The home must undertake a full audit of the training undertaken by staff to ensure that they have access to the required refresher training. The home must ensure that its current induction programme meets the standards set by the Skills for Care Induction modules. Timescale for action 01/03/06 2. YA24 23 01/04/06 3 YA35 19 01/05/06 4 YA35 19 01/09/06 Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 22 5 YA42 12 The home must undertake the visual checks relating to the fire protection systems based on the guidance from the local fire authority. 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA13 Good Practice Recommendations It is recommended that the home continue to work with all the people living at the home to develop and record a menu of meaningful and valued activities that they enjoy and wish to try. It is recommended that the home’s policy and procedures for managing physical intervention be based on the British Institute of Learning Disability (BILD) guidance. It is recommended that the home develop a system for evidencing the competence of staff arising from any training event they participate in. It is recommended that the home develops an action plan from the quality assurance process that sets out how the service wants/needs to improve over the next 12 month period. 2. 3 4 YA23 YA35 YA39 Outreach, 162 Bury Old Road DS0000021621.V279275.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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