Inspection on 25/05/06 for Outreach, 162 Bury Old Road

This inspection was carried out on 25th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach, 162 Bury Old Road 14/02/06

Outreach, 162 Bury Old Road 04/10/05

Outreach, 162 Bury Old Road 29/09/04

Outreach, 162 Bury Old Road 12/01/04

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 Outreach, 162 Bury Old Road 162 Bury Old Road Crumpsall Manchester M7 4QY Lead Inspector Steve O`Connor Key Unannounced Inspection 25th May 2006 1:00pm Outreach, 162 Bury Old Road DS0000021621.V296995.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 Outreach, 162 Bury Old Road DS0000021621.V296995.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. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 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.V296995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 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. The charges for residential fees range from £400 to £500 per week. Information about the home can be gained through contacting the registered provider (Outreach). The CSCI inspection report is available at the home and through the CSCI Internet site. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place on the 25th May 2006.The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and was used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent with the people who use the service, observing how staff work with people, discussions with staff and the manager, assessing relevant documents and files and a tour of the premises. The previous inspection report of February 2006 identified a number of areas that needed improving. Progress had been made in addressing all the areas identified. The CSCI had not received and complaints or concerns about the home since the last inspection. What the service does well: The home supports vulnerable people who, very often, experience difficulties in being able to take up opportunities for social, leisure and educational activities. The home shows that they are committed to encouraging and supporting people to take up activities that they enjoy and that may offer them greater opportunities. Examples of this include several people undertaking a college course to help them find employment and developing their arts and craft skills. People are also supported and encouraged to be involved in their own communities and take advantage of the facilities and opportunities available. Several people are members of their local church, attending services and social events. 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 home supported people to meet together and encouraged them to talk about some problems in the relationships between people and to come up with their own solutions to resolve the problem. Every home needs a manager who provides the leadership and support to maintain high standards of care and support. The home’s manager has continued to show that she 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. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 6 Vulnerable people living in residential care often find that they are not able or allowed to make decisions and choices that affect their daily lives and future. The home actively encourages people to speak their minds and to allow them to make choices and decisions such as what opportunities they wish to take part in, how to increase their own independence and in being able to be critical of the home. Talking to several people showed that they were confident in expressing their views and opinions about the service they received and what they wanted from the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s goals and needs had been assessed prior to coming to live at the home. EVIDENCE: The purchasing local authority had provided the home with pre-admission assessment documentation. The home undertakes its own initial assessment within 7 days of the person’s admission. For an emergency admission information from the purchasing authority is provided within a short time of the person’s arrival. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 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 goals and support needs had been identified and changes reflected in the support provided. People are supported to take risks and the home supports people to make choices and decisions that impact on their lives. EVIDENCE: The purchasing authorities had provided a care plan for each person that contains vague, non-specific goals. From the assessment material the home develops a more detailed Individual Person Plan (IPP) that sets out a persons needs and goals and the support required to meet them. The IPP care plan was reviewed on an ongoing basis based on the complexity of the needs of the person. At a minimum the plan is reviewed every month. The IPP’s had been fully completed, dated and signed by the person. The home were just starting to introduce a new system of care planning based on the principals of person centred planning. Some examples of these documents were seen and although not fully completed the following observations were made. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 10 The format of the document is not very flexible in that information is fitted into the set text boxes. It was noted that the current IPP care plans contained more information than the new format as there was more space to record information. The new person centred format was completed in collaboration with the person and their keyworker. It was found that the keyworkers had received no specific training around the principals of person centred planning nor in recording the new format. The manager recognised that training was required and had arranged for staff to attend a training event. It is recommended that the home ensure that the new person centred care planning process is fully understood by people and staff and that the recording of people’s needs, goals and wishes and the support/activities that meet those goals and wishes are clearly recorded in sufficient detail and in a format that people can understand. 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 home had a clear risk assessment process that identified hazards and risks in people’s lives and guidance in how to support people to minimize the hazards they face. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 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): 12, 13 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to take up opportunities to participate in a range of meaningful home and community based activities within a relaxed routine and have access to a health diet. People are supported to maintain appropriate relationships. EVIDENCE: The home continued to support and encouraged people to take up opportunities and participate in social, leisure, skills development, educational home and community based activities. People were encouraged to maintain their independence skills and to make choices and decisions about their dayto-day lives. It was clear that the home was working alongside people to find new and valued activities and were starting to record a ‘menu’ of activities that one person enjoyed. It was recommended that the home continue this work with all the people living at the home. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 12 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 routines of the home were relaxed and informal and based on the needs of the people living at the home. People were encouraged were they can to take part in the menu planning, shopping, preparing and cooking of meals. One person had their own food budget and shopped for and cooked all their own meals. The food stores were sufficiently varied to provide a choice of nutritious meals. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supported people to maintain their personal and healthcare and the medication administration system supported people’s wellbeing and protection. EVIDENCE: People were encouraged and supported to maintain their independence with their personal care needs. If a person required support with their personal care this would be recorded through the care planning system. The home supported people to access the relevant general and specialist healthcare services and worked in partnership with services to maintain people’s health and wellbeing. The home had completed individual health profiles for each person. The medication administration system was assessed and found that all recording was accurate and medication prescribed ‘as required’ (PRN) had clear guidance for administering and recording. All staff had received in-house training in the administration of medication and were supported through the local pharmacist. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 14 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encourages and supports people to raise their concerns and complaints and had the policies, procedures and systems in place to protect people from abuse. 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 organisation’s Adult Protection Policy was based on the Manchester MultiAgency Adult Protection Policy and Procedure. The organisation had also developed an Aggression Towards Staff and a Physical Intervention Policy and procedure. The Management of Service Users Finances Policy and procedure was seen and found to contain clear guidance on the process, recording and auditing of service users’ personal monies. Evidence was seen that the service had developed behavioural strategies for each person to provide guidance to staff on working with behaviour that may challenge them. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and safe environment. The home was clean and had the systems in place to maintain hygiene standards. EVIDENCE: The premises were generally clean, well maintained and provided a comfortable and safe environment for people to live. The carpet in the basement lounge had been cleaned and bathroom sealant repaired. 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 the majority of staff had received training in food hygiene and infection control. Laundry facilities are domestic in nature and are situated in a secure storage area. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 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): 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. The home has a staff team with sufficient capacity and competence to support peoples’ needs. The home has the systems in place to ensure that staff are safe to work with vulnerable adults. The training systems are generally sound but need to ensure that staff training plans are complete. EVIDENCE: Since the last inspection the home now had a permanent staff team and a small group of regular bank workers who were familiar with working with people at the home. During the day between 2 and 3 support staff were available to support people in the home and the community. Of the current staff team three have completed the NVQ level 2. A number of staff were soon to begin the vocational training. Through discussions with some of the staff team it was shown that they had the values and were developing the necessary skills to provide the support people required. Staff files contained all the required documentation and checks required. Through discussions with staff and assessing staff records it was seen that the home provided an Induction programme that included core skills such as POVA training, health and safety, emergency first aid and basic food hygiene. It is Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 17 recommended that the home undertake a review of the Induction programme to ensure that it meets the new Skills for Care Induction Modules to be introduced in September 2006. Each member of staff should have 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 newer members of the team did not have a completed plan. The home must ensure that all staff have a training and development plan and that ongoing refresher training is clearly identified. The manager is planning to introduce a training evaluation system to assess whether the staff have acquired the skills and competence from the training events they participate in. Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well run home that has the systems in place to listen to their views about the service they receive. Systems are place to protect the health and safety of 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) undertook a quality assurance audit. 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 Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 19 in house meetings and a manager from another service undertakes Regulation 26 visits/inspections. 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 home maintained a fire log that evidenced weekly visual checks of the fire systems. 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.V296995.R01.S.doc Version 5.2 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 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 3 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 2 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 3 13 3 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 3 X X 3 X Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 21 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 YA35 Regulation 19 Requirement The home must ensure that all staff have a training and development plan and that ongoing refresher training is clearly identified. Timescale for action 01/09/06 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 YA6 Good Practice Recommendations It is recommended that the home ensure that the new person centred care planning process is fully understood by people and staff and that the recording of people’s needs, goals and wishes and the support/activities that meet those goals and wishes are clearly recorded in sufficient detail and in a format that people can understand. It is recommended that the home reviews and updates its current Induction programme to meet the standards set by the Skills for Care Induction modules. 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. DS0000021621.V296995.R01.S.doc Version 5.2 Page 22 2. 3. YA35 YA39 Outreach, 162 Bury Old Road Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 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 © 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 Outreach, 162 Bury Old Road DS0000021621.V296995.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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