Inspection on 22/11/05 for Outreach Community & Residential Services 1 Newtown Mews

This inspection was carried out on 22nd November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach Community & Residential... 04/08/09

Outreach Community & Residential... 19/09/08

Outreach Community & Residential... 06/11/07

Outreach Community & Residential... 09/11/06

Outreach Community & Residential... 23/03/06

Outreach Community & Residential... 24/03/05

Outreach Community & Residential... 20/07/04

Outreach Community & Residential... 10/02/04

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

CARE HOME ADULTS 18-65 Outreach Community & Residential Services 1 Newtown Mews 1 Newtown Mews Prestwich Manchester M25 1HE Lead Inspector Sue Evans Unannounced Inspection 22nd November 2005 10:10 Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Outreach Community & Residential Services 1 Newtown Mews 1 Newtown Mews Prestwich Manchester M25 1HE 0161 773 1062 0161 740 5678 Address 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 Mrs Esther Weinstock Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 4 service users, to include: up to 4 service users in the category of MD (Mental Disorder under 65 years of age). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 24th March 2005 Date of last inspection Brief Description of the Service: 1 Newtown Mews is one of a group of homes managed by Outreach Community and Residential Services. Outreach is a charity that provides care and support predominantly to Jewish people with learning disabilities or mental health needs. This home is registered to provide care and accommodation for up to 4 people who have mental health needs. The house is situated in a residential area of Prestwich, close to bus and tram routes, local shops, synagogues, and other local amenities. The house is similar to other houses in the area and it is not distinguishable as a care home. It has a lounge, and a lounge/dining room. All bedrooms are single. Outside, there is car parking space at the front, and an enclosed garden at the back. The philosophy of care, as described in the Statement of Purpose, promotes values such as independence, dignity, rights, fulfilment, and choice. Cultural needs are supported. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took 6 hours. Most of this time was spent watching what went on in the home, talking to 3 of the 4 residents, and interviewing 2 staff members and the manager. The inspector also looked round most parts of the house, and examined some key records. Following the previous inspection in March 2005, the Pharmacist Inspector visited the home (on 8th June 2005) to look closely at the home’s medication procedures. The recommendations that she made were followed up at this inspection. What the service does well: What has improved since the last inspection? The Statement of Purpose has been updated and it contains useful information about the home. The written guidelines covering complaints have been amended to ensure that residents have clear information about their rights. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The Statement of Purpose contains useful information about the home. It gives prospective residents, and others, useful information that can help them decide whether the home is suitable. Residents’ inclusion in the assessment of their needs enables them to have a say about what they feel they need help with. EVIDENCE: Since the previous inspection, the Statement of Purpose had been updated. It contained useful information about the home including details of its facilities, the number of places provided, the experience and qualifications of the manager and staff, and details of the complaints procedure. All four residents had lived in the home for several years. The manager said that a care management assessment was always obtained before a resident came to live in the home. There was evidence to show that review meetings were held to update care management assessments. Records showed that the home also carried out its own detailed assessments (written in the first person), and that residents were included in this exercise. Residents confirmed that they were included in assessments and reviews. They said that Newtown Mews was a good place to live. One said, “It’s all right living here”. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 9 Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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): 6 and 9 Residents know about their individual plans, and they are involved in reviewing their needs and updating their goals. The home encourages residents to be as independent as possible, helping them to keep any risks to their health and welfare to a minimum. One risk management plan needs expanding so that it provides detailed guidance to assist staff in providing the necessary support. EVIDENCE: The manager and staff were asked about the needs of 3 of the residents. Their descriptions of how they assisted them matched with the information given by the residents. The personal files for these 3 residents contained a great deal of written information including assessments, health plans, individual personal plans, and risk assessments. Some contained separate typewritten guidance on specific aspects of a resident’s support needs. This provided a quick reference point for staff members and contained key information about how the person was to be supported. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 11 Individual personal plans were centred upon the “eight accomplishments” of community presence, independence, choice, individuality, status, respect and dignity, continuity, relationships, and culture. They included each resident’s preferences and goals, and reflected the home’s objective of encouraging residents to be as independent as possible. However, the information contained in them was not always very specific about how staff were to support the resident. The information in the typewritten sheets was much more informative. Discussion took place about the value of condensing and simplifying the information held on files so that it was easier to find accurate, specific, up to date information. A care needs summary, with specific guidelines for staff, would be useful. Records showed evidence of risks being assessed, and balanced against the resident’s right to choice and independence. However, again it was felt that these documents could be condensed and simplified. In the case of one service user, it was identified that their risk assessment needed updating. Records showed that residents’ needs and goals were reviewed every month, by the resident and a designated support worker. Formal review meetings, to which relatives and social workers were invited, took place annually, with a mini review held 6 monthly. Residents said that they knew about their written records and they said that they had attended meetings to discuss their support needs. The residents who were spoken with during the inspection said that they were satisfied with the support given to them by staff. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 and 17 Residents choose how they spend their time, taking part in fulfilling activities that they enjoy doing. They participate fully in the community, enabling them to lead valued lifestyles. Practices in the home respect residents’ rights to privacy, dignity, choice, and independence. Cultural needs are supported. Residents can choose their own menus, and they have choice about what time they eat. EVIDENCE: Residents followed their own daily routines. Three of them were able to take part in community activities without staff support. During the inspection, one resident was out at a “Ladies Group” and the others were seen coming and going from the house, engaging in their chosen activities. Sometimes they were accompanied by a staff member, sometimes they went out alone. It was clear, from discussions with residents and staff, that residents were encouraged and supported in pursuing valued, fulfilling activities. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 13 Residents gave examples of the community facilities that they used such as Some were buses, trams, cafes, shops, library, pubs, and synagogues. involved in (or planning to start) various activities such as improving their typing and computer skills, and attending college. The manager said that all residents were on the electoral register and were entitled to vote in elections. One resident described how he regularly went out with a local leisure group, and he said that, once a month, a staff member accompanied him on a visit to the airport. One person said that he regularly attended a Jewish study group (Lubavitch). Two residents had enjoyed a holiday in Portugal this year, and another had been to Greece. At home, residents enjoyed pastimes such as watching television, listening to music or talking books, and using their computer. Residents said that their privacy was respected, for example nobody entered their rooms without permission, and mail was given to them unopened. They said that they could choose what time they got up or went to bed, and how they spent their time. One resident said that he had chosen the colours for his bedroom. Residents undertook some household tasks, such as shopping, cooking, cleaning, and laundry, with varying degrees of staff support. It was observed that staff members and residents spoke with each other in a natural manner. Residents said that staff spoke respectfully to them. One said, “Staff are polite”. Cultural and religious needs were respected. For example, there was an expectation that only kosher food would be brought into the house. Residents said that they had choice about what they had for meals. They shopped individually and had individual cupboards in which to store their food. They said that they prepared and ate their meals at the times they chose. They also said that they were free to make themselves drinks or snacks whenever they wished. Two residents cooked independently, whilst two needed staff support to prepare meals. On Friday evenings (for Shabbas), staff cooked for everyone, and the residents sat down together to eat a communal meal. Prayers were led by service users. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Any changes in health needs are dealt with in liaison with the appropriate specialist health services. Medication storage and procedures promote good health and safety but there is a need to ensure that medication administration records are fully completed. EVIDENCE: Residents used community healthcare services such as opticians, dentists, psychiatrists, and GPs. Details of all contacts with health professionals were recorded. Residents said that a staff member always accompanied them to health care appointments. Specialist services were obtained if necessary, for example one resident was working with an Occupational Therapist. The manager and staff spoke knowledgeably about the emotional needs of the residents, demonstrating that they had the skills to understand and respond to any problems. One resident said that he was trying to follow a healthy diet to try to control his weight. It was noted that accident records were kept. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 15 The home had medication policies and procedures. Since the last inspection, guidelines covering medication taken outside the home (for example on days out or weekends away with families) had been included in the policy. The home was also advised to include a paragraph about non-prescribed medicines. Medicines that were kept in the home were securely stored. Two of the residents looked after their own medication. There were records of medication received, administered, and disposed of. Two residents looked after their own medication, as agreed and risk assessed during care planning. As advised by the Pharmacist Inspector on 8/6/05, the manager was advised to expand the risk assessments to include details of how the medication was supplied (for example in bottles, or in a dosette box), the quantity supplied, for example 1 week’s supply, whether the resident knew what to do if a dose was lost or missing, and how often the arrangements were reviewed. In line with good practice, the medication administration records (MAR), included a photograph of the resident. However, there were some gaps in recordings on the MAR. The manager said that she had noticed this and was intending to bring the omissions to the attention of staff. The manager was advised to ask residents to sign a “Consent to Medication” form. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents are given copies of the complaints procedure. Most feel that any concerns would be listened to and dealt with. Protection policies and procedures, and staff understanding of adult protection, ensure that the home has the means to be able to respond properly to any suspicion or allegation of abuse. EVIDENCE: The home had a written complaints procedure that had been amended since the last inspection so that it clearly stated that complaints could be made directly to the CSCI. Residents’ personal files contained signed confirmation that they had received a copy of the procedure. Residents said that they would speak to the manager or Director of Operations if they were unhappy about anything. However, one resident who had complained about the state of the shower, felt that nothing was being done about it. Records showed that the manager had in fact taken steps to try and resolve his complaint. The manager was asked to make sure that all complaints were responded to, so that complainants knew whether action had been taken. She was also asked to keep a record in the informal complaints book of the action taken in response to complaints and concerns raised. There were written procedures covering adult protection and whistle blowing. Staff members understood their responsibilities in reporting any suspicions of abuse. The manager said that she had been on a training course in adult protection and had cascaded the information to the staff team. She was advised to give staff members opportunities to go on formal training courses in this topic, and to regularly include the topic in agendas for team meetings and 1 to 1 supervision meetings. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 17 Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30 In order to provide a pleasant, comfortable home for residents, the home needs to make improvements to the décor, furnishings, and cleanliness of the home. In the interests of good hand hygiene, paper towels are needed in communal areas. EVIDENCE: The home is situated in a residential area of Prestwich, close to bus and tram routes, local shops, synagogues, and other local amenities. The house is similar to other properties in the area. It is not identifiable as a care home. Residents said that they were reasonably pleased with the home although one wasn’t happy with the shower base, and he felt that the outside of the house needed painting The communal rooms and 3 bedrooms were looked at this time. Bedrooms were all single, and they were personalised with the resident’s own belongings. Residents could lock their rooms. They said that they were satisfied with their rooms. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 19 Communal rooms consisted of a lounge, a lounge/dining room, a kitchen, a laundry room, a bathroom, a toilet, and a shower room/toilet. Furnishings were of the type found in any domestic setting. Outside, there was room for car parking at the front, and an enclosed garden at the back. The general state of the decoration, in most parts of the home was poor, with marked and pitted walls, and scuffed and peeling paintwork. Things needing attention were: the replacement of the shower base, the redecoration of the shower room, painting of the outside of the house, redecoration of most other areas of the home , attention to scuffed and peeling paintwork (for example the staircase and the front door), complete refurbishment of the ground floor lounge (including replacement furniture) and attention to the worn doors and drawer fronts in the kitchen. There was also a need to attend to a problem with the plumbing. There is a need for the home to start addressing these matters, and to ensure that there is an ongoing schedule of maintenance and renewal. Standards of cleanliness in most areas of the home were satisfactory. However, the first floor toilet needed thorough cleaning to remove grime from skirting boards, and cobwebs. Although liquid soap was provided for hand washing in the communal areas, cotton hand towels were being used for hand drying. In the interests of good hand hygiene, paper towels must be provided. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Thorough pre-employment checks are carried out in order to promote the safety and protection of the residents. Outreach provides ongoing training to equip staff with the knowledge and skills that they need to meet the needs of the residents. EVIDENCE: Most staff recruitment records were kept at the Outreach Head Office. A sample of these was looked at during a visit to the office in July 2005. They contained most of the required information. The files held at the home also had some of the required documents. Between the two, all the necessary information was available. During the visit to the Head Office in July, the service was advised to keep a full set of recruitment documents in one place. Employment checks that had been done included obtaining employment histories, 2 written references, medical declarations, photographs, CRB (Criminal Records Bureau) disclosures and POVA (Protection of Vulnerable Adults) register checks. Records for recent recruits showed that gaps in their employment records had been looked into. Training records were looked at. Staff training certificates showed that training was provided in topics such as food hygiene, first aid, moving and handling, medication and health and safety. Other training included epilepsy awareness, the principles of care, and an introduction to mental health. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 21 Fire safety training is covered in the next section of this report. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents benefit from the open management approach of the home and they are able to openly express their wishes and opinions. The opinions of residents, and others, have been sought to help the home to review quality, and improve standards. However, the home has yet to produce a written plan that will show residents and others how their views are being used to improve the service. In order to promote the safety and welfare of residents and staff, two health and safety matters need attention. EVIDENCE: The manager was registered with the CSCI in September 2004. She has completed NVQ level 4 in care, and the Registered Manager’s Award. She keeps updated by attending regular training in topics such as person centred awareness, epilepsy, mental health awareness, and the mandatory health and safety topics. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 23 It was clear, from observations and discussions, that the Registered Manager encouraged an open, inclusive atmosphere within the home. Staff members said that they found her to be approachable and supportive and they said that she listened to them. Regular meetings took place, for staff and residents, where they could express their views. During the inspection, it was observed that service users and staff had no hesitation in approaching the manager if they had anything they wished to discuss. The manager said that the home had recently done a satisfaction survey involving residents, relatives, health and social care professionals, and staff. The completed questionnaires had been sent to Outreach Head Office. The manager said that a report was to be written, summarising the outcomes of this exercise. She was asked to make sure that a copy of the report was made available to residents, and others, so that they know that their views have been noted and, where applicable, acted upon. A copy also needs to be sent to the CSCI. Several safety records were checked. These included the electrical installation certificate, gas soundness certificate, Legionnaire testing, and servicing of fire alarms and emergency lighting. Examination of the fire book showed that fire alarms and emergency lights were tested weekly, and fire fighting equipment monthly. The manager had produced a fire risk assessment. However, although the manager had undertaken fire safety training, it was noted that staff members had not. This needs to be arranged. The portable appliance tests also need to be arranged. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 3 3 X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 2 Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard YA9 YA20 Regulation 14, 15 13(2) Timescale for action One person’s risk management 31/12/05 plan needs updating to reflect the person’s current needs. The registered person needs to 22/11/05 ensure that medication administration records are fully completed. The registered person needs to 22/11/05 keep records to show how service users’ concerns and complaints have been dealt with, and to inform them of any action taken. The registered person must 28/02/06 arrange for the refurbishment of the downstairs lounge. The registered person must 28/02/06 arrange for the shower room to be redecorated, and the shower base to be replaced. The registered person needs to 30/06/06 arrange for the outside of the house to be repainted. The registered person needs to 31/12/05 attend to the problem with the plumbing. The registered person needs to 31/12/05 provide the CSCI with dates stating when the following items of work will be completed. DS0000008443.V265402.R01.S.doc Version 5.0 Page 26 Requirement 3. YA22 22 4. 5. YA24 YA24 16, 23 16, 23 6. 7. 8. YA24 YA24 YA24 23 23 16,23 Outreach Community & Residential Services 1 Newtown Mews The redecoration of the hallway. The redecoration of other rooms in the home. Attention to scuffed and peeling paintwork including the staircase and the doors. The replacement of worn doors and drawer fronts in the kitchen. Proposed timescales for undertaking these jobs must be sent to the CSCI by the date shown in the end column. Paper towels must be provided for hand drying in communal areas. The registered person must ensure that the standards of cleanliness in the bathroom are improved. Following the quality review, an improvement plan must be produced. The plan must be available to residents, the CSCI, and other interested parties. The registered person must ensure that staff working in the home receive annual fire safety training. The registered person must arrange for the portable electric appliance tests to be completed. 9. 10. YA30 YA30 13(3) 16(2)(j) 23(2)(d) 31/12/05 30/11/05 11. YA39 24 28/02/06 12. YA42 23(4)(d) 28/02/06 13. YA42 13, 23 31/12/05 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 The registered person is advised to look at how the information held on residents’ files could be condensed and simplified to make it easier to find specific, up to date information. DS0000008443.V265402.R01.S.doc Version 5.0 Page 27 Outreach Community & Residential Services 1 Newtown Mews 2. 3. 4. 5. 6. YA20 YA20 YA20 YA23 YA23 The registered person is advised to include the management of non-prescribed medicines in the medication policy. Where possible, consent to medication should be recorded. The medication self administration assessments should be expanded. The registered person is advised to provide staff members with opportunities to undertake adult protection training. The registered person is advised to regularly include adult protection on agendas for team meetings and 1 to 1 supervision. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Community & Residential Services 1 Newtown Mews DS0000008443.V265402.R01.S.doc Version 5.0 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!