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Inspection on 09/11/06 for Outreach Community & Residential Services 1 Newtown Mews

Also see our care home review for Outreach Community & Residential Services 1 Newtown Mews for more information

This inspection was carried out on 9th November 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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

From speaking with residents and information relatives gave in comment cards, it was clear they were happy with the care and support provided. Residents said they liked living in the home and that staff treated them well. This was observed during the inspection. Residents had no hesitation in approaching staff members if they wanted to speak to them. Relatives who returned comment cards said they could visit at any time and staff always made them feel welcome. Relatives were also happy with the care provided. One relative who returned a comment card wrote, "All the staff at Newtown Mews are most helpful and kind to my son", a second "Very satisfied. I feel staff are doing an excellent job. I am very thankful for all they do". The records kept on residents (care plans), includes a lot of information about the things residents needs support with and the things they like to do. This means staff have the information they need so they can make sure residents get the care and support they need. Residents` cultural needs are met, for example by making sure that only kosher food is brought into the house. Residents are encouraged to take part in, community activities of their choice, such as work, college courses, leisure activities and holidays, with staff support if needed. Residents make their own choices about things such as daily routines (for example what time they get up or go to bed), activities and meals. The home is good at making sure residents health was taken care of by seeing doctors and other health care workers.

What has improved since the last inspection?

In order staff can look after residents training such as medication, NVQ, infection control and what to do if a resident isn`t being treated properly has been arranged. One of the lounges has been redecorated and a new lounge suite has been purchased. The home is now very clean and tidy.

What the care home could do better:

The outside of the building needs to be painted. A new carpet needs to be fitted in one of the bedrooms. The lock on one of the bedroom doors needs to be repaired. The informal complaints records to show how concerns have been dealt with.

CARE HOME ADULTS 18-65 Outreach Community & Residential Services 1 Newtown Mews 1 Newtown Mews Prestwich Manchester M25 1HE Lead Inspector Kath Smethurst Unannounced Inspection 9th November 2006 09:30 Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 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 stuart@outreach.co.uk 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.V312352.R01.S.doc Version 5.2 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. 23rd March 2006 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. Fees range from £1106. Additional charges are made for hairdressing, toiletries, activities, holidays, transport, magazines and papers. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours. The home had not been told that the inspector would visit. The inspector looked around parts of the building and checked some paper work about the running of the home and the care given. To get more information about the home all four residents, the manager and two staff were spoken with. Carers were also watched as they went about their work. Before the inspection comment cards were sent to residents, their relatives and people such as social workers, district nurses and doctors. Two residents, two relatives, a social worker and community psychiatric nurse returned comment cards. What the service does well: From speaking with residents and information relatives gave in comment cards, it was clear they were happy with the care and support provided. Residents said they liked living in the home and that staff treated them well. This was observed during the inspection. Residents had no hesitation in approaching staff members if they wanted to speak to them. Relatives who returned comment cards said they could visit at any time and staff always made them feel welcome. Relatives were also happy with the care provided. One relative who returned a comment card wrote, “All the staff at Newtown Mews are most helpful and kind to my son”, a second “Very satisfied. I feel staff are doing an excellent job. I am very thankful for all they do”. The records kept on residents (care plans), includes a lot of information about the things residents needs support with and the things they like to do. This means staff have the information they need so they can make sure residents get the care and support they need. Residents’ cultural needs are met, for example by making sure that only kosher food is brought into the house. Residents are encouraged to take part in, community activities of their choice, such as work, college courses, leisure activities and holidays, with staff support if needed. Residents make their own choices about things such as daily routines (for example what time they get up or go to bed), activities and meals. The home is good at making sure residents health was taken care of by seeing doctors and other health care workers. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 6 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 Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. The admission procedure is satisfactory and systems are in place to ensure proper assessments are completed prior to people moving in. EVIDENCE: All four residents had lived in the home for several years. All residents have individual files that were seen to contain the information required covering areas such as family/social contact, assessment, management of risk and personal support. From discussions with the manager it was evident that any future admissions would be handled appropriately. The manager said prospective residents would be offered the opportunity to visit prior to admission. 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. One resident said, “I wanted to move into Newton Mews”. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 & 9 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Staff worked in a positive and enabling way, ensuring understanding and agreement was reached with the resident about their support needs and personal goals. EVIDENCE: Two care plans were examined. Good practice was noted, as there was an extensive amount of personalised and very detailed information about residents’ health and social care needs. This included individual and risk issues, and each resident’s daily routines and how they liked their care and support to be provided. Care plans take note of resident’s religious and cultural needs. For example in regard to meals one plan stated, “In the house I will always choose a kosher diet-outside the home a vegetarian option”. Records goals on every 6 between showed that the resident and staff reviewed residents’ needs and a regular basis. Records showed that needs and goals were reviewed months. There were also reports of monthly informal meetings the resident and their key worker to review needs and goals. DS0000008443.V312352.R01.S.doc Version 5.2 Page 10 Outreach Community & Residential Services 1 Newtown Mews Residents confirmed that they were involved in reviewing their needs and goals. The routines of daily living were observed to be flexible. For example residents were observed getting up in the morning at times that suited them and to choose where they spent their day. Residents spoken with also confirmed they had a choice about daily routines. Residents took part in their own chosen activities, and they had individual menus. They were also involved in choosing furnishings and colour schemes for the home. Records showed that potential risks had been assessed, and balanced against the resident’s right to choice and independence. For example most residents managed their own finances, and two looked after their own medication. When asked, “Can you do what you want to do”, the resident wrote, “Always”. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 & 17 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Residents are actively supported to lead meaningful lives within the community and maintain contact with family and friends. EVIDENCE: Good practice was noted, as the staff team were looking at ways of providing opportunities for the resident to develop practical and personal life skills. For example cooking, shopping and helping with housework etc. Most residents could take part in community activities without staff support. However, staff members did spend time on community activities with residents. Residents described some of the community activities that they were involved in. These included work, college, social groups, meals out, and shopping. All residents had the opportunity to go on an annual holiday. During the inspection, one resident went to work in the morning, two went shopping and one resident went to the library (supported by a member of staff). At Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 12 home, residents enjoyed pastimes such as watching television and DVDs, playing keyboard, and reading. Good practice was noted as staff time was regularly provided to provide support outside the home. For example supporting residents on holiday. Staff were observed to respect residents privacy when entering bedrooms and bathrooms. 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. Residents undertook some household tasks, such as shopping, cooking, cleaning, and laundry, with varying degrees of staff support. Interactions between staff and residents were observed to be frequent and friendly. During the course of the inspection staff were observed spending quality one to one time with residents. For example the manager had lunch with a resident and a member of staff supported a resident to visit the library. While in the evening a resident was going out to a restaurant in Manchester for a meal. Most residents kept in contact with family and friends. Some regularly spent time with family members at their homes. Staff members said that relatives and friends were welcome to visit the home at any time. Feedback in returned relative/visitor comment cards confirmed staff were always welcoming. Residents’ personal plans contain a section covering “relationships, sexuality and partnerships”. Cultural and religious needs were respected. For example, there was an expectation that only kosher food would be brought into the house. Jewish festivals are celebrated. 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. Some residents cooked independently, whilst some 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 residents. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.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 & 20 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Personal, healthcare and medication needs of the resident were well met, promoting good health and independent living skills. EVIDENCE: One of the aims of the service was to assist residents to be as independent as possible. Staff were observed encouraging residents to do as much as they could for themselves. Assessments and care plans contain a lot of information about resident’s preferences and chosen lifestyle. In respect of personal and physical care, residents were generally self-caring, and any assistance from staff members took the form of encouragement and reminders. Resident and staff members were consistent in their descriptions of individual support needs, and these descriptions matched with the information recorded. All residents had lived at the home for a long time and staff are fully aware of their needs and how each individual preferred to be supported. All residents were able to express their wishes about the way they were supported. It was clear, from discussions with residents that they had choice about their daily routines, for example what time they got up, daily routine and meal choices. On arrival the inspector observed residents getting up at various times, while Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 14 at lunch residents had different meal options. Relationships between staff and residents seemed warm, friendly, caring and respectful. Residents and staff spoke with each other in a natural manner. . Residents said that they were happy with the way that staff members treated them, and the way they spoke to them. One said, “Staff are good”. Relatives who returned comment cards were also happy with the care and support provided. One relative wrote, “Very satisfied. I feel staff are doing an excellent job. I am very thankful for all they do”. There was evidence that the resident’s health care needs are regularly monitored. Residents are provided with support to attend regular health care appointments and check ups, details of which are recorded clearly in a designated record sheet. Specialist services were obtained if necessary. 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. The home had written guidelines covering medication. Good practice was promoted as residents were actively encouraged and supported to look after their own medication. Currently two residents self-administer their medication. Staff undertake spot checks to ensure these residents are continuing to manage their medication safely. Medicines were being stored safely, with a clear record of medicines received into the home and any returned to the pharmacist. Medication Administration Records (MAR) were examined and were found to be clear and up to date. Since the last inspection the member of staff who needed to undertake medication training has done so. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Policies, procedures and training were in place to safeguard residents from abuse or harm, and for taking any concerns seriously. EVIDENCE: A detailed complaints procedure is in place. No formal complaints have been received by the CSCI (Commission for Social Care Inspection) or the home since the last inspection. A system is in place for recording complaints. During the last inspection it was noted that the informal complaints book needed to be improved in order to show what action has been taken, the outcome of the investigation, and how and when the complainant was notified of the outcome. This remains relevant. Residents’ personal files contained signed confirmation that they had received a copy of the procedure. Residents who returned comment cards and spoken confirmed they knew who to approach if they had a concern or complaint. None of the relatives who returned comment cards had made a complaint. No allegations of abuse had been made to the home or to CSCI. Adult Protection and Prevention of Abuse policy are in place. The home ensures all staff completes a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) before they commence work. Training in the signs and recognition of abuse is covered during induction and in NVQ (National Vocational Qualification) training. The manager and some staff have undertaken training course in adult protection. During the last inspection it was identified that some staff had not undertaken training. The manager advised training in this area was planned in the near future. A written gifts and Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 16 gratuities policy is in place. Staff are not allowed to take gifts and gratuities from residents. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this area is adequate. This judgement has been made from the evidence gathered both during and before the visit to the service. The standard of the environment is satisfactory providing residents with a homely, comfortable and clean place to live. 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 had the use of two lounges, kitchen, a ground floor toilet and a first floor bathroom and separate toilet. There was also a pleasant enclosed garden for residents to use. A staff office/sleep-in room is located on the ground floor. Since the last inspection a number of improvements have been made to the standard of the environment. The upstairs lounge had been redecorated and a new lounge suite had been purchased. Residents were involved in choosing the colour scheme. This room is now furnished and decorated to good standard providing residents with a bright, comfortable and homely area to use. The worn cupboard doors have also been attended to. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 18 The requirement made regarding the painting of the outside of the house remains outstanding. The manager advised painting contractors but had been contacted for quotes. But as the home had three storeys the contractors contacted were unwilling to undertake the work. The manager said that efforts were continuing to find a company willing to complete this work. Given the circumstances the timescale for meeting this requirement has been extended. Three residents showed the inspector their bedrooms. All were personalised with residents’ own belongings. It was noted that the carpet in one of the residents bedrooms was showing signs of wear and tear and needs to replaced. One of the residents said that the lock on his bedroom door was broken. This was discussed with the manager who advised the organisations maintenance person had been contacted regarding this. The improvement in the standard of cleanliness in the home has continued since the last inspection. The home was very clean and tidy throughout. When asked (comment cards) if the home was clean two residents wrote, “Usually”. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 19 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, 34 & 35 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Residents benefited from a well trained staff team, with their safety promoted through rigorous staff recruitment and selection procedures. EVIDENCE: Relationships between staff and residents seemed warm, caring and friendly, with staff demonstrating a good understanding of residents support needs. It was observed that residents had no hesitation in approaching staff members if they wanted to speak to them. Residents spoken with indicated they were satisfied with the care and support provided. When asked if staff treat you well (comment cards) two residents said, “Always”. Two staff training records were examined. There was evidence that new staff undertake induction training that meets the National Training Organisation (NTO) specifications following which foundation training is undertaken. Staff had undertaken a range of training. Courses completed by staff include food hygiene, moving and handling, fire safety, health and safety, medication, protection of vulnerable adults, epilepsy, drug awareness and introduction to mental health. In addition staff undertake training in Jewish customs and Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 20 traditions. Staff spoken with were satisfied with the range of training opportunities provided. Since the last inspection progress has been made in regard to the provision of NVQ (National Vocational Training) for staff. One member of staff has attained NVQ level 2. A further two staff are currently undertaking training while another member of staff is due to commence training in the near future. This commitment to training needs to be continued to ensure that 50 qualified staff is reached and then maintained. The manager advised that Outreach have recently secured the services of a new training provider (Pendleton College). The manager said the service provided by the college was good as staff no longer had to wait for training. Courses could now be arranged as required which meant staff did not have to wait to undertake training. Staff recruitment records are kept at the Outreach Head Office. A sample of recruitment files (across Outreach homes) was looked at during a visit to the office in June 2006. During this visit the service was advised to keep a full set of recruitment documents in one place and remove any remaining recruitment records from the homes. In the main recruitment records indicated that all necessary recruitment checks had been undertaken. Employment checks that had been done included obtaining employment histories, written references, medical declarations, photographs, CRB (Criminal Records Bureau) disclosures and POVA (Protection of Vulnerable Adults) register checks. Records for recent recruits showed that in the main gaps in their employment records had been looked into. The organisation is reminded that the reasons why prospective employees have left their previous employment now needs to be documented on application forms. Good practice was noted in that prospective staff had completed an application and equal opportunities monitoring form. Details of interview questions and notes are kept on file. Records showed employees were health screened at the Occupational Health Unit at Fairfield Hospital. Following which a statement was issued to confirm that the candidate was fit to undertake their duties. Back to work and exit interviews are routinely undertaken. Records showed that new recruits received induction training. The training booklet included a section covering Judaism, and how to respond to residents’ cultural and religious needs. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 21 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 & 42 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. The home is well managed, with systems for monitoring the quality of the service provided at Richmond Avenue in place, enabling a regular review of the service received by residents. Regular maintenance and fire safety checks were carried out, promoting the health and safety of both residents and staff. 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.V312352.R01.S.doc Version 5.2 Page 22 It was clear, from observations and discussions, that the Registered Manager encouraged an open, inclusive atmosphere within the home. During the inspection, it was observed that residents and staff had no hesitation in approaching the manager if they had anything they wished to discuss. Discussions with residents and staff indicated the manager was approachable and supportive. She is clearly respected by the staff team and committed to improving the quality of life of the residents. Internal and external quality assurance systems are in place. A quality assurance policy is in place, which reads, “ Each member of staff top to bottom should demonstrate a total commitment to quality and quality improvement in every aspect of their working day”. Outreach has undertaken an in-depth quality audit of the service provided by the home. This included asking residents, relatives and staff about their views of the service. A very detailed document had been produced which highlighted areas of good practice and areas identified for improvement. These areas had been summarised into several pages at the back of the document. Internal monthly monitoring visits take place (conducted by managers from other Outreach homes). A sample of which were examined and were found up to date. Members of the organisations management committee also undertake quality audit visits. Resident and staff meetings are held on a regular basis. With the pre-inspection materials, the manager provided a list of maintenance and associated records. A number were checked including including the gas, and electric appliance servicing. All were up to date. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. Records also indicated that fire drills had taken place at frequent intervals. A fire risk assessment was also in place. Staff and residents undertook fire safety training in March 2006. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008443.V312352.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 24 Outreach Community & Residential Services 1 Newtown Mews 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. Standard YA24 Regulation 23 Requirement The registered person must to arrange for the outside of the house to be repainted. Timescale 30/06/06 not met. The registered person must make arrangements for the identified bedroom carpet to be replaced. The registered person must ensure the broken bedroom lock is repaired. Timescale for action 30/04/07 2 YA24 23 30/04/07 3. YA24 23 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The registered person should ensure the “informal” complaints/ concerns book contains sections to include the details of the action taken in response to a concern/complaint, the outcome of the investigation, and how and when the complainant was notified of the outcome. As planned the registered person should ensure staff DS0000008443.V312352.R01.S.doc Version 5.2 Page 25 3. YA23 Outreach Community & Residential Services 1 Newtown Mews members undertake adult protection training. 4. YA32 The registered person should continue to encourage and support staff members with NVQ training with a view to having at least 50 of workers with the qualification. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V312352.R01.S.doc Version 5.2 Page 26 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.V312352.R01.S.doc Version 5.2 Page 27 - 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. 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