Inspection on 04/08/09 for Outreach Community & Residential Services 1 Newtown Mews

This inspection was carried out on 4th August 2009.

CQC found this care home to be providing an Adequate service.

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

Other inspections for this house

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... 22/11/05

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 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Outreach Community & Residential Services 1 Newtown Mews 1 Newtown Mews Prestwich Manchester M25 1HE Lead Inspector Julie Bodell Key Unannounced Inspection 4 & 11th August 2009 11:00 th Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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 akila@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 Manager post vacant 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.V376802.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. 19th September 2008 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.V376802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place over two short visits totalling five hours. The home had not been told that we (the commission) would visit. During our first visit we checked some paperwork about the running of the home and the care given and talked to a person living at the home and a support worker. Because the person at the home had arrangements to go out and so that we could speak to the acting manager a second visit was made to the home. We looked around the property, looked at health and safety and talked with the acting manager. This visit was just one part of the inspection. Before the inspection, we asked the acting manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well and what they needed to do better. We also received surveys from both people living at the home, one of which was completed by a relative and three support workers. Because there are a number of outstanding requirements from our last inspection visit we have asked for an improvement plan from the organisation. What the service does well: What has improved since the last inspection? Agreement is reached with people about what their support needs and personal goals are to ensure it is what they want. Support plans were available to ensure that support workers had the information they needed to support people effectively. The plans were securely held so that peoples right to confidentiality was maintained. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 6 Standards of decoration, hygiene and cleanliness had improved in some areas to enable people to live in a comfortable home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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.V376802.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed assessments are carried out to help ensure peoples needs are responded to appropriately. EVIDENCE: The procedure followed by the organisation for new referrals includes a full initial assessment and visits to the home by the prospective person. Compatibility with people already living at the home would be considered. There have been significant changes at the home over the past six months. One person who had lived at the home for sometime had moved on to another Outreach property. There had been two new admissions since our last visit. One admission had been unsuccessful and the person had been re-admitted to hospital. The acting manager said that lessons had been learnt about ensuring that the placing authority provided the home with accurate information. The second admission had been very successful. There was a lot of information about the person including an up-to-date CPA and risk assessment carried out by a person qualified to do so and the home had completed their own assessment. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Agreement is reached with people about what their support needs and personal goals are to ensure it is what they want. EVIDENCE: One person’s care records were examined. They contained personalised and detailed information about the person’s health and social care needs. The plan covered all the areas of the organisation’s 8 accomplishments, which include individuality, independence, continuity, community presence, choice, status/dignity and respect/religion/culture and relationships and sexuality. The records showed that agreement had been reached with the person about what their support needs were for example the person commented that, “I choose not to be weighed.” The support plan was signed by the person. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 10 People had set goals. These included, completing domestic routines independently and without prompt, accepting daily support, to continue studying and gaining deeper understanding of their faith and to try and become involved in the wider community. Care records were securely held and available to support workers. It was evident that the manager checked the records regularly to ensure that they were being properly maintained. Individual risk assessments were in place such as a behavioural risk assessment, a fire risk assessment and a general risk assessment for the environment. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11 12 13 14 15 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to lead meaningful lives within the community, maintain contact with family and friends and their religious beliefs are promoted. EVIDENCE: We received surveys from people living at the home. They indicated that they were generally satisfied with the support that they received from the home. People take part in community activities with staff support where necessary. On the first day of inspection one person was going to the library using the ring and ride service bus with a support worker. At home people enjoyed watching television and reading, including talking books and newspapers. One person was interested in furthering their religious studies and this was promoted. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 12 The support worker was observed to respect a person’s privacy when entering bedroom and the bathroom. One person said that their privacy was respected for example nobody entered their room without permission. They said that they could choose what time they got up or went to bed and how they spent their time. Interactions between the support worker and the person living at the home were observed to be frequent and friendly. The atmosphere was relaxed. People were encouraged to be as independent as possible. Records showed that one person took responsibility for cleaning their bedroom, changing their bed, going shopping and their laundry. People kept in regular contact with family and friends and either spent time with family members at their homes or by writing to them. Relatives and friends were welcome to visit the home at any time. Cultural and religious needs were respected. For example, there was an expectation that only kosher food would be brought into the house. Jewish festivals were celebrated. People had a choice about what they had to eat. They shopped individually and had individual cupboards in which to store their food. On Friday evenings for Shabbas, staff cooked for everyone and people sat down together to eat a communal meal and prayers were said Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal support was given as people preferred but they were not always receiving their medication as they should and so their health was put at risk. EVIDENCE: One of the aims of the service is to assist people to be as independent as possible. It was clear from observation and discussion that people had a choice about their daily routines, for example what time they got up, daily routine and meals. The pace was very relaxed and people were getting up when we arrived. The support worker was observed to encourage a person to do as much as they could for themselves. The person had no hesitation in approaching the support worker for assistance and said that they were happy with the support they were receiving. Each person had a health file and a traffic light passport to take with them if they need to go into hospital. The manager said that both people living at the home had access to a doctor and a dentist. Where appropriate people had Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 14 access to a psychiatrist and were in regular contact with the assertive outreach team who were responsible for administering their depot injection. We looked at the safety of medication practices. One person is susceptible to eye infections. At our last inspection we expressed concerns about the administration of their eye ointment i.e. using the same tube of ointment to treat both eyes even though a separate tube was being sent by the pharmacist for both eyes to prevent cross infection. At this inspection visit we found that there were still ongoing problems with the administration of both the ointment and drops being used to treat the person’s eyes. There was a significant overstock of both the drops and ophthalmic ointment going back to January 2009, which had not been returned to the pharmacy. It was not clear why this was the case. The manager was not sure about how both the ointment and the drops were to be administered and there was no clear direction on the MAR (Medicine Administration Record). This was also a cause of concern because the manager had recently undertaken training to enable them to assess the competence of the staff team. We asked the manager to check out with the person’s doctor about how both the ointment and the drops were to be administered and ensure that clear direction was added to the MAR sheet. The MAR sheets were not being used effectively so we could not audit the problem easily. This in part was due to duplicate records being kept by the organisation. The record was not accurate for one person’s medication that was not held in the blister pack. Records showed that there were 56 tablets when there were actually 61 tablets. No issues were raised where medication was administered directly from the blister pack. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People said that their views were listened to and acted on and policies and procedures were in place that direct support workers as to what action must be taken to safeguard people from abuse or harm. EVIDENCE: We had received no formal complaints since the last inspection. Five internal complaints had been logged at the home. These related to behaviour of a former resident, which was adversely impacting on an existing resident. We spoke with the person concerned who confirmed that they could approach the manager at anytime and they were confident that they would sort out any problems. An audio complaints procedure had been made available to a person who is unable to read the written procedure. A copy of the local authority safeguarding policy and procedures was available to support workers. The acting manager had undertaken the 2 day safeguarding investigating officer’s course and all the support workers had undertaken local authority safeguarding training so they new what action to take in the event of an incident of abuse or harm. The manager said that all the support workers had received Mental Capacity Act, including deprivation of liberty training but there was no evidence available to support this. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards of decoration, hygiene and cleanliness had improved but more needs to be done to ensure that people to live in a safe home. EVIDENCE: The home is owned by the organisation and is situated in a residential area of Prestwich, close to bus and tram routes, local shops, synagogues, and other amenities such as Heaton Park. The house is similar to other properties in the area. It is not identifiable as a care home. People had the use of two lounges, kitchen and a first floor bathroom and separate toilet. The ground floor shower and toilet was still out of use and waiting to be repaired and refurbished. There was a pleasant enclosed garden for people to use. Access to the garden was via patio doors. The manager had concerns about the security of the locking mechanism and had requested new Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 17 doors. A staff office/sleep-in room was located on the ground floor. We did not look at people’s bedrooms at this visit. The acting manager had produced a maintenance audit and schedule of works. Priority had been given to health, safety and risk areas then to areas of improvement. At our last visit we required that a copy of the schedule of work be sent to us with a timescale of when work is to be completed by. We did not receive this information. Since our last visit most of the communal areas of the house had been redecorated and new carpets and blinds had been fitted. The manager said he had been in contact with the RNIB to look at introducing more aids and adaptations for the benefit of a person living at the home. He said that there were few aids available that would help the person but they had purchased some tactile labels for the person’s drawers. At our last visit we had concerns about fire safety arrangements at the home. The laundry room needed a smoke detector and many of the fire doors throughout the home did not close to the rebate. A cupboard being used for storage under the stairs needed to be emptied and kept locked shut to ensure a means of escape for people upstairs in the event of a fire. None of these issues had been addressed by the acting manager or the organisation. This is a cause of concern and potentially leaves people at risk in the event of a fire. There was also a fire extinguisher on the top floor that was empty. The home was cleaner than at our last visit. As noted at the previous inspections the kitchen would benefit from replacement. The worktops and cupboards are worn and very difficult to clean and do not ensure that good hygiene standards are maintained. The manager said that arrangements to improve the kitchen and the ground floor shower and toilet were to be made as soon as money was released from the sale of another Outreach property. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate staffing levels were available but it was not clear whether they had received the training they needed to support people effectively and safely. EVIDENCE: Relationships between the support worker and the person living at the home appeared warm and caring. There had been a high turnover of staff within the organisation and this had led to a significant change in the staff team over the previous six months. There was a new staff team in place, consisting of two fulltime support workers and one part time support worker. No outside agency support workers were being used. On-call arrangements were in place out of office hours. We received three survey responses from support workers who gave positive responses about working at the home. One support worker commented that, “The training is quite good. We have been involved in numerous training sessions, which are relevant to the job. The managers are always approachable and are always ready to help.” Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 19 Since our last visit the organisation had become a member of the local training partnership and training had been booked for the staff team. The manager informed us that all the support workers were near to completing their NVQ (National Vocational Qualification) Level 2 which was being undertaken at Salford College. Staff training records were not up-to-date. We could see that from training certificates that the new support workers had received some training. We requested updated information from the manager to confirm what mandatory health and safety training the new staff team had received or was planned with the partnership. It should also include relevant mental health training. As at our last visit we did not receive this information by the time the report was completed. We were therefore unable to make an assessment as to whether the staff team had received the appropriate training to help ensure that they have the knowledge and skills to support people safely and effectively. As previously stated there had been a high turnover over of staff within the organisation. This was due to some unforeseen shortfalls in the recruitment of support workers from overseas. The organisation had worked with the relevant authorities to address this matter. Staff recruitment records were kept at the Outreach Head Office. A sample of recruitment files across Outreach homes was looked at during a visit to the office on 7th July 2009. Overall recruitment records indicated that all necessary recruitment checks had been undertaken. Recruitment checks had been done and included obtaining a photograph, employment histories, written references, medical declarations as well as a CRB (Criminal Records Bureau) disclosure. Records showed that in the main gaps in their employment records had been looked into. The acting manager had held regular supervision sessions and team meetings with support workers but these had lapsed recently. The manager said that although they had had a difficult time with one service user who had now left the home that the support workers were, “committed and interested” and was happy with the staff team. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 and 41 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To ensure that the home is well managed by a suitably qualified and experienced person, the manager must apply to register with us. EVIDENCE: At our last visit in September 2008 the acting manager had started the process to become registered with us after being confirmed in post in August 2008. The manager said that he had made numerous attempts to ensure that he had all the correct information in place within the set timescales. An application was recently received by us but was returned to the acting manager because it did not meet our requirements. The organisation must address this situation as a matter of urgency. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 21 The acting manager had responsibility for another Outreach service at the time of our visit. We need to be formally notified about this situation. The manager was not available at the time of our visit and the support worker was unable to locate him. As a person living at the home was due to go out with his support worker we made arrangements to come back and meet with the manager at a convenient time. The acting manager has 8 years experience working in social care and holds the Registered Manager’s Award. During the past 12 months the manager had undertaken the 2 day investigating officers safeguarding training with the appropriate local authority, medication training to assess support workers competence and deprivation of liberty training to ensure his continuous professional development. The manager said that he was well supported by the organisation and could speak to anyone at anytime. He confirmed that he had regular supervision sessions with the director of operations and arrangements were in place for supervision with another senior staff member when she leaves. Not all the requirements made at our last visit have been met. The AQAA we received refers to the registered manager throughout though the manager has yet to register with us. Internal quality assurance systems were in place. The last visit to the house by the chief executive took place on 21st May 2009. The visit was unannounced and said to be thorough. A member of the executive committee had also visited the home on 22nd May 2009. The acting manager said he had taken action to rectify the issues raised. These visits must be undertaken on a monthly basis to meet Regulation 26. Staff meetings had been held on a regular monthly basis up until June 2009. Most maintenance checks had been carried out including the portable electrical appliance test. At our last inspection visit we expressed concern about the validity of the electrical certificate for fittings and fitments relating to whether the person undertaking the work was suitable to do so and a visual inspection only had been carried out. No action had been taken to address this matter within the timescale given however we were informed an inspection of the homes electrical fittings and fitments was due to take place at the end of August 2009. A copy of the electrical certificate must be sent to us when the work has been completed. Records around testing and maintenance of the fire system were in order. However, many of the fire doors throughout the home still did not close to the rebate of the door and therefore did not guarantee that people would be protected from smoke inhalation in the event of a fire. We requested an updated staff training record from the manager to check what health and safety training the staff had received and what training was planned. We did not receive this information by the time this report was completed. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 22 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 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008443.V376802.R01.S.doc 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 X X 2 X Version 5.2 Page 23 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 YA20 Regulation 13 Timescale for action Safe arrangements for recording, 31/08/09 handling, administration and disposal of medication must be made to ensure that people’s health is not put at risk. 30/09/09 To ensure the health and safety of people in the event of a fire. All fire doors must close to the rebate to give people the required protection from smoke inhalation. The cupboard over the stairs needs to be emptied and kept locked shut to ensure a clear means of escape for people in the event of a fire. (Outstanding 31/10/08) A smoke detector must be fitted 30/09/09 in the laundry room. The downstairs toilet and shower 31/12/09 must be refurbished to ensure that the person living on the ground floor has access to use it. The kitchen must be repaired or 31/12/09 replaced to ensure that it can be kept hygienically clean. Verification must be received 30/09/09 from the organisation that the staff team have received all the mandatory training, including DS0000008443.V376802.R01.S.doc Version 5.2 Page 24 Requirement 2. YA24 23 3. 4. YA24 YA27 23 23 4. 5. YA30 YA35 23 18 Outreach Community & Residential Services 1 Newtown Mews 6. YA37 Section 11Care Standards Act 2000 6. YA42 13 mental health training they need to support people safely and effectively. To ensure that the home is well run and complies with the law, we must receive an application from a competent and suitably qualified person to become the registered manager for the home. (Outstanding 30/11/08) Confirmation is needed that the homes electrical safety certificate is valid and that the homes portable electrical appliances have been checked to ensure the health and safety of people living at the home. (Outstanding 30/11/08) 30/09/09 30/09/09 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. 2. Refer to Standard YA36 YA39 Good Practice Recommendations The acting manager needs to resume regular supervision sessions with the new staff team to ensure they receive the support they need. The organisation needs to visit the home on a regular basis to ensure that people are receiving a service that is in their best interests and to check that outstanding requirements have been addressed. Outreach Community & Residential Services 1 Newtown Mews DS0000008443.V376802.R01.S.doc Version 5.2 Page 25 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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