Inspection on 20/02/07 for Outreach Community & Residential Services 17 York Avenue

This inspection was carried out on 20th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach Community & Residential... 07/03/06

Outreach Community & Residential... 06/10/05

Outreach Community & Residential... 29/03/05

Outreach Community & Residential... 27/07/04

Outreach Community & Residential... 04/03/04

Similar services:

Whitewalls

Home Farm

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

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 17 York Avenue 17 York Avenue Prestwich Manchester M25 0FZ Lead Inspector Kath Smethurst Unannounced Inspection 20th February 2007 09:30 Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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 17 York Avenue DS0000008447.V319995.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 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Outreach Community & Residential Services 17 York Avenue 17 York Avenue Prestwich Manchester M25 0FZ 0161 773 5053 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 ** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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 LD (Learning Disabilities 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. 7th March 2006 Date of last inspection Brief Description of the Service: 17 York Avenue is a small care home providing long-term support for four people with a learning disability. It is part of a group of homes managed by Outreach Community & Residential Services, a charitable organisation, which has nine other homes in the south Bury/north Manchester area. The homes are predominantly for Jewish people, although care is also offered for nonJewish residents. 17 York Avenue is an end terrace house in a residential area of Prestwich. There are three single bedrooms on the first floor and one on the ground floor. The home has a small, enclosed lawned area at the rear and on street parking outside. There are shops within close walking distance and public transport is available nearby. Fees are negotiated individually and are dependent on the level of support required. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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 four 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 three residents and two staff were spoken with. Carers were also watched as they went about their work. The manager was not present during the inspection but was spoken with on the telephone following the inspection. Before the inspection comment cards were sent to residents, their relatives and people such as social workers, district nurses and doctors. Four residents and three relatives returned comment cards. What the service does well: From speaking with residents and information relatives gave in comment cards, it was clear they were in the main 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. 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 17 York Avenue DS0000008447.V319995.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. The summary of this inspection report can be made available in other formats on request. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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. The personal files of two residents were examined. Both contained evidence of the home’s own assessments, carried out in conjunction with the resident, and showed that needs and goals had been regularly reviewed and updated by the home. Assessment documents were comprehensive and covered areas such as family/social contact, assessment and management of risk, methods of communication and personal support. There was evidence to show that review meetings were held to update assessments. Residents confirmed that they were included in assessments and reviews. Discussions with staff indicated any future admissions would be handled appropriately. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff worked in a positive and enabling way, ensuring understanding and agreement was reached with residents 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. Care plans also contained separate information which gave specific direction for staff on residents’ daily routines, and the action they were to take to support the residents’ assessed needs. Records showed that residents and Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 10 designated support workers reviewed residents’ needs and goals on a regular basis. More formal review meetings, to which residents their relatives and social workers were invited, took place on a regular basis. Residents spoken with confirmed they were involved in review meetings. The routines of daily living were observed to be flexible. For example residents were observed to choose where they spent their day and meals. Residents spoken with also confirmed they had a choice about daily routines. Good practice was noted, as service users were supported to be as independent as possible, with positive risk taking encouraged (e.g. regarding managing their own money, medication, shopping, meals and mealtimes). Documentation was in place regarding service users taking responsibility for their own medication and for their own and others safety when the home was unoccupied by staff. Records and discussions showed that staff helped and encouraged residents to make appropriate choices, for example when considering leisure, employment and educational opportunities, or choosing menus. Each resident took part in their own individually chosen activities, and they had individual menus. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 looked at ways of providing opportunities for residents to develop practical and personal life skills. For example menu planning, cooking, shopping etc. Residents led busy lives, having jobs and/or taking part in a wide range of courses. Or example on the day of the visit one resident attended college while another had been to work. Residents could take part in community activities without staff support. However, staff members did spend time with residents when they participated in community activities. Residents described some of the community activities that they were involved in. These included work, college, social groups, meals Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 12 out, and shopping. On the day of the visit one resident was attending college another had been to work. At home, residents enjoyed pastimes such as watching television, DVDs and listening to music. Two of the residents have computers. All residents had the opportunity to go on an annual holiday. Good practice was noted as staff time was regularly provided to provide support outside the home. 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 were also observed using their own front door and bedroom keys. 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. On Monday and Friday evenings (for Shabbas), residents sat down together to eat a communal meal. Residents agreed the menu at the residents meetings and took turns to prepare these meals. Prayers were led by residents at the Shabbas meal. . Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal, healthcare and medication needs of the residents 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 Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 14 clear, from discussions with residents that they had choice about their daily routines. 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. Relatives who returned comment cards were in the main happy with the care and support provided. 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. 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. Records were kept of current medication, plus consent to, and risk assessments regarding, their use. Medicines were being stored safely, with a clear record of medicines received into the home and any returned to the pharmacist. Staff working in the home have completed medication training in 2006. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The homes complaints book was examined and showed three concerns had been logged since the last inspection. The concerns related to a change in the staff duty roster, the use of communal milk and noise made by another resident. There was written evidence these concerns had been investigated. All the concerns raised had been resolved to the complainant’s satisfaction. Residents who returned comment cards and spoken confirmed they knew who to approach if they had a concern or complaint. 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. Training records showed that permanent staff had attended training on the protection of vulnerable adults. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 16 An investigation relating to one of the residents finances has taken place. This issue has been satisfactorily resolved. The manager took appropriate action when concerns were raised and notified all relevant professionals including the CSCI. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is in the main satisfactory but some improvements are needed to ensure standards don’t fall below an acceptable standard. EVIDENCE: 17 York Avenue is an end terrace house in a residential area of Prestwich. Communal space comprises of a lounge, dining room, kitchen, bathroom and two toilets. There are three single bedrooms on the first floor and one on the ground floor. The home has a small, enclosed lawned area at the rear and on street parking outside. There are shops within close walking distance and public transport is available nearby. It is not identifiable as a care home. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 18 Two of the residents showed the inspector their bedrooms. Both were personalised with residents’ own belongings. Residents had keys to their bedrooms. In the main they were satisfied with their rooms. Improvements to some areas of the home are needed. It was noted that an area of damp was visible in the lounge (on the outside wall). This needs to be investigated and attended to. Plans need to be made to re-furbish the bathroom in order to make the room pleasant for residents to use. The tiling is old and the grout discoloured, the bath is stained and the flooring showed signs of wear and tear. Responsibility for cleaning/housework is shared between residents and staff. This continues to work well, as the home was clean and tidy. Infection control measures are in place. Liquid soap and paper towels are provided in toilets. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit 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) all replied “Always”. Three 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, medication, personal safety awareness, Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 20 epilepsy, communication, equality and person centred planning. In addition staff undertake training in Jewish customs and traditions. Staff spoken with were satisfied with the range of training opportunities provided. NVQ (National Vocational Qualifications) are promoted and 75 of staff are in receipt of the award. 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 17 York Avenue DS0000008447.V319995.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, with systems for monitoring the quality of the service provided at York 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: Since the last inspection Jeannette Taylor has been appointed as manager of York Avenue. Jeannette is also the registered manager of another Outreach home. The manager advised that the organisation hoped she could continue managing both establishments given that the homes are in close proximity. The CSCI would normally require one manager for each establishment however this decision will be made once an application for registration has been made. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 22 Confirmation from the CSCI central registration team has been received that an application from the proposed manager has now been received. The two staff spoken with felt management arrangements were working well as both homes were in close proximity and the resident and staff group at York Avenue were stable. The proposed manager has worked for Outreach for 15 years and has extensive management experience. She is qualified to NVQ level 4 and has the RMA (Registered Manager’s Award). She keeps updated by attending regular training in topics such as the mandatory health and safety topics. 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 undertook an in-depth quality audit of the service provided by the home in 2005. 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. This exercise should be undertaken again in order to ensure residents relatives and staff continue to be satisfied. 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 also 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 the electrical installation, gas and electrical 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. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.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 3 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008447.V319995.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 2 X 3 X X 3 X Version 5.2 Page 24 Outreach Community & Residential Services 17 York Avenue Are there any outstanding requirements from the last inspection? No 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 (2) (b) Requirement To ensure the home is maintained to a good standard for residents the area of damp in the lounge must be investigated and rectified. To ensure the bathroom is a pleasant area for residents to use plans must be made to refurbish it. Timescale for action 01/04/07 2 YA27 23 (2) (b) 31/07/07 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 YA39 Good Practice Recommendations To ensure service users and other stakeholders remain satisfied with the service received consideration should be given to repeating the wide ranging quality audit undertaken in 2005. Outreach Community & Residential Services 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 25 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 17 York Avenue DS0000008447.V319995.R01.S.doc Version 5.2 Page 26 - 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!