Inspection on 01/12/06 for Outreach Community & Residential Services 2 Devonshire Place

This inspection was carried out on 1st December 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach Community & Residential... 30/03/06

Outreach Community & Residential... 22/06/05

Outreach Community & Residential... 14/12/04

Outreach Community & Residential... 23/08/04

Outreach Community & Residential... 21/01/04

Outreach Community & Residential... 03/09/03

Outreach Community & Residential... 07/01/03

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 2 Devonshire Place 2 Devonshire Place Prestwich Manchester M25 3FF Lead Inspector Kath Smethurst Key Unannounced Inspection 1st December 2006 10:00 Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.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 2 Devonshire Place DS0000008449.V310359.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 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Outreach Community & Residential Services 2 Devonshire Place 2 Devonshire Place Prestwich Manchester M25 3FF 0161 798 9023 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 Barbara Holden Care Home 4 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 4 service users, to include: Up to 3 service-users in the category of MD (Mental Disorder under 65 years of age); Up to 1 service-user in the category of LD (Learning Disabilities under 65 years of age). That the service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 30th March 2006 2. Date of last inspection Brief Description of the Service: Devonshire Place is one of a group of care homes managed by Outreach care services. Outreach is a charitable organisation offering 24-hour care, 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. The house is owned by Irwell Valley Housing Association. It is situated in the centre of Prestwich village, close to bus and tram routes, shops, banks, 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, dining room, kitchen, and laundry room. All bedrooms are single. Outside, there is a small car parking space at the front, and an enclosed yard 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 are dependent on the level of support required and range from £302.04 to £887.78 per week. Additional charges are made for hairdressing, toiletries, activities, holidays, transport, magazines and papers. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.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 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. All four residents and two relatives responded. 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, “I am very happy with the care my son is receiving”. 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. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.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 2 Devonshire Place DS0000008449.V310359.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 2 Devonshire Place DS0000008449.V310359.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: There have been no new residents admitted to the home since the last inspection. All the residents living in the home have lived there a long time between 10 to 13 years. The assessments, which accompanied them have now been archived. 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. Some residents could not remember what information they had been given prior to moving into the home but all confirmed they had visited the home before they moved in. One resident said, “I came to visit twice. I was introduced to other clients and staff”. Relatives who returned comment cards Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 9 indicated they had been provided with sufficient information about the home and service provided. 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. Part of the process would include an overnight stay. This would allow staff and existing residents to come to a decision as to compatibility with existing residents and whether needs could be met. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 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. They included assessments, health plans, individual personal plans, review notes and risk assessments. Care plans also contained separate information that gave specific direction for staff on residents’ daily routines, and the action they were to take to support the residents’ assessed needs. Records and discussions also showed that risks were assessed, and balanced against the resident’s right to choice and independence. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 11 Residents’ preferences and choices, for example their preferred times for getting up and going to bed, were included in these records. Records showed that the resident, their representative and staff reviewed residents’ needs and goals on a regular basis 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 confirmed they had a choice about daily routines. When asked, “Can you do what you want to do”, one resident said, “I can please myself” a second, “ I can make decisions on what I do”. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 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. However, staff do provide support as necessary. It was evident that residents undertake a range of activities in the community. Public transport and “ring and ride” are utilised to access community facilities. Residents living at the home are involved in attending college, visiting family, going to the shops and meals out. Some residents were able to take part in community activities without staff support. However, staff members spent some time on community activities Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 13 with all residents. All residents had the opportunity to go on an annual holiday. During the inspection, one resident went to college in the morning and two went for walks and to the shops. At home, residents enjoyed pastimes such as watching television and listening to music. 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. 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 sitting and chatting with residents. 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. Residents are encouraged to assist in the preparation of a meal, and where possible are encouraged to undertake making a meal without staff assistance, particularly breakfast and lunch. The evening meal is seen as a social event, and is used as a time for everyone to catch up with one another. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 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. 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. 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. For example residents were observed choosing 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 Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 15 them, and the way they spoke to them. One resident who returned a comment card said, “I am happy with the staff and get on well with them all”. Relatives who returned comment cards were also happy with the care and support provided. One relative wrote, “I am very happy with the care my son is receiving. Also the staff are aware of my feelings and are always available to talk with me”. 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. One shortfall was noted. In one residents care file concerns regarding nutrition had been identified. It was however noted that this residents weight had not been regularly monitored. Omissions in recording were noted in one of the care plans examined. In this instance the resident had not been weighed since August 2006. In future staff need to be mindful where concerns regarding nutritional needs have been identified, weight is monitored as instructed. 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 medication policies and procedures. Medicines that were kept in the home were stored in a locked cupboard. None of the residents looked after their own medication. Risk assessments to include the arrangements for the safe storage and administration of medication taken out of the home (holidays or overnight stays with relatives) had been completed. There were records of medication received, administered, and disposed of. The manager had asked residents or relatives to sign a “Consent to Medication” form evidence of which was seen on the files examined. Staff have completed medication training. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. 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). A system is in place for recording complaints. The homes complaints book was examined and showed three complaints had been logged since the last inspection. There was written evidence the complaints had been thoroughly investigated. All the concerns raised had been resolved to the complainant’s satisfaction. No formal complaints have been received by the CSCI (Commission for Social Care Inspection) since the last inspection. Residents and relatives who returned comment cards indicated they knew whom to approach if they had a concern or a complaint. One resident said, “I can tell staff on duty or speak to the manager” a second, “I will tell the staff or family or Outreach office”. 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 Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 17 undertaken training courses in adult protection. During the last inspection a recommendation was made for all staff to undertake training in this area. This has now been addressed with staff already having undertaking training and further courses arranged in early 2007. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. Devonshire Place provides a homely, comfortable, clean and well maintained environment for residents, suited to their lifestyles. EVIDENCE: The home is situated in the centre of Prestwich village, close to bus and tram routes, shops, banks and synagogues. The house is a large terraced home, similar to other properties in the area. It is not identifiable as a care home. Residents said that they liked the house. The lounge, dining room and kitchen were furnished and equipped in a homely way. There was a separate laundry room. Outside there was a small car parking space at the front, and an enclosed yard at the back. While environmental standards are generally good it was noted that the lounge suite was beginning to show signs of wear and tear and as such plans need to be made to replace this item. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 19 There is a bathroom with toilet on the first floor, and a toilet on the ground floor. Since the last inspection the home has had a shower fitted. Standards of cleanliness were good. Residents and relatives who returned comment cards had no adverse comments regarding the standard of hygiene in the home. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 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) one resident said, “I am happy with the staff. I get on well with them” a second, “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 moving and handling, food hygiene, communication skills, protection of vulnerable adults, medication, infection control, first aid, drug awareness, and epilepsy. In addition staff undertake training in Jewish customs and traditions. While a good range of training is provided, opportunities for staff to undertake specific Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 21 training relating to mental health should be explored. All permanent staff are in receipt of NVQ (National Vocational Qualification) level 2. Staff spoken with were satisfied with the training provided. 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. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 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 quality monitoring systems in place, enabling a regular review of the service received by residents. Maintenance and fire safety checks were carried out, however there is a need to improve to fire safety issues in order to ensure the safety of residents and staff. EVIDENCE: The manager 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. It was clear, from observations and discussions, that the Registered Manager encouraged an open, inclusive atmosphere within the home. During the Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 23 inspection, it was observed that residents and staff had no hesitation in approaching the manager if they had anything they wished to discuss. 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 gas and portable appliance servicing and both were up to date. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. The last recorded fire drill took place on the 1/10/06. Staff completed fire safety training in October 2006. The fire safety officer undertook an inspection in March 2006. He identified a number of areas, which needed to be improved upon. The manager advised that the housing association had been informed but to date no action has been taken to address all the issues identified. This now needs to be addressed as a priority in order to ensure the safety of both residents and staff. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008449.V310359.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Version 5.2 Page 25 Outreach Community & Residential Services 2 Devonshire Place 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 YA19 Regulation 12 (1) (a) Requirement The registered person must ensure residents weight regularly monitored when concerns relating to nutrition have been identified. Timescale for action 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. 2. 3. Refer to Standard YA23 YA24 YA42 Good Practice Recommendations The registered person is advised to provide staff members with opportunities to undertake mental health training. The registered person should make plans to obtain a new lounge suite. The registered person must address the fire safety requirements made by the Fire Safety Officer on 30/3/06, and inform the CSCI, by the date in the end column, of the action taken to comply. Outreach Community & Residential Services 2 Devonshire Place DS0000008449.V310359.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 2 Devonshire Place DS0000008449.V310359.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. 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