Inspection on 08/08/06 for Outreach Community & Residential Services

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach Community & Residential... 10/02/09

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

Outreach Community & Residential... 16/10/07

Outreach Community & Residential... 09/03/06

Outreach Community & Residential... 17/08/05

Outreach Community & Residential... 16/12/04

Outreach Community & Residential... 19/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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 86 Meade Hill Road Prestwich Manchester M25 0DJ Lead Inspector Stuart Horrocks Key Unannounced Inspection 8th August 2006 09:30 Outreach Community & Residential Services DS0000008445.V303747.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 DS0000008445.V303747.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 DS0000008445.V303747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Outreach Community & Residential Services Address 86 Meade Hill Road Prestwich Manchester M25 0DJ 0161 740 3256 0161 740 5678 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 Lesley Ann Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 5 service users, to include: Up to 5 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. 9th March 2006 Date of last inspection Brief Description of the Service: 86 Meade Hill Road is one of a number of care homes managed by Outreach Care Services. Outreach is a charitable organisation offering 24-hour care, mainly to Jewish people with a learning disability or mental health problems. 86 Meade Hill Road is a six bed roomed detached house owned by Greater Manchester Jewish Housing Association. The home provides care and accommodation for five service users with profound learning disabilities. The remaining bedroom is used as an office. The house is located close to local shops, pubs and Post Office. Buses to and from Prestwich and Manchester pass nearby and a metrolink station is within walking distance. A ramped path is provided to the front door and the house is accessed by one step both at the front and back entrances. A drive provides parking space and on street parking is available outside the house. A safe enclosed lawned and patio area is provided to the rear of the property. A Service User Guide that describes the home’s services is available in the home and the provider gives other information about the home to new and prospective residents and their families verbally. As of August 2006 the weekly charge for accommodation and services is between £518.00 and £875.00 with an additional charge being made for hairdressing, chiropody, toiletries, some outside activities and holidays. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which included a site visit that was started at 9.15am on the 8th August 2006 that took place over the one day. Much of this time was spent in talking to the manager and two staff members and in looking at paperwork. Some time was also spent in looking around the home. The care services (case tracking) provided to two specific residents were used as a basis for the process of the inspection. None of the residents have the ability to communicate verbally therefore the inspector was not able to talk to the residents to get their views about what it is like to live at the home. However the inspector noted that the residents seemed to be happy, settled and content. What the service does well: What has improved since the last inspection? What they could do better: The staff need to be provided with training in adult protection issues and details of the home’s proposed training programme should be sent to the CSCI. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 6 Overnight staffing levels must be increased therefore ensuring that the needs, including the health and safety needs of the residents and the staff can be met. The requirements made in the GMC Fire and Rescue Service inspection report of the 8th march 2006 must be fully dealt with, and two other health and safety matters must be addressed. 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 DS0000008445.V303747.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 DS0000008445.V303747.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 outcome area could not be assessed, as no recent initial referral or assessment information was available at the home. EVIDENCE: There have been no recent resident admissions to the home. At the time of the previous inspection the inspector was told that all initial referral and assessment information is kept at the Outreach central office. The inspector was also then informed that when residents are first referred to the organisation that their needs are assessed by staff in the central office with a decision then being made by these staff about which of the Outreach houses that the resident will be placed to live at with a trial period of residence then following. Further assessment is then done, the suitability of the placement is then assessed and a care programme is put together. Should a resident need to be moved between houses then this is done over a gradual introductory period of between six to eight weeks. All of the residents presently living at Meade Hill Road have been accommodated there for between one to ten years and they have lived within the scheme between fourteen to eight years therefore their initial assessment information was not available for inspection. Following discussion with the manager it was decided that for future placements the initial referral and assessment information would be available Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 9 at the home for inspection so that the suitability of the arrangements can then be checked. Outreach Community & Residential Services DS0000008445.V303747.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 & 9. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Good care delivery information is available, residents are encouraged and assisted to make decisions and choices and detailed risk management information is also kept. EVIDENCE: At the previous inspection it was found that the residents care files contained such a large volume of information that this made it difficult, to see what the resident’s care needs were. It was felt that accessing these would probably be taxing for a new worker for example, where a considerable amount of reading would need to be done before a picture of the resident’s care needs could be established. Recommendations were therefore made that archive and slimmed down working files for day-to-day information be developed that would bring benefits in terms of ready access to the information about the residents’ needs. It was also recommended that developing care plan summaries for each resident with the level of support identified, would be useful and that this should be included in the working file. All of these recommendations have been implemented. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 11 The care files of the two case tracked residents were looked at. These were found to contain care plan summaries that described the residents personal, health, social and risk care needs. These files also contained daily progress reports, a person centred plan, a health action plan, detailed risk assessments and strategy and goals guidelines for the care of the resident. All of this information was up to date, well laid out and easy to access and in combination with the care plan summary provided a good picture of the residents overall care needs. The residents presently living at the home have very limited ability to make decisions and choices about their lives. They do to some extent make some choices about the clothes that they wear, about the food they eat and at what time they go to and get up from bed. Each resident has a written decision making assessment that confirms that they are largely unable to make anything other than simple choices with the bulk of decisions being made by the staff, parents and care managers. Discussion with the staff showed that they are however well aware of the residents personal preferences regarding their daily lives and they encourage, assist and support the residents in making appropriate choices and decisions about their daily activities. As mentioned above the home has detailed risk assessment and risk management systems that protect the residents and other people from potential harm. The risks assessed are for personal risk and for activities that the residents are involved in both inside and outside of the home. They describe the management and the support needed for each sort of risk and activity. These risk assessments had been reviewed and they were up to date. Outreach Community & Residential Services DS0000008445.V303747.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,& 17. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The residents are encouraged and supported to take part in activities that provide interest and purpose in their lives and enables them to be a part of the local community. Family and community contact helps the residents to have personal relationships and the resident’s health is maintained by the provision of proper meals. EVIDENCE: None of the residents living at the home are able to take part in formal education or work activities. Two residents attend a day centre where they have a meal and take part in a number of social activities and one other resident attends a local college where he takes part in pottery, art and horticulture and computer classes. The residents go out on shopping trips and they usually go out for a drive on Sundays (a vehicle is available) and they have lunch. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 13 The residents had recently been on day trips to Blackpool and Southport and they went out to Blackpool in the late morning of the day of this inspection. All of the residents have a “weekly planner” that describes how their time is spent. Although the residents are not able to travel independently they do use local buses, trams, shops, parks, pubs and cafes and they are a part of the local community. Visitors are welcome at the home at any time and the residents are supported in seeing their relatives. All of the residents have contact with their families although for some this can be irregular whilst others see their relatives more often. The cultural and religious needs of the residents are respected and the home follows Jewish laws and customs. The home presently accommodates five residents, two of these are female and three are male. Four of these people follow the Jewish religion whilst the other follows Christian beliefs The staff group is made up of six females and two males. The make up of this staff and resident group does not appear to cause any difficulties. From speaking with the staff, looking at paperwork and from observations made during the inspection, it was evident that the staff promote the residents rights and that the residents are encouraged to be as independent as possible, subject to any restrictions which are recorded in the residents’ care files. The residents are not able enough to have door keys or to open their mail without help, but they do have virtually unrestricted access to most parts of the home and garden and some residents do help with setting and clearing the table at mealtimes, with washing up and some straightforward cleaning tasks. Staff call the residents by the name they (the residents) prefer and the staff have a comfortable and natural manner with the residents. A Kosher diet is provided through a six-weekly menu. This menu has been put together from the known likes and dislikes of the residents. The menu describes a nourishing and attractive diet with the main meal of the day being eaten in the evening. The staff and the residents communicate in variety of ways with the staff knowing when the residents want a drink or a snack. The residents weight is checked regularly thus helping the staff to check their wellbeing. Outreach Community & Residential Services DS0000008445.V303747.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 & 20. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Personal support is provided in a dignified and respectful manner, medications are properly managed, and the residents’ health care needs are suitably dealt with. EVIDENCE: All of the residents living at the home are fully dependent upon the staff for nearly all personal care tasks. The staff makes sure that the residents personal hygiene, clothing, hair care and general appearance is appropriate and enhances their dignity. Some residents are able to decide about which clothing to wear whilst others require assistance. Each resident has a designated key worker and written information is available regarding each resident’s likes, dislikes and preferred routines. The routines of the home are flexible this includes mealtimes and the times for getting up and going to bed. The residents presently require no specialist equipment, aids or support. Each resident has a Health Action Plan that covers a wide range of topics including eye care, hearing, mobility, nutrition and medical care and hospital visits. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 15 From talking to the manager, the staff and the checking of the above records it is clear that the resident’s health care needs are looked after and that prompt action is taken if a resident becomes ill. The residents’ medicines are provided in pre-filled blister packs with preprinted prescription/recording sheets also provided. These records were found to be properly completed and to be up to date. Medicines are stored in a locked unit. Those staff that give out medicines have been given the necessary training for this task. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines and the use of covert medicines. No resident was dealing with their own medicines at the time of the inspection. Outreach Community & Residential Services DS0000008445.V303747.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 & 23. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home has a clear complaints system that ensures that concerns are properly dealt with and although good protection of vulnerable adults guidance is available staff training in this topic is needed to make sure that residents are protected from abuse. EVIDENCE: The home has a satisfactory complaints procedure that states how a complaint is to be made, who to and that an initial response will be provided within two days with a final outcome forwarded within four weeks. Those staff spoken with were aware of the home’s complaints procedure. They showed that they knew what to do if a complaint was made and they said that they would assist residents in making their concerns known. No complaints have been made to the home or the CSCI in the period since the last inspection in March 2006. The home has a record for writing down complaints; no entries have been made. The manager is reminded that should this record need to be brought in to use, that details to be recorded should include the date of the complaint, the name of the complainant, the nature of the complaint, and of the outcome and actions taken The home has a full copy of local area inter-agency adult protection policies that give good, clear and sound guidance to the staff should an abuse situation Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 17 arise. This, and another available document also advises staff about “whistleblowing” if they were to find themselves in such a situation. Discussion with staff showed that they had some understanding of adult protection issues but looking at staff training records showed that apart from the manager all of the staff needed training in this topic. Outreach Community & Residential Services DS0000008445.V303747.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 & 30. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Although Meade Hill Road provides a clean, comfortable and homely environment for the people living there health and safety has been compromised due to a failure to fully comply with requirements made by the GMC Fire and Rescue Service. EVIDENCE: Meade Hill Road care home is a large detached house. It is comfortable, bright, cheerful, clean and welcoming, with a good standard of decoration and furnishings. The home is situated on a main road and it is not distinguishable as a care home therefore promoting ordinary life principles. The building is well maintained both to the exterior and the interior. A new central heating boiler has recently been fitted, a new wardrobe provided in a resident’s bedroom, a new vacuum cleaner purchased and a computer donated to the home. The property is close to shops, a park and pubs and there is easy access to public transport. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 19 Ramps are provided to both the front and rear doors and there is a pleasant and well-maintained garden at the back of the building The two case tracked residents’ bedrooms were checked, these were found to be properly decorated, furnished and equipped. However one of these rooms was seen to have a window that can be opened widely so presenting a safety risk to the residents. The inspector therefore requires that an opening restrictor be fitted to this window. Although the premises comply with the requirements of the local environmental health department, the GMC Fire and Rescue Service requirement of the 9th March 2006 that “Action to provide an extra member of staff at night requires prioritising for early completion” has not yet been fully dealt with. This requirement is with regard to there being sufficient staff available overnight to assist with the evacuation of the residents from the home in the event of a fire. The requirement made in the previous inspection report that the home must comply with the GMC Fire and Rescue Service requirement is therefore repeated. The home was clean and tidy on the day of this inspection with a good standard of hygiene and cleanliness achieved. No malodours were detected. Laundry equipment is sited in a small room adjacent to the home’s kitchen with hand washing facilities being available in the kitchen. Care must be taken in ensuring that cross-infection does not occur. The home has control of infection policy and procedural guidance. Outreach Community & Residential Services DS0000008445.V303747.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 & 35. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Daytime staffing levels are satisfactory but overnight staffing levels need to be increased therefore making sure that the care needs of the residents and the health and safety needs of the residents and the staff can be met. EVIDENCE: Staff training has been provided with regard to the NVQ courses. Three staff have achieved an NVQ at Level 2 and the inspector was told that the remaining four other staff are intended to start this training in September 2006. The manager has already achieved the NVQ Level 4/Registered Managers Award. Discussion with staff and from random sampling of staff training records showed that they have been provided with training in the required health and safety topics such as food hygiene, moving and handling and first aid. The inspector and the manager discussed the way that staff training is presently recorded. The inspector suggested that the development of a stafftraining matrix would assist the manager in seeing what training had been completed, the date it had been done and what other training the staff needed to undertake. A requirement made at the time of the previous inspection was that “The registered person must ensure that where required the staff are provided with Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 21 training in the care of residents with learning disability needs”. The manager told the inspector that senior staff from the Outreach organisation had put together a training programme to address this requirement that will be implemented later in 2006. The inspector therefore requires that details of this training programme be forwarded to the CSCI. The home has a detailed and comprehensive six-week induction programme for new staff. However the inspector was told that the Outreach organisation is considering the introduction of a commercially produced system to replace the existing method. Progress with this work will be checked at forthcoming inspections. A number of the staff have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. Staff moral appeared to be good with staff saying that “there is a good atmosphere” and that “we get on together” The inspector checked the care staffing rotas for the period 20th July to 16th August 2006. These showed that two support worker were available from 8am to 10pm with one worker on waking duty overnight. A requirement made at the time of the previous inspection was that “The registered person must review overnight staffing provision and consideration must be given to providing two staff from 9pm onwards and that one of these staff must be on waking duty during the night”. This requirement has not been fully complied with in that the overnight sleep-in worker has been removed from the duty rota. The requirement was made in response to the risks attached lone overnight working for both residents and staff where in some circumstances staff and residents are vulnerable, and, also in response to the requirements of the GMC Fire and Rescue Service report of the 9th March 2006 where it was described that lone working was inadequate with regard to health and safety issues. The inspector therefore requires that this decision be changed to provide both one waking and one sleep-in worker overnight. Outreach houses do not usually keep detailed staff recruitment information within each home. This information is kept in a central office. The CSCI therefore undertook a random sample of staff personnel files in June 2006 to check on the vetting arrangements for care staff working in Outreach properties. From the findings of this sample it was reported that “Although some minor shortfalls were identified, the inspectors felt that the recruitment procedures were robust and safe and promoted equality and diversity”. Outreach Community & Residential Services DS0000008445.V303747.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 & 42. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well run and safely maintained and the intended extension of the home’s quality assurance process will allow residents and other interested people to have a voice in the running of the home. EVIDENCE: The home manager has been previously approved and registered with the CSCI and she has been running the home for approximately the last four years. The registered manager has successfully completed the Registered Managers Award and she therefore has qualifications in both care and management. The staff said that the manager runs the home in an open and inclusive way and that she is fair-minded, approachable and easy to get along with. A requirement of Standard 39 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 23 At the previous inspection the inspector was shown a comprehensive and detailed quality assurance assessment process document that was completed for Meade Hill Road in November 2005. This assessment covers a wide range of topics including the operation of the service, the care of the residents and staff issues. Unfortunately due to their disabilities the residents were not able to be involved in this quality assurance assessment and neither were their relatives and families consulted. A requirement was therefore made that “The registered person must ensure that the homes quality assurance process includes the views of the residents, their relatives and other interested parties (GP’s, social workers etc)”. Discussion with the manager at this inspection indicated that this requirement has been addressed and that the views of the above people will be sought in November 2006 when the next survey is due to take place. Information obtained from the Pre-inspection Questionnaire and random sampling of records showed that the home’s equipment is properly and safely maintained. The details of accidents are properly written down. Checking of the home’s fire precautions book showed that the fire alarm system has until very recently been checked and tested at the required weekly intervals. The home’s fire alarm control panel has recently become defective, and although the system is still fully working testing as described above cannot take place. The manager told the inspector that a new control panel is due to be fitted by the 22nd August 2006 when testing can then recommence. Outreach Community & Residential Services DS0000008445.V303747.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 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13 Timescale for action The Registered Person must 30/09/06 ensure that all of the staff are provided with training in adult protection issues. The registered person must 15/09/06 ensure that the home complies with the requirements made in the Fire Authority inspection report of the 9th March 2006. (Previous timescale of 19/05/06 not met) The registered person must 15/09/06 ensure that details of the proposed staff training programme if forwarded to the local CSCI office. The registered person must 15/09/06 provide one overnight waking staff member and one overnight sleep-in worker. The registered person must 22/08/06 ensure that the defective fire alarm control panel is replaced. The Registered Person must 15/09/06 ensure that an opening restrictor is fitted to an identified upper floor bedroom window therefore ensuring the safety of the residents. Requirement 2 YA24 23 3 YA32 18 4 YA33 18 5 6 YA42 YA42 23 13 Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 26 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 YA32 Good Practice Recommendations The Registered Person should give consideration to the development of a training matrix that can be used to show any gaps in staff training and also to show when training needs to be updated. Outreach Community & Residential Services DS0000008445.V303747.R01.S.doc Version 5.2 Page 27 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 DS0000008445.V303747.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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