Inspection on 19/12/05 for Outreach Community & Residential Services Highbury Court

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Outreach Community & Residential... 05/03/08

Outreach Community & Residential... 05/09/06

Outreach Community & Residential... 23/06/05

Outreach Community & Residential... 27/01/05

Outreach Community & Residential... 24/08/04

Outreach Community & Residential... 12/02/04

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 Highbury Court Highbury Court 443-5 Bury Old Road Prestwich Manchester M25 1QP Lead Inspector Sue Evans Unannounced Inspection 19th December 2005 09:30 Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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 Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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 Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Outreach Community & Residential Services Highbury Court Highbury Court 443-5 Bury Old Road Prestwich Manchester M25 1QP 0161 773 0776 0161 740 5678 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 Care Home 6 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 6 service users, to include up to 3 service users in the category of MD (Mental Disorder under 65 years of age); up to 3 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. 23rd June 2005 2. Date of last inspection Brief Description of the Service: Highbury Court is one of a group of care homes managed by Outreach Community and Residential Services. Outreach is a charity that provides care and support predominantly to Jewish people with learning disabilities or mental health needs. Highbury Court is made up of six single occupancy flats, each linked by intercom to the staff flat. There are no shared areas apart from a small, private garden. The home is situated in a residential area of Prestwich, about three quarters of a mile from the village centre. It is close to bus and tram routes, local shops and synagogues. Staff members are available in the home 24 hours per day, including at night when a staff member sleeps-in. The level of staff support to be provided to each resident is agreed before the person moves in, and reviewed regularly. The aims of the service, as described in the Statement of Purpose, are to empower individuals, supporting them to make choices and decisions in their lives and to develop their independent living skills to enable them to live independently in their own homes. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took 6½ hours. This time was spent watching what went on, talking at some length with 3 residents, and briefly with 2 others, and talking to a support worker, the manager, and the Director of Operations. The inspector also saw 4 of the flats, and examined some key records. This inspection was the second to take place in the current inspection year. In order to gain a fuller picture of the home, this report needs to be read in conjunction with the report of the previous inspection of June 2005. A condition of registration for this home is that it employs a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The manager has been in post since February 2005 and she has applied for registration. What the service does well: Residents are fully included fully in planning what support they need ensuring that their rights to make choices about their lives are fully respected. One resident had typed up guidelines for staff about how he needed to be supported. Residents are encouraged to be as independent as possible. They have control over their own daily routines and they take part in, community activities of their choice (with staff support if needed). Chosen activities include employment, leisure pursuits, and attending Jewish study groups. This helps them to lead meaningful and fulfilling lives. Cultural and religious needs were supported, for example there is an expectation that only kosher food will be brought into the flats. The flats provide a homely, comfortable environment for the occupants. Residents said that they were happy living there. They said that staff treated them well. One said, “They are very good”. The manager and staff spoke with, and about, residents in a respectful way. Regular residents meetings are held during which residents are encouraged to raise any matter that they wish. Residents feel comfortable about airing their views, and are confident that they will be listened to. The safety and protection of residents is promoted by means of safe medication procedures, and regular safety checks. The manager and support workers are offered training and support to equip them with the knowledge and skills that they need to provide a good service to residents. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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 Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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 Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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): None None of the above standards were assessed this time. EVIDENCE: Standard 2 was assessed in June 2005. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Residents know about their individual plans, and they are involved in reviewing and updating their needs and goals. However, there is a need to ensure that the plans contain specific information about the support required from staff. EVIDENCE: Standards 6, 7 and 9 were assessed in June 2005. The manager and one of the staff members were asked about the support needs of 3 of the residents. Their descriptions of how they supported them matched with the information given by the residents. However, two of the personal files that were looked at did not contain specific enough information about the action required by staff. The manager was asked to add the necessary guidelines. The 3rd file that was looked at did contain specific information, and it was noted that the guidelines had been typed by the resident himself. This gave an example of how the home included residents in drawing up their personal plans. Personal plans were centred upon the “eight accomplishments” of community presence, independence, choice, individuality, status, respect and dignity, continuity, relationships, and culture. They included each resident’s preferences and goals. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 10 Residents confirmed that they had attended meetings to discuss their support needs. They said that they knew about their written records. They were given copies of key information. The personal files contained a great deal of written information including initial assessments, a health plan, care plans, and risk assessments. Discussion took place about the value of simplifying the information held on files so that it is easier to find accurate, specific, up to date information. The Director of Operations said that he was planning to do this. Residents were happy with the support given to them by staff. “They are very good”. One said, Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Residents choose how they spend their time, taking part in fulfilling activities that they enjoy doing. They participate fully in the community, enabling them to lead valued lifestyles. Contact with families and friends is encouraged. Practices in the home respect residents’ rights to privacy, choice, and independence. Cultural needs are supported. Residents choose their own menus, and they have choice about what time they eat. They are encouraged to eat healthy diets. EVIDENCE: Standards 12, 13, 14 and 16 were assessed in June 2005. Residents followed their own daily routines. Most were able to take part in community activities without staff support. During the inspection, a staff member accompanied a resident on a day out to Manchester Airport. Another staff member accompanied a resident to the shops. Other residents were seen coming and going from their flats, engaging in their chosen activities. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 12 It was evident, from discussions with residents and staff, that residents were encouraged and supported in pursuing valued, fulfilling activities. They gave examples of the community facilities that they used such as buses, trams, shops, pubs, restaurants, leisure centres and synagogues. Some had part time jobs. One resident regularly went out with a local leisure group. Another described how he attended a Jewish study group. Residents said that they kept in contact with family and friends. Some regularly spent weekends with family members. Residents’ involvement in the community gave them opportunities to meet new people. Residents’ personal plans contained a section covering “relationships, sexuality and partnerships”. Residents were fully able to express their wishes. It was clear, from discussions with them, that they had control over their daily routines, for example what time they got up or went to bed, what time they had their meals, and what activities they took part in. Residents had their own flat and it was observed that staff members only entered a person’s flat with permission. Residents said that they did their own shopping, cooking, cleaning, and laundry. Some carried out these tasks fully independently, others had varying degrees of staff support. It was noted that staff members and residents spoke with each other in a natural manner. Residents said that they were satisfied with the way staff members treated them. Cultural and religious needs were supported. For example, there was an expectation that only kosher food would be brought into the flats. Residents said that they chose what they had for meals. They shopped individually. Staff members accompanied 2 of the residents for grocery shopping. The other residents shopped independently. They said that they prepared and ate their meals at the times they chose. They were free to make themselves drinks or snacks whenever they wished. Most residents cooked independently, whilst one person needed staff support to prepare meals. The home kept copies of the menu plans for this resident. It was clear, from discussions, that staff members encouraged residents to eat healthily. One resident was referred to a dietician following concerns about weight gain. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents are encouraged to be as independent as possible and they look after their own medication if it is considered safe for them to do so. EVIDENCE: Standards 18, 19 and 20 were assessed in June 2005. The home had written guidelines covering medication. As recommended during the last inspection, the guidelines had been expanded to include details of the procedure for administration of medicines outside the home, for example on days out or weekends away with families. The home was also advised to include a paragraph about non-prescribed medicines. The home encourages residents to be as independent as possible, and it was noted that most residents looked after their own medication, as agreed and risk assessed. Residents had signed a “Consent to Medication” form. Training records showed that, as required during the last inspection, all staff members apart from a recent recruit had had undertaken medication training. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 14 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 Residents are given copies of the complaints procedure. They feel that any concerns would be listened to and dealt with. Protection policies and procedures, and staff understanding of adult protection, ensure that the home has the means to be able to respond properly to any suspicion or allegation of abuse. However, the manager is asked to regularly check out the staff team’s understanding of this topic, and seek opportunities to attend formal training. EVIDENCE: Standard 22 was assessed in June 2005. The home had a written complaints procedure that had been amended since the last inspection so that it clearly stated that complaints could be made directly to the CSCI. Residents’ personal files contained signed confirmation that they had received a copy of the complaints procedure. The manager said that relatives had also been provided with an updated copy. Residents said that they would speak to the manager or Director of Operations if they were unhappy about anything. One person said that he might contact the CSCI. Residents felt that any complaints that they might have would be listened to and dealt with. Residents had the opportunity to voice their opinions either individually, or during the regular residents’ meetings. Minutes were taken by one of the residents and kept on file to show what topics had been discussed at the meetings. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 15 There were written procedures covering adult protection and whistle blowing. Staff members had signed to show they had seen them. The staff member who was consulted during the inspection said that he had done some training in adult protection as part of his NVQ course. He understood his responsibilities in reporting any suspicions of abuse. However, discussion took place with the manager about the value of regularly including the topic in agendas for team meetings and 1 to 1 supervision meetings. Staff understanding might also be checked out by means of questionnaires. The manager was also asked to seek opportunities for herself and the staff team to go on formal training courses in this topic. The Director of Operations immediately booked the manager onto a course due to take place in January 2006. The manager said that she would cascade her learning to the staff team. Systems were in place to safeguard residents’ finances. All except one resident looked after their own money. It was noted that two staff members checked financial records at each staff handover to make sure there were no discrepancies. The personal money held on behalf of the resident was checked against his balance sheet and found to be in order. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The flats provide a homely, comfortable and safe environment for those who live there. EVIDENCE: Highbury Court consists of six single occupancy flats, each linked by intercom to the staff flat. The flats are situated in a residential area of Prestwich, about three quarters of a mile from the village centre. The flats are close to bus and tram routes, local shops, and synagogues. Most residents were very independent and they took responsibility for keeping their own flat clean. Staff supported those who needed it. The inspector saw inside 4 of the flats. Each consisted of a lounge, kitchen, bedroom and bathroom. They were adequately equipped with furniture, electrical equipment, and utensils. Residents said that they liked their flats. One flat had recently been redecorated, and had an extra wall unit fitted in the kitchen. There is a need to re-varnish or replace the dining table in this flat. There was evidence to show that the home kept an eye on the maintenance of the flats, and reported any items of work needing attention. The manager said Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 17 that the owners of the flats, Irwell Valley Housing, also carried out annual inspections to see if any work was needed. Measures were in place to ensure a safe living environment. These included, regular checks of fire alarms, lighting, and means of escape, regular checking of the electrical system, and regular safety checks of portable electric appliances. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36 Residents are supported by a staff team of which 50 of support workers are qualified to NVQ level 2. Outreach provides ongoing training to equip staff with the knowledge and skills that they need to meet the needs of the residents. Staff members are appropriately supported and supervised to help them to develop professionally and provide a good service. EVIDENCE: Standards 34 and 35 were assessed in June 2005. Residents were pleased with the support they received from staff members. It was observed that residents had no hesitation in approaching staff members if they needed them. Discussions and examination of records showed that the staff team had a range of knowledge and experience. 50 of support workers were qualified to NVQ level 2. Training records were looked at. All staff, apart from a new recruit, had up to date training in the mandatory health and safety topics. The manager said that the new recruit would be enrolled onto courses in the New Year. This will be checked at the next inspection. Staff training certificates showed that training was provided in topics such as food hygiene, first aid, moving and Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 19 handling, medication and health and safety. As required at the time of the last inspection, staff members have now received updated training in fire awareness. Some staff members had improved their specialist knowledge through the Learning Disabilities Award Framework. Some had undertaken training in epilepsy awareness, and an introduction to mental health. Staff records showed that staff had regular 1 to 1 supervision meetings with the manager. This was confirmed by a support worker. The worker also said that the manager was approachable and supportive and that she gave feedback on practice matters. Records also showed that staff meetings were being held regularly. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Residents benefit from the open management approach of the home and they are comfortable about expressing their wishes and opinions. However, the manager needs to complete her NVQ level 4 course. Residents, and others, have contributed to a detailed quality audit, which has identified areas for improvement. The improvement plan needs a little expansion so that residents will know what action is being taken to improve the service. The health and safety of service users and staff are promoted by means of regular safety checks. EVIDENCE: Standard 42 was assessed in June 2005. The manager is not yet registered with the CSCI but she has applied for registration. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 21 The manager has been employed by Outreach for 3 years, firstly as a support worker, and then since February 2005, as a manager. She is currently undertaking NVQ level 4 in care and management. She keeps updated by attending regular training in topics such as epilepsy, and the mandatory health and safety topics. She said that she received supervision and support from the Director of Operations. From observations and discussions, it was evident that the manager encouraged an open, inclusive atmosphere within the flats. Residents and staff said that they found her to be approachable. Regular meetings took place, for staff and residents, where they could express their views. During the inspection, it was observed that residents and staff were quite comfortable in approaching the manager if they had anything they wished to discuss with her. Outreach had undertaken an in-depth quality audit of the service which included asking residents, relatives and staff about their opinions 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. However, although the summary identified areas for improvement it did not clearly show what action the service was going to take to bring about the improvements. The Director of Operations was asked to do this, and also to make sure that the summary did not specifically name anyone who had provided feedback. When this has been done, a copy of the summary needs to be made available to residents, and others, so that they know that their views have been noted and, where applicable, acted upon. A copy also needs to be sent to the CSCI. Several safety records were checked. These included electrical installation, portable electrical appliance tests, weekly checking of fire alarms, lighting, fire fighting equipment and means of escape. Since the last inspection, arrangements had been made for the fire alarms to be serviced. The manager was part way through completing a fire risk assessment. The Fire Officer visited the flats in July 2005 and the requirements that he made had been addressed apart from the fitting of intumescent strips to the new fire doors. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 2 X Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Timescale for action Residents’ personal plans need 31/01/06 to contain more specific guidance about the action required by staff members. The dining table in flat 6 needs 31/03/06 re-varnishing or replacing. The summary section of the 28/02/06 quality review document needs to be more specific about what the service will do act upon the findings. Specific references to individuals who have given feedback should be removed from the summary to preserve their anonymity. The summary must be made available to residents so that they know their views are being acted upon. The registered person needs to 28/02/06 finish compiling the fire risk assessment. As advised by the Fire Officer, 31/01/06 the new fire doors need to be fitted with intumescent strips. Requirement 2. 3. YA24 YA39 16 23 21 24 4. 5. YA42 YA42 23(4) 23(4) Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 Page 24 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. 4. 5. Refer to Standard YA6 YA20 YA23 YA23 YA37 Good Practice Recommendations The service is advised to look at how the information held on residents’ files could be condensed and simplified to make it easier to find specific, up to date information. The home is advised to expand the medication procedures to include management of non-prescribed medicines. The registered person is advised to provide staff members with opportunities to undertake adult protection training. The registered person is advised to regularly check out staff members’ understanding of their adult protection responsibilities. The manager is part way through the NVQ level 4 course and she needs to continue to progress with this until completed. Outreach Community & Residential Services Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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: 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 Highbury Court DS0000008444.V265411.R01.S.doc Version 5.0 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!