Inspection on 05/03/08 for Outreach Community & Residential Services Highbury Court

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

Outreach Community & Residential... 19/12/05

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 Julie Playfer Unannounced Inspection 5 March 2008 09:30 th Outreach Community & Residential Services Highbury Court DS0000008444.V337688.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 Highbury Court DS0000008444.V337688.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 Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 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 akila@outreach.co.uk Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Outreach Community & Residential Services Mrs Beverley June Barrow 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.V337688.R01.S.doc Version 5.2 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. 5th September 2006 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 flats are situated in a residential area of Prestwich, about three quarters of a mile from the village centre. They are close to bus and tram routes, local shops, and synagogues. There is ample parking adjacent to the flats for visitors. Staff members are available on the premises 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. A statement of purpose and service users guide is available, which informs current and prospective residents about the services and facilities available at the home. 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. Fees vary depending upon assessed needs. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Highbury Court on the 5th March 2008. The previous key inspection was carried out on 5th September 2006. During the visit we (the commission) looked at written information including policies and procedures and some key records. We also spoke to the residents, the registered manager and staff and visited three of the flats. As part of the inspection process we used “case tracking” as a means of gathering information. This process allows us to focus on a small group of people living at the home, to assess the quality of service provided. Prior to the inspection satisfaction questionnaires were sent to the home. Four questionnaires were returned from the people living in the home, four questionnaires were received from relatives and three from staff. The quality assurance manager also completed a detailed factual questionnaire (Annual Quality Assurance Assessment) about the home. Information from the questionnaires was collated and used as evidence throughout the inspection process. At the time of the inspection there were 5 people accommodated in the home. What the service does well: The residents were provided with useful up to date information about the home, which was explained by the staff team, as appropriate. The residents’ needs were properly assessed and reviewed at regular intervals. This meant the staff were aware of the residents’ current needs and how best to provide care and support. The residents were fully involved in the development and review of their care plans, which were person centred and focused on the person’s strengths and personal preferences. Clear guidance was provided for staff on how best to meet the residents’ current needs and aspirations. The residents were aware of their files and could access information whenever they wished. This meant the residents had significant input into the delivery of their care and support. The residents were supported to make their own decisions and be as independent as possible. The residents pursued a number of activities and were well integrated into the local community. The residents spoken to were very happy with the service provided. Staff support was offered flexibly and was primarily designed to meet the needs of the residents. One person wrote in a questionnaire, “I can do virtually everything I want to do – overall I am very happy with the care and support I receive”. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 6 Cultural and religious needs were respected and supported. Staff received training in Judaism and had a good understanding of the Jewish way of life and the important festivals. They also honoured a commitment to only bring kosher food into the home. Residents’ meetings were held on a regular basis and the residents were confident that their views would be listened to and acted upon. The residents could also have some involvement in the running of the service, which included participation on interview panels for new staff. This ensured that residents were able to influence the recruitment of new staff to the home. The residents were provided with a single occupancy flat, which was spacious and furnished in accordance with their personal tastes and preferences. This meant the residents were able to live an independent lifestyle and make their own daily living choices. The recruitment and selection procedures protected the residents and ensured that all new staff were fully vetted. The staff were provided with good training opportunities, which were relevant to their role. This ensured that staff had a good understanding of the needs and aspirations of the residents. Appropriate systems were in place to monitor the quality of the service and planned developments were based on the views and wishes of the residents. This meant the residents had significant input into any improvements and they were able to lead a valued lifestyle within the community. What has improved since the last inspection? What they could do better: The residents spoken to were very pleased with all aspects of the service provided, all records viewed were found to be accurate and up to date and all legal requirements were met. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 8 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.V337688.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were provided with useful information about the services and facilities provided in the home and their needs were properly assessed and reviewed. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents clearly set out the philosophy and objectives of the service and provided good information about the services and facilities available in the home. Since the last inspection the service users guide had been updated in line with the changes in staff. Work had also commenced on producing the guide in different formats. The residents spoken to were familiar with service users guide and had a copy in their files. The residents who had completed a questionnaire indicated that they had received sufficient information before moving into the home. The residents had lived in the flats for several years and were well established. However, one person had been admitted into the home for a short period of time in December 2007. The admission process was discussed with the registered manager and a member of staff. It was clear a full assessment of the person’s needs was undertaken prior to arrival and further assessments Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 10 were carried out throughout the time the person was residing in the home. Before moving into the home the person was invited to spend time getting to know the other residents and staff. A member of staff was allocated to provide the person with continuity and answer any questions about life in the home. This meant the person and the registered manager could make an informed decision about whether the home was suitable for meeting the person’s needs. The personal files relating to two residents were looked at in detail as part of the case tracking process. The files contained care management assessments from the placing authority. There was also evidence to indicate that the manager and staff had carried out periodic reviews of the assessments, to ensure the residents’ current needs were recorded. The residents spoken to confirmed they were fully involved in the assessment of their needs and were aware of the information kept in their personal files. The residents had been issued with a contract, which meant they were well informed about the terms and conditions of residence. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home were in control of their own lives and played an active part in planning the care and support they needed. EVIDENCE: The case tracking process demonstrated that each person had an individual plan, which reflected their health and welfare needs. The plans contained detailed information and were supplemented by risk assessments, health plans and a variety of records including the care provided and medical appointments. The care plans set out each person’s current needs and included details about how their needs and aspirations were to be met. The plans were person centred and were developed, reviewed and owned by each resident. The residents spoken to described how they had participated in the care planning processes and how they were able to make their own informed decisions about Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 12 their lives. One resident said he checked his file each day and was able to read any comments made by staff. The care plans were structured around the service accomplishments of “community presence, continuity, independence, choice, individuality, status, respect and dignity, continuity, relationships and culture”. The accomplishments provided a framework on which to base the service to ensure the residents live a valued lifestyle within their own community. Each person was allocated a key worker, who kept the care plan up to date and made sure other staff were aware of the person’s current needs and wishes. A member of staff spoken to explained that individualised support was offered to each person on a regular basis. The type of support provided depended on the person’s needs and preferences and could range from assisting with domestic tasks to having a chat. The residents said the manager and staff were “excellent”, one person said, “They always listen and fit in with what I want”. The care plans were working documents and were reviewed at a minimum of six monthly intervals. The residents decided whom they wished to invite to their review. It was part of the ethos of the home to support people to make their own decisions and take responsible risks. Detailed risk assessments and management strategies covered activities indoors and in the wider community and were included in the residents’ care plan documentation. This meant that risks were managed positively to help people lead the life they wanted. During conversations with the residents, it was evident they were consulted both formally and informally and they were able to fully participate in the life of the home. Residents meetings were held on a regular basis and it was evident a wide variety of topics were discussed. Minutes of the meetings demonstrated that the residents fully contributed to the agenda and discussions. One resident said he sometimes typed up the minutes from the meetings. The residents were also represented on interview panels for new staff within the organisation. The residents were supported with their financial affairs and detailed written records were maintained of all transactions. A random check of money deposited with the home for safe keeping corresponded accurately to the records. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home were supported to live a meaningful lifestyle and enjoy all the rights and responsibilities of citizenship. EVIDENCE: Individual plans and records demonstrated that the residents had opportunities to maintain and develop practical life skills. Staff spent time with each resident to enable them to focus and develop specific life skills. One person explained that he had learnt to carry out several domestic tasks, which meant he could lead a more independent lifestyle. Most residents had responsibility for tasks such as shopping, cooking cleaning and laundry. Some carried out these tasks independently, others had varying degrees of staff support as agreed in their personal plans. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 14 Discussions, observations and records showed that residents followed their own daily routines. Four of the residents were able to participate in community activities without staff support. It was very clear that each person was supported and encouraged to pursue a range of valued and fulfilling activities. The residents spoken to described some of the community facilities they used which included, colleges, restaurants, art galleries, markets, shops and synagogues. Two people had part time jobs and one person was looking for further work. Another person described how he liked to listen to music recitals in Manchester and attend lectures on Jewish culture. Residents were observed to be following their chosen activities during the inspection. One person said he had been out to the shops and for a long walk with a member of staff. Staff support was offered flexibly throughout the day and it was evident this support was designed to meet the needs of the residents. As such residents were observed negotiating different times with staff to enable them pursue their chosen activities during the day. Two residents organised a monthly activity for the whole group. The outings were discussed at the residents’ meetings and included visiting places of interest and going out for meals. The residents were provided with the opportunity to go on holiday with staff support. One person said he was looking forward to going to Menorca in May. The residents were supported to maintain good contact with their families. As such friends and family were welcome to visit the home at any time convenient to the residents. The relatives who completed a questionnaire prior to the inspection were satisfied with the level of care provided and all felt the needs of their relative were met. One person commented, “I think it does very well and the staff are very helpful”, this person added, “I have never had to make a complaint, they do excellent work in every way”. The residents were well integrated into the local community and visited their friends on a regular basis. All residents were entered onto the electoral register and exercised their right to vote by attending the local polling station or by entering a postal ballot. Each resident had his own flat and staff members and other residents only entered a person’s flat with the permission of the resident, unless there was an emergency situation. Residents communicated freely with staff by means of an intercom, which was installed in the staff’s office/accommodation. The residents’ cultural and religious needs were fully supported and respected. For instance there was an expectation that only kosher food would be bought into the flats. Residents chose their own menus and most people shopped for their food independently. One person needed staff support to plan and prepare meals. Healthy eating was encouraged. During the Sabbath, staff were responsible for all meal preparations and cleaning. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home received effective personal and healthcare support, which fully respected their privacy and dignity. EVIDENCE: The delivery of personal care was varied and dependent upon the needs and preferences of the residents. Staff respected the residents’ rights to privacy and dignity and supported the residents to be as independent as possible. Where personal support was required individual details were recorded in the care plans along with guidance on how this support was to be delivered. The residents were fully able to express their preferences about how they wished to be supported and in turn staff listened to what was in important to them and took into account their wishes. This approach was reflected in a comment received in a questionnaire from a person living in the home, which stated, “I make most of the decisions pertaining to my everyday life, however, I do receive support from staff if I have any difficulties and I am very happy with the support I get”. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 16 The registered manager and staff ensured consistency and continuity for residents by the use of the key worker system. The residents felt the staff were approachable and supportive, one person commented in the questionnaire, “the staff are always there for any problems”. Personal healthcare needs were clearly recorded in each resident’s care plan and health action plan. The residents were registered with a General Practitioner and used community healthcare services as necessary. Whilst support was offered to attend appointments, the residents were helped to take responsibility for their own healthcare needs, wherever possible. There was evidence to indicate that the residents had access to NHS services and the advice of specialist services, where appropriate. There was a set of policies and procedures in respect of medication and appropriate records were maintained of receipt, administration and disposal of medicines. All records seen were fully completed, contained the required entries and were signed by staff. Four residents were given the support to manage their own medication, within a risk management framework. The residents had signed a “consent to medication” form. Since the last inspection, arrangements had been made for all staff members to complete accredited medication training. This meant the staff had received appropriate training to enable them to handle medicines in a correct and safe manner. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home were able to express their concerns and had access to an effective complaints procedure. Written procedures and practice protected people from abuse and neglect. EVIDENCE: Both informal and formal arrangements were in place to ensure the registered manager and staff listened to and acted on the views and concerns of the residents. This was achieved during daily conversations, one to one discussion with residents and their key workers and residents’ meetings. Residents were observed approaching the staff and manager with personal queries throughout the visit. The complaints procedure was included in the service users guide and each person had a copy of the procedure in their file, which had been signed by them. The residents said they would speak to the manager or staff if they wished to raise a concern or they might discuss the matter at a residents meeting. They felt that their concerns would be listened to and acted upon. All said the registered manager and staff were very approachable. According to the information submitted by the quality assurance manager prior to the inspection, there had been no complaints received during the last twelve months. The relatives who completed a questionnaire indicated they were aware of the complaints procedure. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 18 Copies of local protocols relating to safeguarding adults procedures were available in the home, along with an internal policy and procedure and whistle blowing procedures. These documents set out the required response in the event of any allegation, suspicion or evidence of abuse. Staff working within the home had received safeguarding adults training and were aware how to respond in the event of an alert. Knowledge and understanding in this area was periodically tested and updated at team meetings and during supervisions. Staff completed POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks as part of the recruitment and selection of new staff. This meant the staff were properly vetted and residents were protected from unsuitable people. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Highbury Court provided a comfortable and safe environment. People living in the home were able to personalise their flat and create an individual space suitable for their needs. EVIDENCE: Highbury Court consists of six single occupancy flats, five of which offer independent living. The flats are linked by an intercom system to the staff office/sleeping in room. The complex has no distinguishing features from the surrounding community. The flats are situated in a residential area of Prestwich, about three quarters of a mile from the town centre. The flats are close to bus and tram routes, local shops and synagogues. The residents had a bus pass and used public transport with or without staff support. This meant the residents were able to visit family and friends nearby. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 20 The flats consisted of a lounge/dining room, kitchen, bedroom and bathroom. The flats visited, on the invitation of the residents, provided spacious accommodation, which had been personalised in line with the person’s tastes and preferences. The residents spoken to said they liked their flat and enjoyed living at Highbury Court. Most of the residents were very independent and took responsibility for keeping their own flat clean. Arrangements were in place with the Housing Association to carry out routine repairs and maintenance, as necessary. The residents were encouraged to participate in the décor and furnishings plans for their flat. Since the last inspection, some of the flats had undergone redecoration and refurbishment. Measures were in place to ensure a safe living environment. The flats had been inspected by, the fire officer, who had drawn up a fire risk assessment, an environmental health officer and an inspector from the local council, who carried out a health and safety check. Policies and procedures were in place in relation to infection control and staff had received appropriate training. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment and selection procedures were thorough and ensured the protection of the residents. The staff were well trained and skilled to meet the needs of the people living in the home. EVIDENCE: Staff had been issued with a job description, which was commensurate with their role, as part of the recruitment process. From discussions with the staff during the inspection, it was evident they had a good understanding of the needs of the residents and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. Staffing levels were sufficient to meet the needs of the residents and allowed for activities outside the home. This meant the residents received the level of support they needed and enabled them to live a lifestyle of their choice. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 22 A recruitment and selection procedure was available, however, it was noted this needed some minor amendments, to ensure it covered current regulatory requirements. The recruitment and selection procedure was underpinned by the organisation’s Equal Opportunities Policy. Since the last inspection, a tracking sheet had been introduced to enable the staff to track the checks and records required for the recruitment of new staff. The personal file of one member of staff was looked at in detail. It was evident the person had completed an application form and had attended an interview. The interview panel included a representative from the people living in the home. One resident explained that he enjoyed sitting on interview panels and had received appropriate training from the organisation to help with this role. Relevant checks had been obtained from the criminal records bureau along with two written references, prior to the commencement of employment. An induction training package was available for new staff, which covered the “Skills for Care” standards. Each member of staff had a training assessment and profile and there was an overall training development plan for the staff team as a whole. It was evident the staff had access to a broad range of training courses associated with the care and support of the residents. This included training on the main tenets of Judaism, to enable them to respond to the residents’ cultural and religious needs. At the time of the visit, two members of staff had achieved NVQ level 2 or above. This equated to 66 of the staff team. Staff meetings were held on a regular basis and minutes were seen during the visit. The meetings gave the opportunity to staff to share experiences and develop teamwork. A programme had been established to ensure all staff received appropriate supervision at least six times a year and had an annual appraisal of their work. Staff spoken to said the team worked well together and the registered manager was responsive to their needs. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to monitor and develop the quality of the service and the health and safety of the residents was promoted and protected. EVIDENCE: The registered manager had overall responsibility for the management of the home and had a job description, which reflected the aims and objectives set out in the statement of purpose. The manager had completed NVQ level 4 in Management and Care and the Registered Manager’s Award. This meant the manager had completed the necessary qualifications to enable her to carry out her role effectively. The manager had undertaken a variety of courses during the last twelve months in order to update her knowledge and skills. The Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 24 courses included training on the Mental Capacity Act, person centred planning, first aid and the protection of vulnerable adults. The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. The registered manager had established systems to monitor the quality of the service, which included weekly checks. The checks included general maintenance, first aid box, fire tests and money deposited in the home. Satisfaction questionnaires were distributed in January 2007 to the people living in the home and their relatives. The results of the surveys had been collated. An annual development plan based on the outcomes of the monitoring processes had been produced, which identified the planned developments for the service. This document linked to the annual quality assurance questionnaire (AQAA) submitted to the Commission. The AQAA contained comprehensive information about the service and the plans for improvement over the next twelve months. There were policies and procedures covering all aspects of health safety in the home. The staff received health and safety training, which included food hygiene, first aid and fire safety. This meant the staff were aware of safe working practices and the safety arrangements within the home. According to the AQAA and documentation seen during the inspection the electrical, heating and fire systems had been serviced at regular intervals. The registered manager had carried out risk assessments of the environment and there was a procedure in place for the reporting of any accidents or incidents. Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 3 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 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008444.V337688.R01.S.doc 3 4 4 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 4 17 4 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 3 3 X X 3 X Version 5.2 Page 26 Outreach Community & Residential Services Highbury Court Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Outreach Community & Residential Services Highbury Court DS0000008444.V337688.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Outreach Community & Residential Services Highbury Court DS0000008444.V337688.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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