Inspection on 05/09/06 for Outreach Community & Residential Services Highbury Court

This inspection was carried out on 5th September 2006.

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

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

Other inspections for this house

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

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 Sue Evans Unannounced Inspection 5th September 2006 09:35 Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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.V297315.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.V297315.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 stuart@outreach.co.uk Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Outreach Community & Residential Services Mrs 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.V297315.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. 19th December 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 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. 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. 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.V297315.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the flats. Seven and a quarter hours were spent there, watching what went on, talking to four residents, two staff members and the manager, visiting four of the flats, and examining some key records. Several weeks before the visit, questionnaires were sent to the home to be given out to residents and regular visitors. Four residents and four relatives returned completed questionnaires. Written comments were also received from a Social Worker and a Community Psychiatric Nurse. What the service does well: Highbury Court flats provide a homely, comfortable environment for the occupants, giving them space and privacy. Residents said that they were happy living there. They said that staff treated them well and respected their privacy. This was noted during the inspection visit. Comments from residents included, “Staff don’t intrude”, “They are easy to get on with”, and “Staff make time to talk”. One resident described staff as “Excellent and very understanding towards everyone’s needs”. Comments from relatives included, “The staff are excellent at Highbury Court”. Residents are fully included in agreeing what help they need from staff, and they make their own decisions about their lives. They are encouraged to take responsibility for things, and to be as independent as possible. They take part in community activities of their choice, with staff support if needed. Chosen activities include employment, college, leisure pursuits, and attending Jewish study groups. This helps residents to lead meaningful and fulfilling lives as part of the local community. Cultural and religious needs are supported, for example there is an expectation that only kosher food will be brought into the flats. Regular residents meetings are held. Residents know what to do if they are unhappy about anything. They feel that any concerns would be listened to and dealt with. Residents and staff said that the manager was approachable. They are able to give their views either individually, or at one of the regular residents or staff meetings. Residents can, if they wish, have involvement in the running of the service. For example, one resident has been involved in staff interviews, and 2 residents organise monthly outings for the group. The service makes sure that before staff start work they are properly checked to make sure they are suitable to support the people living in the flats. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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 Highbury Court DS0000008444.V297315.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): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Needs are assessed before people move in, and written information about what the service offers is provided so that all concerned can decide whether the service will be suitable. EVIDENCE: The service had a Statement of Purpose and Service Users’ Guide. There was evidence that they were updated if anything changed. The service needs to think about producing them in different formats, such as audio, for anyone who may have difficulty reading standard print. The residents living in the flats had been there for between 2 and 20 years so there had been no recent admissions. However, the written comments provided by the residents suggested that they had received enough information about the flats before moving in. The manager said that any prospective new residents could come and meet the rest of the residents before moving in, and that overnight stays could be arranged. She said that there was a settling in period of 4 weeks. Residents’ written and verbal comments indicated that they were happy living in the flats. One resident said, “I like it here”. The personal files relating to 2 residents were looked at. They contained care management assessments from the placing authority. There was also evidence of the service carrying out its own assessments. Residents were aware of the written information that was kept in their personal files. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 9 Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents are included in agreeing and reviewing their personal plans. They are able to make choices and decisions about their lifestyles, and are encouraged to be as independent as possible, whilst keeping any risks to their health and welfare to a minimum. EVIDENCE: Personal files relating to 2 of the residents were looked at. As observed during the last inspection, the personal files contained a great deal of written information including initial assessments, a health plan, personal plans, and risk assessments. However, files also contained a useful summary sheet, “Guidelines for Support” for quick reference. Personal plans had been drawn up with the involvement of the resident. They were written in the first person, and they included each resident’s views, preferences and goals. Residents knew about their written records and knew that they could see them whenever they wanted. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 11 Personal plans were centred upon the “eight accomplishments” of community presence, independence, choice, individuality, status, respect and dignity, continuity, relationships, and culture. Records showed that residents’ needs and goals were reviewed approximately monthly by the resident and a designated support worker. More formal review meetings, to which relatives and social workers were invited, took place every six months. Residents confirmed that they attended these meetings. The manager and staff members spoke knowledgeably about the needs of the residents, and the information that they gave was in line with the information given by the residents, and the written information in the care notes. A Social Worker and a Community Psychiatric Nurse who provided written comments said that staff demonstrated a clear understanding of the needs of the residents. It was observed that the residents’ routines of daily living were flexible. For example residents got up at the times they chose, and they pursued their individual activities. They confirmed that they made their own decisions about their lifestyles. Five of the six residents managed their own finances. Three looked after their own medicines. Records and discussions showed that staff helped people to make appropriate, informed choices, for example when considering leisure activities. Residents said that they held regular meetings to discuss various things that were relevant to the group. Minutes were seen. One resident said that sometimes he typed up the minutes. Two of the residents organised monthly outings for the group. The manager said that one resident had been on staff recruitment panels. It was observed that all the residents could speak up for themselves, although information about advocacy services was available to them. One of the aims of the service was to help residents to live as independently as possible. Risk assessments had been completed, with risks balanced against the resident’s right to choice and independence. The residents, relatives, and health and social care professionals who gave their views about the home said that they were satisfied with the support provided. One relative commented, “Excellent and caring staff. Always ready to listen to you at all times”. Another said, “The staff are excellent at Highbury Court”. A resident described staff as, “Excellent and very understanding towards everyone’s needs”. Another said, “Staff make time to talk”. Discussions with staff confidentiality meant. members showed that they understood what Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. 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. Care practices respect residents’ rights to privacy, choice, and independence. Cultural needs are supported. Residents choose their own menus, but are encouraged to eat healthy diets. EVIDENCE: Discussions, observations and written records showed that residents followed their own daily routines. Five of the six residents were able to take part in community activities without staff support. Staff rotas were arranged to enable the sixth resident to take part in a variety of outside activities. During the inspection visit he went out for the afternoon with one of the staff. He chose to go to Manchester. Other residents were seen coming and going from Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 13 their flats, for example one went off to his part time job, and another said he was going out to a museum. It was very clear, from discussions with residents and staff, that residents were encouraged and supported in pursuing valued, fulfilling activities. They described some of the community facilities that they used such as colleges, buses, trams, shops, pubs, restaurants, leisure centres and synagogues. Some had part time jobs. One did voluntary work. One resident regularly went out with a local leisure group. Another described how he liked to listen to musical recitals in Manchester, and attend lectures on Jewish culture. Proposed college courses for next term included computers, textiles, French, and possibly cookery. As already stated in this report, 2 residents organise a monthly outing for the group. They have been to places like Blackpool and Southport, and enjoyed meals out. Residents have the opportunity to go on holiday, with staff support if needed. One resident said that he had been to Ibiza, and was going to Majorca next time. The manager said that residents were included on the electoral roll. Residents talked about the contact that they had 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”. It was observed that 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. Each resident had his own flat. Staff members only entered a person’s flat with the permission of the resident unless there was an emergency. One resident said, “Staff don’t intrude”. Residents had responsibility for tasks such as shopping, cooking, cleaning, and laundry. Some carried out these tasks fully independently, others had varying degrees of staff support as agreed in personal plans. Residents said that staff were friendly and treated them well. This was observed during the inspection, when there was a natural rapport between residents and staff. One resident described staff members as, “easy to get on with”. 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 their own menus, and they shopped individually. Most did so independently. They prepared and ate their meals in their own flats at the times they chose. One person needed staff support to prepare meals. Staff members described how they tried to encourage healthy eating. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 14 Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Personal and health care needs are promoted, and medication storage and procedures promote good health and safety. However, two staff members are not yet trained in the safe handling of medicines (see “Staffing” section of this report). EVIDENCE: One of the aims of the service was to assist residents to be as independent as possible. In respect of personal and physical care, the residents were generally self caring, and any assistance from staff members took the form of encouragement and reminders. Residents were fully able to express their views about the way they were supported. As already stated in this report, residents 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 said that they were happy with the way that staff members treated them, and the way they spoke to them. Residents used community healthcare services such as GPs, Community Psychiatric Nurses, opticians, dentists, and psychiatrists. Details of all contacts Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 16 with health professionals were recorded. On the day of the inspection visit the manager accompanied a resident to an appointment with his Consultant. Residents’ personal files contained an individual health plan. The manager and staff spoke knowledgeably about the physical and emotional needs of the residents, demonstrating that they had the skills and experience to understand and respond to any problems. There were written guidelines covering medication. The home was advised to include a paragraph covering guidelines for staff if residents bought nonprescribed medicines. It was noted that the home encouraged residents to be as independent as possible, and it was noted that most residents looked after their own medication (apart from PRN medication) as agreed and risk assessed. Residents had signed a “Consent to Medication” form. A monitored dosage system was being used, with medication being supplied to the home weekly. During the inspection visit, the pharmacist delivered the dosette boxes. The contents were checked and agreed by a staff member, who recorded the details in the receipt book. These details were countersigned by the manager. The dosette boxes were locked away in a wall cupboard. A resident who looked after his own medicines was later observed collecting his dosette box. He signed to confirm receipt. Staff members looked after one resident’s medication. The Medication Administration Records (MAR) were appropriately completed. There were also records for any PRN medicines administered, which included the reasons given, and what strategies had been tried beforehand. A list of staff members’ usual signatures was maintained. Training records showed that some staff had received training in the safe handling of medicines, but 2 had not. This has been covered in the “Staffing” section of this report. Despite the fact that not all staff are trained in medication, outcomes for service users were still good, and therefore the quality rating in this section has been rated “good”. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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 at least once during a 12 month period. 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 the service. Residents know who to complain to and they feel they would be listened to. Protection policies and procedures, and staff understanding of their adult protection responsibilities, ensure that the service has the means to be able to respond appropriately to any suspicion or allegation of abuse. EVIDENCE: The service had a written complaints procedure. Residents said that they would speak to the manager or staff if were unhappy about anything, or they might raise their concerns at a residents’ meeting. They felt that their concerns would be listened to and dealt with. Complaints records showed that, since the last inspection, one resident had made a complaint to the manager. Details had been recorded and the manager had responded to the resident in writing. Of the 4 relatives who sent back written comments, 2 said that they were not aware of the complaints procedure. The manager had sent copies of the procedure to relatives following similar comments last year. She said that she would write to them again. There were written procedures covering adult protection and whistle blowing. Staff members had signed to show they had seen them. The two staff members who were spoken with confirmed that they had seen them. They also understood their responsibilities in reporting any suspicions of abuse. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 18 It was noted that the organisation ensured that all staff completed a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) check before they commenced work. During the last inspection, discussion took place with the manager about the value of regularly including adult protection in agendas for team meetings and 1 to 1 supervision meetings. She said that this had been done. A staff member confirmed it. Since the last inspection, the manager had undertaken formal training in Adult Protection. Her training certificate was seen. The proposed training schedule showed that the opportunity to attend this training was to be widened to include support workers. 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. The home’s policy manual included policies covering, for example, bullying and racial harassment. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The flats provide a homely, comfortable and safe environment suited to the needs of 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, as agreed in their personal plans. This was confirmed by residents. 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. As required during the last inspection, a dining table in one flat had been revarnished. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 20 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 that the owners of the flats, Irwell Valley Housing, responded well to reports of work needing to be done. The window frames of one flat needed attention, and this work was in the Housing Association’s schedule of proposed maintenance. 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. Residents were happy with their flats. It was clear from discussions that they were included in decisions about the purchase of new items. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff members receive appropriate supervision and support to enable them to carry out their duties, and develop professionally. Residents are protected by safe recruitment practices. However, although the organisation offers a range of staff training, new recruits can potentially wait almost a year before undertaking the mandatory courses. EVIDENCE: Residents were happy with the support they received from staff members. It was observed that residents had no hesitation in approaching staff members if they needed them. They said that staff members were always available if they needed them. Both male and female support workers were employed. Staffing levels were sufficient to allow outside activities for a resident who needed to be accompanied outside the home. Discussions and examination of records showed that the staff team had a range of knowledge and experience. Of the 5 people working at the home, 2 were qualified to at least NVQ level 2, and 2 others were on the course. The home was therefore making good progress in this area. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 22 Staff recruitment records were kept at the Outreach Head Office. A sample of recruitment files (across Outreach homes) was looked at during a visit to the office in June 2006. During this visit the service was advised to keep a full set of recruitment documents in one place and remove any remaining recruitment records from the homes. In the main, recruitment records indicated that all necessary recruitment checks had been undertaken. Employment checks that had been done included obtaining employment histories, written references, medical declarations, photographs, CRB (Criminal Records Bureau) disclosures and POVA (Protection of Vulnerable Adults) register checks. Records for recent recruits showed that, in the main, gaps in their employment records had been looked into. The organisation is reminded that the reasons why prospective employees have left their previous employment now needs to be documented on application forms. Good practice was noted in that prospective new staff had completed an application and equal opportunities monitoring form. Details of interview questions and notes were kept on file. Records showed employees were health screened at the Occupational Health Unit at a local Hospital, following which a statement was issued to confirm that the candidate was fit to undertake their duties. ‘Back to work’ and exit interviews were routinely undertaken. Records showed that new recruits received induction training. The training booklet included a section covering Judaism, and how to respond to residents’ cultural and religious needs. Staff members confirmed that they had received training in Judaism, and said that induction training included the principles of care. Staff members gave examples of some of the training that they had undertaken. These included infection control, medication, moving and handling, health and safety, food hygiene, first aid, and fire training. Copies of their training certificates were held on their personal files. Files also contained certificates for other training such as LDAF (Learning Disability Awards Framework), epilepsy, and ‘An Introduction to Mental Health’. There was no evidence of training in respect of two staff members. One was a fairly recent recruit, the other commenced in November 2005. The manager said that the mandatory courses were done only once a year in September and October. This meant that the staff member who had started in the preceding November had waited almost a year before being give the opportunity for mandatory training. This is not satisfactory. The organisation needs to look at providing the training for new recruits more often, at least 6 monthly. The staff members who were spoken with felt that the manager was supportive and approachable. There was an on call system in place. Staff members said that they had regular 1 to 1 supervision and appraisal meetings with the manager (every 1 or 2 months). They also said that regular staff meetings were held. Minutes were seen. But for the gaps in staff training, this group of standards would have been rated “good”. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 23 Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgment has been made using available evidence including visits to this service. Residents, and others, have contributed to a detailed quality audit, which has identified areas for improvement. The health and safety of service users and staff is promoted by means of regular safety checks. EVIDENCE: The manager is registered with the CSCI, and she has completed the RMA (Registered Managers Award). The manager has been employed by Outreach for 4 years, firstly as a support worker, and then since February 2005, as a manager. She keeps updated by attending regular training in various topics. Observations and discussions indicated that the manager encouraged an open, inclusive atmosphere within the flats. Residents and staff said that they found her to be approachable. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 25 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. At the time of the last inspection, the service was asked to produce a summary for residents, and others (including the CSCI), so that people would know that their views had been noted and, where applicable, acted upon. This was done. The service needs to begin to think about its next annual audit. Several safety records were checked. These included electrical installation, portable electrical appliance tests, servicing of fire alarms, and weekly checking of fire alarms, lighting, fire fighting equipment and means of escape. Since the last inspection, a fire risk assessment had been completed and intumescent strips fitted to the new fire doors. A test for Legionella was done in August. A valid Employers Liability Certificate was seen. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 26 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008444.V297315.R01.S.doc 3 4 4 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 4 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 27 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. 1. Standard YA20 Regulation 13 Timescale for action The 2 identified staff members 30/11/06 must be trained in the safe handling of medication. The 2 identified staff members 30/11/06 must be trained in the mandatory health and safety topics. Requirement 2. YA35 18 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 YA1 Good Practice Recommendations The registered person needs to think about producing information such as the Service Users’ Guide in formats other that print (for example audio) for anyone who may have difficulty reading standard print. The service is advised to expand the medication procedures to include management of non-prescribed medicines. The registered person is advised to encourage staff DS0000008444.V297315.R01.S.doc Version 5.2 Page 28 2. YA20 3. YA23 Outreach Community & Residential Services Highbury Court members to take advantage of the opportunities to undertake adult protection training. 4. YA32 The service needs to continue to support staff members with their NVQ level 2 training to ensure that the minimum standard of 50 is achieved. Outreach Community & Residential Services Highbury Court DS0000008444.V297315.R01.S.doc Version 5.2 Page 29 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. 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