Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0474, written 27 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2019 |
|---|---|
| Reference | 2019-0474 |
| Deceased | Janie McFadyen |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
This report is made under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.
Recipients
This report ts being set to.
The Trustees of Victory Outreach Manchester.
_
,
e Senior Pastor and Head 0 Safeguarding iy
Coroner
| am Nigel Meadows, HM Senior Coroner for the area of Manchester City.
Coroner's legal powers
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Investigation and Inquest
On 27 November 2017 | commenced an investigation into the death of Janie
McFadyen, aged 38 The investigation concluded at the end of the inquest on 26
February 2019.
The cause of death was found to be.
1a Hypothermia
1b Use of Diazepam, Zopiclone, Cocaine and Heroin
The conclusion of the inquest was Drug Related
Circumstances of death
The deceased was born on 6 December 1978 in Irvine, Scotland. (Her mother was
for many years employed as an Accident and Emergency nurse, primarily in Ayr )
She was the eldest of four siblings Shortly after her 16" birthday, she left home and
immediately began taking illicit drugs and quickly followed a pattern of homelessness
and staying in hostels or hotels, and would normally tell the authorities that her
mother would not allow her to go home although this was untrue. She gravitated
back to staying at hostels or rough sleeping. She injected Heroin and consumed
such other drugs as she could acquire. For a long period of time she was also being
prescribed and taking Methadone
She never married but had a partner who was also a drug user and they had two
children, but she was unable to look after them appropriately and they were brought
up their grandmother from being a few months old They are both now adults
The deceased claimed to have psychiatric problems, and at one time indicated she
suffered from bipolar disorder, but it was not clear what, if any involvement, she had
actually had with local mental health services in Scotland. Her mother was aware
that she had been admitted to hospital on a number of occasions having suffered
overdoses or the toxic effects of illicit drugs. She had also been sentenced to
periods of imprisonment.
Over the years, her contact with her mother became increasingly infrequent. She
had attended a number of detoxification and drug rehabilitation programs but without
SUCCESS.
In early 2017, she contacted her mother asking for help. She wanted to go into
rehabilitation again and try to ‘get off drugs’, despite her previous history of failing to
do so. Through her family, she managed to secure a place at what was understood
to be a drug rehabilitation program in Manchester called Victory Outreach. This was
essentially a religious retreat. Some of the staff may have been previous drug or
alcohol abusers.
The deceased travelled from Scotland to Manchester in July 2017 and her mother,
together with some of her siblings, visited her a number of times during her overall
stay at the premises. Her mother was told that initially it was what was described as
a ‘cold turkey’ program and she struggled to cope with it in the first few weeks.
It would appear that Victory Outreach run similar facilities elsewhere in Britain as well
as in other countries. The service users are asked to sign what is described as a
‘withdrawal from substance abuse addiction agreement’ This declares that the
premises are a drug and alcohol free residential sober living facility and does not
qualify as a detoxification facility. Its approach to recovery is holistic with a strong
spiritual emphasis The court understood that an individual with drug and/or alcohol
problems would be expected to in effect begin the program in what was described as
a ‘cold turkey’ abstinence state.
The court was not told that the staff at the program had any understanding that
sudden abstinence from alcohol can lead to severe withdrawal symptoms and
complications which, if untreated, can actually lead to death. However, it did not
appear that there were any written protocols, policies or processes used by Victory
Outreach in dealing with this.
The agreement also provides that if the service users experiences negative
symptoms from substance abuse or addictions they will be referred to a medical
facility for treatment However, that may depend upon the service user honestly
reporting such symptoms or those at the home being in a position to recognise them.
It did not appear that there were any written protocols, policies or processes used by
Victory Outreach in dealing with this Nor exactly what ‘medical facility’ they may be
referred to.
The service user is provided with accommodation as well as food and either pays for
this privately or through state benefits There is an accommodation charge and
separate charges for other aspects of their board and lodging. It is understood that
the deceased was receiving Disability Living Allowance and that the relevant local
authority would pay the accommodation costs and that she would contribute £40 per
week from her other sources of income
The service users also agrees to give permission for those staff at the home to
inspect their clothing and possessions, and that this may be conducted at any time
when it is deemed necessary. However, it did not appear that there were any written
protocols, policies or processes used by Victory Outreach in dealing with this
The normal expected period of stay was between 9 and 12 months.
The service user also agrees to comply with a drug screen and/or alcohol test at
random periodic times The service user is also asked to agree that if they decide to
leave they will indicate why they wish to do so but they may be able to return
following a 28 day waiting period, although there is no guarantee that a vacancy will
be available.
The ‘departure agreement’ in addition describes additional criteria which are
recorded as ‘walked away, negative departure, asked to leave and other’ However,
it did not appear that there were any written protocols, policies or processes used by
Victory Outreach in defining what these terms actually mean or exactly how this
would be operated and what would happen if the service user had relapsed or was
about to or there was an imminent risk of this occurring. There can be a number of
conditions for return, including daily contact with the director of the home with
required church attendance It appears that there is an expectation generally that
service users will attend church services, prayer meeting and participate in reading
the Bible.
There is a template Drug Test Record Sheet for each service user, which simply
indicates a positive or negative result. For drug testing, the court was told this was
undertaken by means of a ‘urine dip test’. However, it was not clear exactly what
drugs were tested for, by what equipment or processes, the accuracy of such testing,
the types or nature of any drugs detected or any recognition of the potential acute
health implications of positive tests without knowing the quantities involved or the
effect of a combination of illicit drugs with or without the consumption of alcohol.
However, it did not appear that there were any written protocols, policies or
processes used by Victory Outreach in dealing with this
The manager of the female unit acknowledged that they had no power or provision to
ask or seek the consent of a service user for an intimate body search in case any
illicit drugs had been secreted within the body. This would include within the mouth
and other body orifices
It is not clear exactly what relationship Victory Outreach have with local primary and
secondary NHS drug and mental health services.
The court was told that there was one local home for female residents, which could
cater for up to six occupants, but any individual has to share with a room-mate.
There was also another local facility for male residents, but the court was not told
exactly how many service users would be able to stay there.
The manager of the female unit is described as being a ‘Recovery Program
Manager’ She personally has no medical qualifications but may have undertaken
some training, but it was not clear exactly where, when or what this actually involved.
Service users are expected to attend group counselling sessions but can leave the
program at any time.
The organisation does not accept service users with mental health problems or who
require medication administering. It was understood that applicants are asked to
indicate if they have any mental health problems and consent to the organisation
contacting previous services who may have diagnosed or treated the individual. This
depends upon the person being truthful about their history and providing the right
contact details However, it did not appear that there were any written protocols,
policies or processes used by Victory Outreach in dealing with this. At the inquest
hearing, the manager was unable to indicate what, if any, information the deceased
had provided about this aspect or any details of her past and most recent drug abuse
history and treatment.
The manager accepted that the deceased struggled in the first few weeks of the
program because of the ‘cold turkey’ aspect It was not clear whether or not there
was any understanding of the potential short or longer term health implications of
ceasing from prescribed medication or illictt drugs. However, it did not appear that
there were any written protocols, policies or processes used by Victory Outreach in
dealing with this.
The deceased had indicated that she felt this was her last chance to try to overcome
her drug problem.
Service users were not allowed mobile phones and had to be accompanied by a
member of staff whenever they left the premises. The court understood that there
was a full time manager but with a number of other volunteer staff. However, it was
unclear what experience or training each of them may have had and any chain of
governance, and what they might do in the event of circumstances arising, and
whether or not they could or should seek advice or guidance from someone else
However, it did not appear that there were any written protocols, policies or
processes used by Victory Outreach in dealing with this
By November 2017 it appeared that the deceased was progressing well and had
apparently not provided any positive drug tests, although it was unclear when and
exactly how many were undertaken or when Nor had anything been found, erther in
her shared room or within her clothing or possessions. But again, it was not clear
when these searches had been made.
The manager accepted when giving evidence that service users on arrival may not
have a genuine or sincerely held Christian faith belief and may feign or pretend to do
so. In addition, whilst they may outwardly appear to either continue with such beliefs
or develop them, then once again there were a possibility that these may not be
genuinely held
The deceased's family visited her from Scotland over the weekend of 18 and 19
November 2017. When they went out, it seems that the deceased behaved
unusually because she was singing aloud on public transport and appeared to be
restless and her conversation included a degree of religious content, and was unable
to maintain eye contact with her family. The family were able actually to stay at the
retreat premises but the deceased made no attempt to speak to her family in private
Her mother, who was of course a very experienced A&E nurse, described her
presentation as being psychotic
Before the family left, they did not raise any concerns about the deceased’s
behaviour with the manager or any other staff member, but the manager was made
aware that on 23 November 2017 it would be the anniversary of the deceased's
father’s death and that she might have difficulty coping on that day.
The manager also indicated when giving evidence that the deceased had been in the
process of developing a relationship with a male service user who was resident in
the male unit and they had apparently been exchanging letters {t was not, however,
clear how the deceased ever first met or had contact with this individual or how long
this putative relationship had been ongoing. It was not clear that there were any
written protocols, policies or processes used by Victory Outreach in dealing with this.
The manager told the court that the deceased was actively encouraged to consider
that the relationship was not appropriate and this was an unhealthy situation. There
had been some recognition by the manager that the deceased’s behaviour at this
time might be described as ‘overactive’ and that the deceased was supposedly
feeling guilty about the situation.
At any rate, this male individual had apparently himself been in the process of
leaving the male unit at about the same time as the family’s last visit and was
understood to be returning to his home address.
The court was told that at the very least, the female service users were locked in the
premises at night, although their individual rooms may be open for entrance and exit,
and that there would be a member of staff within the premises overnight who had the
keys. It was not clear what would happen if a service user wished to leave the
premises overnight but was physically or practically unable to do so; or that any
consideration had been given to the potential risk of a service user being falsely
imprisoned A member of staff would be in possession of keys but it was not clear
what would happen if they themselves became incapacitated.
The court was told by the manager that Greater Manchester Fire and Rescue
Service were aware of these arrangements and had not raised any concerns This
came as a surprise to the court.
The evidence suggested that the deceased had retired to bed on the evening of 22
November 2017 in the company of her roommate but it was not clear at what time. It
seems that at some time between then and about 0600 on 23 November 2017, the
deceased left her room wearing what was described as a tracksuit and a pair of
shoes, but leaving her coat and other belongings behind. An open kitchen window
was found and when the staff were alerted to this, a search of the premises was
made but the deceased could not be found and it was felt that she had exited the
building through this window.
The manager told the court that it was unknown what contact, if any, the deceased
had had with the male service user who had left a few days before The manager
told the court that previous experience indicated that those who leave the program
suddenly return to their home addresses. Sometimes they may simply leave for a
short period of time to ‘clear their head’ but then return. The deceased did not do so
for a number of hours and contact was made with her mother to explain the situation.
No contemporaneous record was made by the manager of exactly what was said to
the deceased’s mother, but it seems that the family were left to decide whether or
not to contact the Police to report the deceased as a missing person. The manager
also learned that the deceased had managed to be able to withdraw about £300 in
cash from a bank account
Neither the manager nor any other member of staff thought it appropriate to report
the deceased missing to the Police at any time thereafter, even when the deceased
had not returned for at least two days and they had no contact with her, and there
was no indication that the family had had any contact either.
The deceased was clearly a very vulnerable person who was at constant risk of
relapsing into the consumption of drugs with all the attendance risks to her health
and life Leaving suddenly in all the circumstances, bearing in mind her recent
behaviour and the concerns about her presentation, she was at significant risk of
trying to access Illicit drugs as quickly as possible. However, it did not appear that
there were any written protocols, policies or processes used by Victory Outreach in
dealing with this
Overall, it was not clear to the court whether or not the male unit was run on the
same basis or indeed any other premises within England and Wales.
It was established that after the deceased left Victory Outreach, she travelled to
Manchester, which is a short distance away, and managed to make contact with a
known drug user who was a homeless man_ He indicated that he knew the
deceased and that she had purchased from him quantities of illicit drugs. This man
claimed that the last time he saw her, she was clearly acting under the influence of
drugs
At about 1045 on 25 November 2017, an off duty firefighter happened to be passing
close to some derelict land adjacent to Pollard Street East in the centre of
Manchester and saw what appeared to the body of a person lying on the ground He
immediately went to investigate the situation and discovered the deceased to be a
female who was unconscious and unrousable Due to his immediate concerns about
her breathing and pulse, he commenced CPR and called the emergency services.
An ambulance arrived and paramedics took over the care and management of the
deceased. She was conveyed urgently to Manchester Royal Infirmary but had
apparently already suffered one cardiac arrest prior to admission and sadly suffered
another shortly after arrival. She had an unrecordable low body temperature, from
which it was deduced that she must have been outside in the open for some
considerable time before she was found. She was pronounced dead very shortly
after arrival at hospital because attempts to resuscitate her proved unsuccessful
A subsequent post mortem examination and toxicology tests revealed that she had
consumed quantities of Heroin, Diazepam, Zopiclone and Cocaine. The combination
of these drugs can result in profound sedation and a loss of consciousness
Coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action Is
taken. In the circumstances it is my statutory duty to report to you
The matters of concern are as follows.
1 The clear lack of the apparent existence of appropriate protocols, policies,
processes or other guidance to deal with the large number of issues identified
above
2. The lack of an apparent clear and cohesive set of arrangements for seeking
help and guidance from primary or secondary NHS drug/alcohol and mental
health services or seeking advice from the Police about a Missing Persons
Policy
3 Acomplete lack of clarity about when and in what circumstances who leaves
the program should be reported to the Police as being a missing person. Itis
suggested that the deceased would have fallen into the category of a High
Risk Missing Person in all the circumstances and that there should be
established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of
a family to decide whether or not they wish to report an individual as a missing
person to the Police
5 It is suggested that every person who works at either the male or female unit
has appropriate and recognised training for their roles and this is regularly
reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way
elsewhere in England and Wales, a similar program of review identified in
paragraphs 1-5 immediately above should be undertaken.
Action should be taken
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
Your response
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 26 April 2019. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is proposed.
Copies and publication
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons’
- The family of the deceased
{am also under a duty to send the Chief Coroner a copy of your response
1 am also sending a copy for information to:
- Salford City Council Adult Social Services
- Greater Manchester Mental Health NHS Trust
- Greater Manchester Police
- Greater Manchester Fire and Rescue Servicep
- Care Quality Commission
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the coroner, at the time
of your response, about the release or the publication of your response by the Chief
Coroner.
N Meadows N J 27 February 2019
H.M. Senior Coroner — Manchester City area
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Victory Outreach Manchester
Charity Commission
PO Box 211
Bootle
L20 7YX
Date: 13 January 2020
Thank you for the correspondence of December 2019 which has been considered along with the
information provided to the Commission since May 2019.
You should bring this letter to the attention of all the trustees.
As you are aware the Commission opened a Regulatory Compliance case into Victory Outreach
Manchester following receipt of a report from the Coroner’s Office in February 2019 regarding the
death of a resident of the Victory Outreach Manchester Women’s Recovery Home in 2017.
The Commission engaged with the charity from April 2019, and we recognise that the charity has
responded to all requests for information. We also note that the Commission and yourselves have
had contact with several external agencies to address the matters raised in the Coroner’s report
along with issues which subsequently came to light following our interaction with the charity.
Whilst the Commission is pleased that the trustees are, based on the information provided,
addressing the issues of concern, we require the changes implemented by the charity to be
embedded and it is on that basis that the following advice is given.
Trustees are legally responsible for managing, controlling and directing the affairs of their charity.
They must ensure that it is well-run, with serious incidents, including safeguarding incidents,
responded to in an appropriate way. This applies to each of the trustees as individuals and trustees
cannot avoid or hand over this responsibility. As a trustee it is important that you take an active role
in the charity and ensure you perform your duties well, seeking and acting on advice as required.
The steps detailed below are the Commission’s regulatory advice and guidance. If the trustees do
not take these steps, they risk being in breach of their legal duties in the administration of the
Visit www.gov.uk/charity-commission for help
on filing your annual return and accounts
t: 0300 066 9197 (General
enquiries)
0300 066 9219 (Textphone)
On track to meet your deadline?
w: www.gov.uk/charity-commission
charity. We may also regard any failure to act on the advice and guidance as evidence of
misconduct and/or mismanagement.
As previously highlighted, I would ask that you direct any correspondence regarding this case to
me at
quoting the above case reference number.
Regulatory advice
The Commission is providing you with advice and guidance under section 15(2) of the Charities
Act 2011. Although this advice is not a legal direction or order, you are expected to follow it to
comply with your trustee duties to manage the charity effectively. The Commission will consider its
regulatory position if we find that you have not acted on the advice given.
Issue/concern identified
Charity’s response
Action required (date)
1
.
2.
Coroner’s Report
identified concerns
regarding, “the ability of
occupants to leave the
building in the event of
an emergency.”
GMFRS have visited the
property and any
concerns have been
addressed.
Failure to report the
incident to the
Commission as a serious
incident
Recognised that
incidents should be
reported in line with
Commission’s
guidance.
Charity to ensure that it
fully complies with all
requirements regarding
entry and exit to its
properties, including in
an emergency.
(Ongoing)
All serious, including
safeguarding, incidents,
to be reported in line
with
Commission
guidance.
(Ongoing)
Procedure to be reviewed
on an annual basis, and
after any serious incident.
(August 2020 or earlier)
3. Charity advised that the,
“management team did
not inform Trustees when
Janie left and about her
death due to
communication
breakdown at the time of
the incident.”
4.
Lack of clarity about the
type of accommodation
provided by Victory
Outreach
Manchester.
5. Absence of key
policies, including
review dates
Charity confirmed that,
“Communication gaps
have been closed and
that the system as
established is
functioning properly.”
Charity confirmed that
they, “are working on this
… to clear any doubts or
ambiguities which some
people and other
statutory agencies may
have about Victory
Homes.”
Charity provided copies
of revised policies, and
review dates, including
15 to be reviewed by
August 2020.
All material, including
promotional and website
information to be clear
about Victory Outreach
Manchester, and that it
is not a care provider
(April 2020)
Charity to ensure that
policies are reviewed in
line with the confirmed
dates (Ongoing)
Issue/concern identified
Charity’s response
Action required (date)
Page 2 of 3
6. Absence of policy
awareness
Charity advised all
affected persons, “are
required to read through
and familiarise
themselves” with the
policies
Charity to have an audit in
place to ensure all
affected persons have an
awareness of policies
(April 2020)
7. Absence of
comprehensive training
programme
Charity advised that,
“Trustees (have) resolved
to
recommend more
diversified training.”
Charity provided a list of
training to be completed,
including dates for
refresher training.
8. Absence of clarity
about financial
charging for
accommodation.
9. Concerns regarding
accompanying residents
to their GP
Charity provided a
breakdown of charges
and copies of benefit
award
letters
Charity advised that it
was undertaking an
‘awareness raising’
programme with local
GP’s
10. Ambiguity around use of
‘Medication
Administration Record’
Charity confirmed form
renamed to
‘Self-Medication
Monitoring Sheet’
Programme of “diversified
training” to be agreed and
delivered (Agreed May
2020, delivered April
2021)
Training programme
to delivered by
confirmed
dates, and reviewed on
an annual basis
(Ongoing)
Charity to review charges
on, at least, an annual
basis and respond to LA
requests for information
(Ongoing)
Charity to be clear
about when it will, and
will not, offer to
accompany
residents to their GP, and
always respect their
wishes. (Immediately
and ongoing)
Charity to review use of
form (Ongoing)
If there are any significant developments or material changes to the above, including meeting the
deadlines, the trustees should contact us again. It is likely that we will contact the charity in the
near future to ensure compliance. We may also make additional enquiries if we become aware of
new information and this may lead to us considering more formal action.
If you would like, at this stage, to comment on the factual accuracy of the statements made in this
letter and/or the actions required, then please contact me.
Yours sincerely
Case Manager/Regulatory Compliance
Page 3 of 3
RESPONSE TO THE CORONER’S LETTER OF CONCERN DATE: 25/04/2019. –Trustee Chair - Trustee - Trustee - Trustee -Trustee - Senior Pastor - Safeguarding Coordinator BY: - - - - - - - Page | 1 Dear Mr. Meadows, Thank you for your email we received on Wednesday, 27 February 2019, with the attached copies of the following: 1. The Record of Inquest. 2. Chief Coroners Guidance number 5 on prevention of future deaths. 3. Prevention of Future Death report (PFD). 4. Letter of Concern written under Paragraph 37 of Guidance number 5 above. i) INTRODUCTION Janie McFadyen (deceased) died on the 25th November 2017 after which you opened an inquest which was concluded on the 26th February 2019. The deceased was once a resident in our female Non-Medicated Sober Living Facility with no detox, address number 216 Worsley Road Swinton M27 5YF, who left the Home on the 23rd November 2017. We understand the concerns you have raised and they have been looked into carefully. Please find our response to the concerns, changes that have occurred and policies and procedures that Victory Outreach Manchester - Victory Homes now have in place. In addition a copy of a similar incident that took place and how the trustees and management of Victory Homes dealt with the situation, demonstrating how Victory Homes’ new policies and procedures are working. First of all, this is who we are: ii) WHO WE ARE Victory Outreach Manchester is a charitable incorporated organisation registered in England and Wales with charity registration number 1167670. The charity runs a Non-Medicated Sober Living Facilities with no detox, loosely referred to as “Recovery Homes”. The facilities are Fellowship Homes providing safe, comfortable Christian family living environment for men and women who willingly come to our homes after they meet the admission criteria and an initial intake procedures completed. The men and women are unrelated but live as a family, helping each other to live Christian lives, free from drugs and other substances they were addicted to. The purpose for running a non-medicated Christian living facility is to reclaim, redeem, and restore lives that have been destroyed or disrupted by drugs, alcohol and or other substance abuse by establishing three essential values; - A commitment to Christ. - Restoration of the family values. Page | 2 - And a positive and progressive work ethic. Victory Outreach Manchester’s non medicated Christian living facilities for men and women also called “Recovery Homes” are not care homes or rehabilitation centres and hence NOT regulated by the Care Quality Commission. We do not receive statutory grants from the government or employ the services of detoxing medical experts to treat residents living in our facilities, except the normal attendance to GPs and other agencies if the residents need their support when necessary. Victory Outreach Manchester and it’s non-medicated Christian living facilities are regulated by the Charity Commission. iii) HOW WE OPERATE The concept came from United States of America, the headquarters and home of Victory Outreach International. Hence there is an Operational Manual from America which contains the Policies and Procedures by which the “Victory Homes International” as it is called in America are run. The Policies and Procedures that are found in the manual are a compilation of years of practical hands-on experience, which has been proven to be successful; comprised of the Programs and Training Committee, Working Groups and Teams. The Manual’s fundamental dynamics and three regenerating values are integrated throughout the manual: - - Instituting holistic habitation in Christ, “Cause, Community, Corporation” (3C’s), “Exaltation, Envisioning, Evangelism, Establishing, Equipping” (5E’s) - And “Faith, Family, Work” (3 essential values). If a situation in ministry arises that the manual does not directly address, and we are not clear on what we should do or what the procedure is, we are guided by the Charity Commission regulations and standards of safeguarding and the UK law. And also we call and discuss the issue with the Victory Homes International Administrative Office in America for assistance, support and advice where necessary. Victory Outreach Manchester’s Non-medicated Christian living facilities follow this document and its concept - Christian-based approach to meet the individual needs of the men and women when they are in the Homes. We provide a safe, and supportive service and a place to live, encouraging independent living, promoting a sense of belonging and dignity. In addition teaching them to remain free from addiction. And be built into the mighty men and women that God called them to be within the communities they live. Page | 3 In addition, Victory Homes acknowledges the importance of the UK’s national guidance and seeks to comply in all respects with current safeguarding legislation and regulations of the Charity Law 2011. We also follow current laws and regulations relevant to what we do through our policies and procedure such as: - Health and Safety Regulation including Fire Safety - Safeguarding vulnerable people - Volunteers Management - Complaint Handling - Conflict of Interest - Risk Management Our philosophy is: - The development of character and positive work ethics. - To promote personal integrity, responsibility and accountability. - To instil within our residents a sense of dignity, belonging and destiny. Programmes We Offer We offer a 9 – 12 months residential programme, followed by 3, 6, or 12 months personal growth tracks also called “discipleship programme”. This includes:- - prayer, - Bible studies, - Signposting to further education classes, - Life skills training through volunteering opportunities. - Employment and rehousing advice for the residents. - Participating in community life and leisure activities. Agencies and Relevant Stakeholders Victory Homes partner with - Medical and Health Care: - Local GP Practices, Hospitals, Dentists within the catchment area. - Legal Aid Services: - Probation officers appointments, Citizen advice - Security Services: The Police where necessary and Fire Services - Local Authorities: - Salford City Council and Manchester City Council - Education & Training Services: - Salford City College - Advisory Services: - Stewardship Consultancy Helpline and other private solicitors.. Page | 4 Victory Homes also have working relationship with the following local agencies to support Residents when needed - Cheshire & Greater Manchester Community Rehabilitation Company ( 0161 451 5350) - Step Together Volunteering – Transforming Lives through Volunteering (07912 842477) - The Goodman Centre for Sexual and Reproductive Health Churchill Way, Salford M6 5QX ( 0161 206 1099) - Salford Community Dental Service – Pendleton Gateway 2nd Floor, Pendleton Gateway, 1 Broadwalk Salford, M6 5FX (0161 206 1513) - Reach - Christian Counselling 85A Allerton Rd, Liverpool L18 2DA (0151 737 2121) - Other Christian Organisations: - The Message Trust, Prayer Storm, Greater Manchester Churches Together. Number of Facilities Currently in Operation We have four (4) facilities in operation, these are: - 83 Lower Seedley Road, M6 5WP – 5 bedrooms House as the Men’s Victory Home - 6 Nadine Street, M6 5WG –5 bedrooms House as Men’s Discipleship Victory Home (Phase 2) - 216 Worsley Road, M27 0YF – 4 bedrooms House as the Women’s Victory Home - 275 Worsley Road, M27 0Y – 6 bedrooms House as Women’s Discipleship Victory Home (Phase 2) How each Victory Home operates (Dynamic) The Men’s and Women’s Victory Homes are different from the Men’s and Women’s “D” - Homes. Victory Homes concept operates as a Houses In Multiple Occupancies HMO/Shared House as the individuals who live in them are not related but share the house as if they are a related family. In a way we are related as all the people in the Homes are Christians at different levels of maturity and understanding. The individual rooms are not locked to promote that family element of trust and interdependence. Page | 5 216 Worsley Road Swinton M27 0YF (women only) and 83 Lower Seedley Road Salford M6 5WP (men only) - HMO licencing - Operate as a Shared House and work directly with residents in their efforts to remain sober. - A 12 months recommended time spent in Home programme supported and run by Home Overseers (Paid by the Church Charity) (previously called Home Directors) 275 Worsley Road Swinton M27 0YE (women only) and 6 Nadine Street Salford M65WG (men only) Discipleship (D) - Homes - HMO licencing - Operate as a Shared House – Independent Living - Is a place where people in the church live in as a community. - Some residents (People from the church) rent the rooms, live their independent lives, take care of their own living and usually have full or part time jobs and voluntary jobs. - Residents who complete the 12 months recommended time spent in Home programme as stated above have an option of where they want to go. If they choose to rent this facility and take part in our phase two (reintegration programme) they are supported to do so. - There are Home Leaders (Voluntary not Paid by the Church Charity), (Previously called Home Directors) who run this facilities and also rent rooms in this facilities. Page | 6 iv) TRUSTEES AND SENIOR LEADERSHIP - OUR FINDINGS AND WHAT HAVE CHANGED - FINDINGS Trustees have looked into this incident and can confirm that there was no formal investigation conducted as per the Home Overseer’s (Director) account, a copy of this document can be found in the Victory Homes Supporting Document File content list number 4. In the case of the deceased, Victory Homes management team did not inform Trustees when Janie left and about her death due to communication breakdown at the time of the incident. Even though the Victory Homes Management Team did not inform Trustees when Janie passed away; they were in touch with her family when she went missing and upon news of her death (of which the Victory Homes Management Team only knew of two days later), worked closely with the family to arrange the subsequent funeral proceedings of which pastoral/ministerial team was sent to officiate the ceremony. Residents close to the deceased and the Victory Home Overseer representatives were sent to the funeral ceremony. Trustees only became aware as a result of the Coroner’s inquest report and as over a year had already passed since the actual incident occurred, we decided not to report it as a serious incident but informed the Charity Commission on the 30th March 2019 in an email communication. Trustees considered two factors in arriving at this decision: 1. The deceased died in the hospital and not in the Home. 2. Much time had already elapsed since the incident. Please read below an account of , Victory Homes representative regarding what they did when the news of Janie’s passing away came through and the subsequent funeral and burial on Monday 18th December 2017:- Page | 7 AN ACCOUNT BY “As the Victory Homes team we had a substantial amount of involvement with the funeral of Janie Mcfadden. Home Overseer- had offered our support to Anne (deceased mother), asking if there was anything we could help with before or on the day of the funeral. A group of 10 people from our Victory Homes team were in attendance including Pastor who officiated and residents at that time who had been close with Janie during her stay at Victory Home. had built a positive relationship with the Home Director (Home Overseer) and asked her to support by writing a eulogy. Due to a prior commitment of Home Directors (Home Overseers) training in San Jose America was unable to attend the funeral but wrote a eulogy to be read out by on the day. assigned to attend with some of the residents. I myself have been a Home director (Home Overseer) and would be considered a trusted member of staff with appropriate DBS checks. (deceased mother) was also in communication with (a member of the Victory Homes Management Team) and she asked that he would officiate the funeral and arrange the eulogies for the day. They also requested songs that Janie had spoken about during her stay at Victory Homes. We were received warmly upon arrival and family members spoke of Janie's time at the Victory Home as being some of the best that they had seen her in many years. They expressed love and gratitude for what we (Victory Homes) had been able to do before Janie made a decision to leave the Victory Home. The funeral took place at a crematorium in Ayr and the time with family after took place at Kincaidston and Belmont Bowling club. It was here we (Manchester Victory Homes representatives) had more time to connect with other family members and share stories of Janie's time with us. There was no point that I recall of us being received with anything other than warmth and love. There are a couple of team members that have a relationship with the family and have stayed in contact with who is Janie's mother since the funeral and have had no negative interactions to my knowledge”. Page | 8 - IMPROVEMENTS AND CHANGES MADE Meanwhile, since the Coroner's’ Report, there have been improvements and changes in regard to developing certain processes and procedures important in maintaining a high level of accountability , safeguarding, improved channels of communication and the reporting structure and its mechanisms. Trustees have since being working relentlessly reviewing, amending and updating protocols, policies and procedures of the Victory Homes based on the relevant safeguarding regulatory framework in compliance with charity law requirements and other laws that apply to our charity alongside the Victory Homes Manual. Since the receipt of the Coroner’s Inquest report, Trustees can confirm that all communication gaps have been closed and that the system as established is functioning properly. As a life transforming and successful charity in what we do, working across Salford and Manchester, supporting the vulnerable, families, people misusing substance, prostitutes and all shades of members of society, we are working relentlessly as a trustee team with the Police, Fire Service, the local authorities and all relevant regulatory bodies to ensure that these lapses do not happen again. LIST OF IMPROVEMENTS AND CHANGES: 1. Policies and Procedures as detailed in the table below and copies of these can be found in the Victory Homes Supporting Document File content list number 2. Number Policies and Procedures 1 2 3 Safeguarding Adult Policy/Incident Reporting Form Missing Person Policy and Procedure/Missing Person Profile Medication Control and Administration Policy. GP Prescription Only Medicines (POM). 4 Eligibility Policy and Procedures Page | 9 5 6 7 8 9 10 11 12 13 14 Whistleblowing Policy Managing client's health procedure, Managing withdrawal symptoms, Managing mental health and Welfare check procedure. Chaperones Policy - Taking a resident to an appointment and other visits in the community. Drug Testing Policy and Procedure. Fire Evacuation Procedure. Left Luggage/ Belongings Policy - After 28 days. Victory Homes Cash Handling Procedures Communicable Diseases and Infection Prevention and Control Policy - HIV/AIDS Safe Handling and Disposal of needles and syringes Procedure Volunteers Management Policy These policies and procedures will be reviewed and amended every 6 months or earlier when necessary and others will be created when the need arises. 2. Residents Files have been reviewed, amended and updated as detailed in the table below: Copies of these can be found in the Victory Homes Supporting Document File content list number 3. Initial intake form Residents licencing agreement letters Support plan, withdrawal from substance agreement form, risk assessment. Daily notes Welfare check Medical and health appointment forms Mar sheet, medication checklist, residents self-medication assessment Page | 10 Drug testing consent form, drug testing result record form Personal belonging inventory PEEP (Personal Emergency Evacuation Plan) where necessary. Missing Person Profile/ Completed Incidents forms Image authorisation Form and Data Protection/confidentiality authorisation form Finances Feedback Forms Departure forms Below are other relevant documents being implemented and are not included with the supporting documents as they are still under review. - Resident’s quality service surveys forms 3. Relevant Mandatory Trainings: Our Home Overseers attend a specific Victory Outreach training at the URBAN TRAINING CENTER (UTC) Leadership Training before they are employed. They are trained either at America or South Africa or at any other location of choice by the Home Overseer. The course/training runs for 6 months to a year. They are issued a certificate of graduation at the end of the training. For more information on this please see the link below: http://victoryoutreach.org/connect/urban-training-center/utc-south-africa/ http://victoryoutreach.org/connect/urban-training-center/ In addition to the above Specific Training for the Home Overseers, there is a mandatory training for them as well as the Home Leaders (Volunteers who do not need to go to UTC) , please see table below. The Home Overseers and Home Leaders are supervised and advised to undertake relevant and applicable free online trainings which are verified by the Victory Home Management team. Page | 11 List trainings being done Training Training Provider Date completed Date to be Completed Urban Training Center (UTC) Leadership Training West Coast UTC Los Angeles September 2012 to March 2013 Children and Young People Safeguarding Basic Awareness Training First Aid Training Griffin Care Limited 7th May 2018 Tutorcare Limited Spectrum House,Beehive Ring Road, Gatwick,RH6 0LG 7th September 2018 Email: info@tutorcareltd.co.uk Fire Safety - Marshal Training http://www.ukfiretraining. com/ 20th August 2018 Meridian House, Saxon Business Park, Hanbury Rd, Stoke Prior, Bromsgrove B60 4AD Monitoring and Evaluation Salfordcvs.co.uk 24th April 2019 Medication Awareness Training Training being sorted Page | 12 Adult Safeguarding basic Awareness Training (Specific) Adult Safeguarding basic Awareness Training (Specific) Salfordcvs.co.uk 22.05.2019 Salford CVS Training Salfordcvs.co.uk 10.07.2019 Salford CVS Training Emergency First Aid at Work TutorCare. 01/06/2019 Food Safety Awareness TutorCare. 25/05/2019 Fire Safety Awareness and Practical Fire Extinguisher TutorCare. 25/05/2019 There is a continuous supervision and meetings that are scheduled with the Victory Homes Management team to ensure they are up to date with all trainings and where refresher training are due they attend. 4) Victory Homes Chain of Reporting To promote an effective channel of communication between all parties involved, the following reporting channel is in place: Home Overseers and Home Leaders reports to: 1. Trustee (Designated Person: Stella Worwui-Ashiadey) 2. Victory Homes Management team (Pastoral and Leadership Team) 3. Safeguarding Coordinator 4. Other Trustees 5. The Senior Pastor (CEO) Page | 13 V) CONCLUSION In conclusion, Trustees and senior leadership of Victory Outreach Manchester and the Victory Homes management team want to assure you that we have investigated this matter and the findings highlighted gaps in communication and hence impacted the manner this incident was managed at the time. Going forward, we have taken on board the concerns you raised and have accordingly worked tirelessly to review our policies and procedures to reflect the necessary current regulatory changes to make our Homes fully compliant. Perhaps, it may interest you to know that since your report, we have experienced a similar incident when one of our residents went missing on 8th April 2019. We have included a copy of this incident and how it was managed for your perusal. This also comes to show you that your feedback from the inquest has been taken on board and has had an impact in our processes. Copies of this document can be found in the Victory Homes Supporting Document File content list number 5. Due to data protection regulation and confidentiality names have been covered. Victory Outreach Manchester Victory Homes have contributed some significant life changes in the lives of people from the background of drug addiction and their lives have been turned around and they are achieving and impacting other people’s lives over the years. Copies of these success stories can be found in the Victory Homes Supporting Document File content list number 6. Yours Faithfully, On Behalf of Trustees ( Victory Outreach Manchester (Charity Number 1167670) 19 Liverpool Street, Salford, M5 4LY Email: trustees@vomanchester.org Page | 14
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