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.

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- 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.

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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..

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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.

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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.

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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:-

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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”.

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- 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 Safeguarding Adult Policy/Incident Reporting Form 2 Missing Person Policy and Procedure/Missing Person Profile 3 Medication Control and Administration Policy. GP Prescription Only Medicines (POM). 4 Eligibility Policy and Procedures

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5 Whistleblowing Policy 6 Managing client's health procedure, Managing withdrawal symptoms, Managing mental health and Welfare check procedure. 7 Chaperones Policy - Taking a resident to an appointment and other visits in the community. 8 Drug Testing Policy and Procedure. 9 Fire Evacuation Procedure. 10 Left Luggage/ Belongings Policy - After 28 days. 11 Victory Homes Cash Handling Procedures 12 Communicable Diseases and Infection Prevention and Control Policy - HIV/AIDS 13 Safe Handling and Disposal of needles and syringes Procedure 14 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

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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:

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.

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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 Griffin Care Limited

7th May 2018

First Aid Training Tutorcare Limited Spectrum House,Beehive Ring Road, Gatwick,RH6 0LG

Email: info@tutorcareltd.co.uk

7th September 2018

Fire Safety - Marshal Training

com/

Meridian House, Saxon Business Park, Hanbury Rd, Stoke Prior, Bromsgrove B60 4AD

20th August 2018

Monitoring and Evaluation Salfordcvs.co.uk

24th April 2019

Medication Awareness Training Training being sorted

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Adult Safeguarding basic Awareness Training (Specific) Salfordcvs.co.uk

Salford CVS Training

22.05.2019 Adult Safeguarding basic Awareness Training (Specific) Salfordcvs.co.uk

Salford CVS Training

10.07.2019 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)

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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.

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 Coroner’s Report GMFRS have visited the Charity to ensure that it . identified concerns regarding, “the ability of occupants to leave the building in the event of an emergency.” property and any concerns have been addressed. fully complies with all requirements regarding entry and exit to its properties, including in an emergency. (Ongoing)
2. Failure to report the incident to the Commission as a serious incident Recognised that incidents should be reported in line with Commission’s guidance. All serious, including safeguarding, incidents, to be reported in line with Commission guidance. (Ongoing)
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.” Charity confirmed that, “Communication gaps have been closed and that the system as established is functioning properly.” Procedure to be reviewed on an annual basis, and after any serious incident. (August 2020 or earlier)
4. Lack of clarity about the type of accommodation provided by Victory Outreach Manchester. 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.” All material, including promotional and website information to be clear about Victory Outreach Manchester, and that it is not a care provider (April 2020)
5. Absence of key policies, including review dates Charity provided copies of revised policies, and review dates, including 15 to be reviewed by August 2020. Charity to ensure that policies are reviewed in line with the confirmed dates (Ongoing)

Issue/concern identified Charity’s response Action required (date)
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. 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)
8. Absence of clarity about financial charging for accommodation. Charity provided a breakdown of charges and copies of benefit award letters Charity to review charges on, at least, an annual basis and respond to LA requests for information (Ongoing)
9. Concerns regarding accompanying residents to their GP Charity advised that it was undertaking an ‘awareness raising’ programme with local GP’s 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)
10. Ambiguity around use of ‘Medication Administration Record’ Charity confirmed form renamed to ‘Self-Medication Monitoring Sheet’ 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.