Inspection on 18/07/06 for Falkner Square 12

This inspection was carried out on 18th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Falkner Square 12 23/04/08

Falkner Square 12 21/08/07

Falkner Square 12 03/03/06

Falkner Square 12 24/11/05

Falkner Square 12 07/01/05

Falkner Square 12 17/02/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Falkner Square (11/12) 11/12 Falkner Square Toxteth Liverpool Merseyside L87NU Lead Inspector Lesley Owen Unannounced Inspection 18th July 2006 09:30 Falkner Square (11/12) DS0000025344.V331128.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 Falkner Square (11/12) DS0000025344.V331128.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. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Falkner Square (11/12) Address 11/12 Falkner Square Toxteth Liverpool Merseyside L87NU 0151 708 5891 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) www.peterhouseschool.org Autism Initiatives *** Post Vacant *** Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 11 learning disabilities (18-65 years) and 1 named young person with a learning disability under the age of 18 years. That the registration reverts back to 12 persons with a learning disability (aged 18-65) on 19 December 2002. 3rd March 2006 Date of last inspection Brief Description of the Service: 11 and 12 Falkner Square is a care home registered with the CSCI to provide accommodation and care for up to 12 adults with a learning disability. The home is part of a network of homes managed by Autism Initiatives. 11 and 12 Falkner Square is situated in the Toxteth area of Liverpool and is close to local amenities, bus and rail routes. 11 and 12 Falkner Square are separate units, which are both accessible via doorways from the main street. 11 Falkner Square is currently an assessment facility for young adults with Aspergers Syndrome. 12 Falkner Square provides care for young adults with Autism. Briefly, the building comprises of three floors with the ground floor providing kitchen, W.C, office and communal space and the first and second floors providing service users’ bedrooms, bathing, W.C, and staff sleep in facilities. The laundry provision is located in the basement area. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit began at 11am and took place over 8 hours. The acting team leader at 11 Falkner Square was on duty at the time and the team leader for 12 Falkner came on duty later in the day. At the time of the inspection their were 9 people resident within the two houses, however not all were in the building as a number of service users were at daycentre or out with staff. The inspector spoke with both team leaders and four members of staff during the time at the home. A second site visit was made on the 21st July all relevant documents for residents and staff were viewed and a sample of maintenance records were seen. In addition the manager completed a preinspection questionnaire which provided the inspector with additional information and a record of training undertaken by staff was forwarded. What the service does well: What has improved since the last inspection? The home has continued to reduce the number of hours agency staff work and a number of new support staff have been recruited since the last inspection. The majority of the requirements in relation to the environment at 11 Falkner Square have been acted upon. Approval has been given for the outstanding Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 6 work in relation to the house to be carried out, although no date had been given at the time of the inspection. Dates have been provided for two staff to undertake training in positive intervention and for three staff to undertake training in the protection of vulnerable adults. A number of staff have begun NVQ training. 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. The summary of this inspection report can be made available in other formats on request. Falkner Square (11/12) DS0000025344.V331128.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 Falkner Square (11/12) DS0000025344.V331128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Prior to prospective service users moving into the home, a full assessment is undertaken either by the organisation or the placing authority. EVIDENCE: Since the last inspection discussions have been taken place with both current users of the service and staff in relation to changing the service provided at 11/12 Falkner Square. To date due to the individual circumstances all the service users who were living at 11 Falkner Square have all moved to different resources. As a result of this as an interim measure number 11 is currently providing respite care for younger adults with a learning disability, not assessment for younger adults with Aspergers. The service user group at 12 Falkner Square remains the same. In relation to 12 Falkner Square, there have been no new admissions to this unit for approximately eighteen months. During previous inspections the assessments were found to be acceptable with a service manager from the organisation undertaking an assessment of the person’s needs prior to them being admitted to the unit. The assessment was then used as a basis for the initial care planning. In relation to 11Falkner Square the assessment documentation held for the last person admitted to the unit was examined and the assessment procedure Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 9 discussed with the acting team leader. Prior to their admission the acting team leader and a support worker visited the prospective service user and met with the staff group who were then providing support, the persons social worker and community nurse in order to ensure the service could meet their needs. The information available on file included a full care assessment undertaken by the placing authority, information from a language therapist, from staff who supported the service user in their previous placement and risk assessment documentation. The staff at the home then used the assessment as a basis for compiling the initial care plan. From discussion, staff at the home have not always had the opportunity to meet prospective service users prior to placement, it has been dependant on the circumstances surrounding the admission and has in a number of instances involved the social worker for the prospective service user visiting the unit prior to placement. Where possible it is recommended that staff meet the prospective service user prior to placement. The range of fees for each service user is dependent upon their level of assessed need, as a number of care packages include additional one to one support. Additional charges are made for holidays, chiropody, hairdressers, toiletries, horse riding, music therapy and social activities, this information was provided in the pre-inspection questionnaire. Falkner Square (11/12) DS0000025344.V331128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Care plans were in place to ensure the individual needs of service users are met. Service users were being supported as individuals and activities chosen to meet their particular needs. Risk assessments were in place to support work with service users and managed in such a way as to maximise independence. EVIDENCE: A named key worker system is operated in both houses. At 11 Falkner Square from the service user’s individual care plan, each area that the service user requires support/assistance with e.g. maintaining personal hygiene, their morning routine is broken down into tasks which assists service users to maintain and develop skills and routines and ensures that staff meet the individual service user’s needs. These plans are then reviewed six weeks after admission and a review with a social worker from a placing authority was taking place for one service user during the second visit to the service. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 11 At the time of the inspection care plans for service users at number 12 were being reviewed and support plans drawn up. As the service provided is long term reviews are held every six months. An annual review is also held which would involve the service user where possible, their family and social worker and during these reviews long term goals and future plans are considered. The team manager confirmed that long-term plans have been made for all the service users living at the unit. During internal monthly reviews any changes in service users needs and practical issues are addressed. Where any limitations or restrictions are placed on the service user they are agreed via the care planning process and are only made when it is in the persons best interests and following risk assessment. From discussion with the team leader and staff it is clear that service users are involved in decision making and supported in areas such as choosing holidays and activities. Risk assessment and risk management are addressed within individual care plans and behaviour management guidelines are provided for staff. From discussion staff are aware of individual service users needs and work hard at balancing the service user’s need for privacy and independence whilst maintaining their safety and this is reflected in the individual arrangements in place for each service user. Falkner Square (11/12) DS0000025344.V331128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15,16 & 17 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The individual interests of service users are promoted whilst maintaining their safety. The staff team ensure that individual service users are offered opportunities to take part in a range of activities, including household tasks, which develop skills and promote independence. EVIDENCE: The service users living in both units have complex needs, including specific communication needs and challenging behaviour. At the time of the inspection in number 11 two service users were out of the house attending day centre which they do on week days. The other service user in the unit was supported at home by staff and spent a great deal of time outside in the walled area at the back of the house. A number of service users in number 12 were out with staff on an outward bound day and did not return to the unit until teatime. Individual service users are supported to take part in a variety of activities and in number 12 have Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 13 weekly activity charts that are completed with the service user at the beginning of the week and provide details of planned activities for the week. The home has its own vehicle provided by the organisation, which is used frequently to take service users out. Staff rotas are arranged to enable at least one service user to undertake an individual activity with staff each day and one shift each week is designated as keyworker time for staff with service users. Rotas also reflect where service users require the support of two staff. Where possible service users access community facilities, however due to the complexity of certain service users needs and the challenging behaviours that may be presented at times, staff can be placed in difficult situations whilst support is being given in a community setting. At the time of the last inspection it was recommended that staff carry contact cards that could be given to members of the public should they be affected by service users behaviour and this is being explored. During the inspection staff in number 12 were observed supporting individual service users to participate in the day-to-day routines in the unit wherever possible. All participation in daily routines for service users is dependent on the individual service user’s mood and staff are provided with guidelines to advise when and how to approach people. Household activities are arranged around the needs of the people living at the home and there are guidelines and protocols for supporting individuals. Life in the home revolves around the service users and although staff need to be aware of where service users are at all times, they work hard to give them as much privacy and independence as possible, whilst maintaining their safety. There is a range of communal space within the home, which, allows for individuals to spend time alone should they choose to do so. Staff on both units support service users to maintain contact with family and friends, many of whom particularly at number 12 live some distance from the home. All contact with family and friend is recorded and in number 12 significant dates such as birthdays are recorded. The service has operated from Falkner Square for twelve years and the team leader said that service users were known in the area. As a number of the service users have lived at number 12 since the service opened they are familiar with the area. Meals for service users in both units are prepared by staff with help from the service users who are able. Each unit has its own routine and at Number 12 a number of service users have specific arrangements in place for meal times i.e. one person has their meals on their own. Food preferences are recorded and meals are varied taking into account service users likes and dislikes. Records are maintained of food provided. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 14 Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 The quality in this outcome area is good. The judgement has been made using available evidence including a site visit to the home. Care plans give clear guidance to staff to assist service users in the way that meets individual needs. Medication practices are within a safe framework and arrangements are put into place to ensure that service users healthcare needs are met. EVIDENCE: All the service users at 11/12 Falkner Square require varying levels of support with maintaining personal care and how this is provided is clearly laid out in their personal support assessment. Files seen confirm that individual guidelines and routines are in place. All personal care is provided in service user’s bedrooms or in the bathrooms/ toilets. Service users are supported to choose their own clothes where possible. Times for going to bed and getting up are flexible according to the needs and preferences of the individual. However during the week this maybe dictated for service users who go to day centre. During the inspection the inspector was able to observe staff supporting service users and good working relationships have been developed. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 16 All service users have access to primary health care and members of staff always take service users to their appointments. Arrangements are in place or are put into place for service users to access the services of a doctor, an optician, dentist and other health care professionals. Records are kept of all appointments. A medical assessment is completed for each service user, which provides staff with a medical history. Staff work closely with health care professionals and at the start of the inspection a community nurse was at the home discussing assessments with the acting team leader. The organisation also has a clinical team to give staff advice and support. Medication in the home is currently dispensed by staff, as all service users are unable to administer their own. Prescriptions obtained are faxed through to the pharmacy and the originals are sent on. When medication is delivered to the home, it is booked in and signed for. Medication on both units is stored in a medication cabinet in a locked room. Medication given is recorded on Medication Administration Record (MAR) sheets and those seen were completed satisfactorarily. Any medication returned to the pharmacist is recorded and signed for. Patient information sheets were available. Medication is only administered by staff who have received training. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Policies and procedures are in place to protect and promote the rights of service users. Additional training on the protection of vulnerable adults is needed to ensure the protection of service users EVIDENCE: The organisation has a complaints procedure that covers all areas of making a complaint and includes timescales. However it is unlikely that any of the service users currently at 11-12 Falkner Square would be able to register a formal complaint using this procedure without assistance. As all the service users have communication difficulties the service users individual key workers talk to and observe their behaviours. Staff also use non verbal communication such as Makaton, symbols and facilitated communication to find out if service users are unhappy with anything The pre-inspection questionnaire received indicates that the home has received no complaints since the last inspection. One concern was raised with Commission which was addressed with the service manager for the home. Any complaints made are recorded. The home also has a copy of the Autism Initiatives comment, compliment and complaints brochure. The home has a copy of Liverpool City Council’s procedures in relation to adult protection for reference. The company has a designated adult protection coordinator and appropriate policies and procedures are in place in relation to Whistle blowing and dealing with aggressive behaviour. Issues relating to adult Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 18 protection are covered during induction for new staff. Information in the training matrix confirmed that not all staff have received training in relation to the protection of vulnerable adults/ service user protection although this has been a requirement in the last two inspections. The training matrix also confirmed that at Number 11three staff have received training in positive intervention 1, and 2 of those have completed the training positive intervention 2, the third person has a place to complete this training later in the year, a fourth member of staff has been booked on this training later in the year. Five of the 8 permanent members of staff at number 12 have undertaken positive intervention training. New staff do not undertake this training until they have successfully completed their probationary period. The organisation have a policy in relation to the management of service users money and financial affairs. Currently no service users are able to manage their own finances. Records are kept of any monies held or spent on behalf of the service user and these records are checked at the end of each shift. Any monies held in the units were not checked during this inspection. Where service users have building society books, these are kept at head office and a countersignatory is required before any money can be withdrawn. Random checks on monies held are carried out by staff from the organisations head office and the inspector informed the last one was on the 13/7/06. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26, 27, 28 and 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a sit visit to the home. The environment in number 11 has improved since the last inspection but additional work is required. The proposed decoration in number 12 needs to be completed in order to provide service users with comfortable surroundings. Provision must be made to ensure that the furnishing and décor in both units are adequately maintained at all times. EVIDENCE: A tour of both 11 and 12 Falkner Square was carried out in order to monitor the progress made since the last inspection, in meeting the requirements made in relation to the environment Number 11 The carpet in the corridors had been cleaned and the worn areas on the landings had been replaced. The lounge, dining room, hallways and stairwells had been painted. The shower room tiles had been fixed and the room has been decorated. A new cooker had been fitted and the kitchen ceiling repaired. 3 of the 6 bedrooms had been repainted. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 20 The top floor bedrooms were not occupied but would need to be upgraded before they are used. The carpet in the back bedroom on the first floor requires replacing, the arm of the settee in the dining room is badly damaged and the foam exposed, this should be recovered if this is not possible then the settee should be replaced. Number 12 The dining room has been painted, new kitchen units have been installed and a new cooker has been fitted. The back bedroom on the 2nd floor has been painted, the damaged ceiling in the 1st floor back bedroom has been repaired, the expel air cleaned and the missing washbasin door replaced. The lounge and corridors still require decoration, the first floor corridor carpet has some staining and an iron burn, the vanity unit in C’s room needs replacing and the drier in the laundry, which was repaired, has broken again. The dining room floor is badly marked and should be replaced. Staff are to decorate the three bathrooms in the house. The majority of the work identified work in relation to number 11 has been completed, it is understood that all outstanding work in number 12 has been approved and they are waiting for a date for the work to be done. An on-going maintenance and decoration programme should be implemented to ensure both units are maintained to a good standard. The domestic post at number 12 is still vacant and as the service provided at number 11 has changed to providing a respite service, consideration should be given to providing domestic support on the unit. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Recruitment procedures provide protection for service users. All new staff receive induction training, records indicate that mandatory training is not always renewed at the appropriate intervals and specialist training provided to ensure staff can meet the needs of service users. EVIDENCE: Although 11/12 Falkner is registered as one service the two houses operate as separate units, have dedicated staff groups and separate staff rotas, although on occasion there is some interchange of staff. The resident group at 11 Falkner Square has changed completely since the last inspection when it was an assessment facility for young adults with Aspergers syndrome. The unit now provides a respite service for young adults with a learning disability. 12 Falkner Square provides a service to younger adults with Autism and the resident group remains the same as their have been no new admissions to the service. From information provided 11 Falkner Square currently has a vacancy for a team leader and a deputy team leader, five new support staff have been recruited since the last inspection and are in the process of completing induction training. 12 Falkner Square has a vacancy for a deputy team leader, Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 22 part time support worker and a domestic post, two new support staff have been recruited since the last inspection and are in the process of completing their induction training. At the time of the inspection agency staff were not being used except in an emergency. The organisation provides the home with a training programme and staff are nominated to undertake the various training courses. Training records provided confirmed that not all staff had undertaken the required mandatory training and that training was not being up dated at the appropriate intervals. Records also indicate that limited specialist training had been undertaken. A training programme should be drawn up for all staff to address areas where they require training and that clearly identifies the dates when training should be renewed. Since the last inspection some progress has been made in relation to NVQ training and a number have been enrolled on the course. Information in the pre-inspection questionnaire confirmed that in both staff groups two people have obtained NVQ 2 or above. The recruitment records for two new staff employed in each house were viewed at this inspection. The records available included a completed application form, two written references and either an Enhanced Criminal Records Bureau check had been received or a POVA first check had been obtained prior to the member of staff beginning work. Induction training is provided and is comprehensive. Team leaders currently undertake responsibility for the induction training and have a specific induction pack that the new employee works through. The induction process is completed over a period of six months and covers a number of modules including the building, health and safety issues, direct work with service users and service specific issues. As part of their induction new members of staff shadow an experienced member of staff for two weeks and this was confirmed during discussion with a newer member of staff on the day of inspection. The inspector was informed that staff are only confirmed in post after satisfactorarily completing their induction and probationary period. Records are held of staff supervisions undertaken, but from discussion with the acting team leader is not being provided for all staff at the appropriate intervals, this should be addressed. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. A manager must be appointed to provide staff with clear guidance and support and to ensure that the service users rights and best interests are promoted. EVIDENCE: After the last inspection interviews were held and a new manager appointed unfortunately this person did not take up the position and the service still does not have a manager. One team leader is in post in number 12 and there is an acting team leader in number 11. Both team leaders should have deputy managers, however three posts are vacant as one deputy is at present acting team leader. Both staff residents and their families/representatives are aware that the service provided at 11/12 Falkner Square is to change in the future and it is the organisations aim to provide a service to young adults with mental health/ learning disabilities. Reviews have been held with all families/ representatives to look at future plans for residents but as yet there is no date Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 24 set for any changes to be implemented. In the interim a new service manager has been appointed for the service and is providing the team leaders and staff with support. The new service manager undertakes the monthly visits to the home on behalf of the registered provider and forwards copies of these reports to the Commission for Social Care. At present residents meetings are not held in either of the houses, as residents would not be able to attend such meetings and communicate their own issues or concerns. Each resident has a key worker who advocates on their behalf and during the inspection one resident with his key worker was able to communicate with the inspector using facilitated communication. The organisation has a service users consultative Committee, however there are no representatives from Falkner Square on this committee. Autism Initiatives has its own Quality Assurance section, and random visits are made to services. A resident/service user profile is also completed annually to gather the views of service users with the questionnaires being sent to relatives. Autism Initiatives have the Investors in people award. A random sample of maintenance and safety certificates were inspected as part of this visit. These included gas safety which was inspected on 5/4/06, electrical wiring which was inspected on the 24/1/06 but no certificate was available, this should be obtained. All records relating to fire safety except the fire risk assessment were up to date. The fire risk assessment should be reviewed yearly as should the risk assessments related to COSHH. Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 X X 2 x Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 18 Requirement The registered person must continue to make adequate arrangements in order that all staff receive appropriate and adequate training in relation to managing challenging behaviour. (Previous timescale of 31/03/06 and 31/05/06 not met) The registered person must make adequate arrangements for training in respect of protection of vulnerable adults (Previous timescale of 31/03/06 and 31/5/06 not met) The registered person must ensure that the necessary action is taken in relation to the following: • The painted walls were marked in the ground floor corridor and stairs leading to the first floor, entrance hall wallpaper ripped. • The first floor corridor carpet had some staining and an iron burn. • The ground floor lounge wallpaper was damaged and the room was sparse • D’s bedroom stain remains on the ceiling following a DS0000025344.V331128.R01.S.doc Timescale for action 31/10/06 2. YA23 13(6) 31/10/06 3. YA24 23 31/10/06 Falkner Square (11/12) Version 5.2 Page 27 4. YA24 23 (b) 5. YA35 18 leak. • 1st floor shower room damage to wallpaper near show due to damp, ceiling damaged due to a possible leak. • First floor bathroom/toilet bath side panel warped and damaged. • Stairs to attic badly stained. • C’s room sink damaged and unit needs replacing, carpet badly paint stained needs replacing. • Laundry wall damaged behind washing machine, drier not working, ceiling water damaged needs repair. No11 • Stairs leading to attic badly stained. • T’s room carpet badly stained needs replacing. Two walls on the 1st floor had holes in them. Previous timescale of 31/03.06 not met. The registered person must 18/11/06 ensure that: • No 11 The bedrooms on the top floor should be upgraded before they are used. • The carpet in the 1st floor back bedroom should be replaced. • The arm of the settee in the dining room is badly damaged, this should be recovered , if this is not possible it should be replaced. No 12 The dining room floor should be replaced as it is badly marked. The registered person should 30/09/06 DS0000025344.V331128.R01.S.doc Version 5.2 Page 28 Falkner Square (11/12) 6. YA36 18(2) 7. YA37 8 and 9 ensure that all staff receive training appropriate to the work they perform and that it is up dated at the appropriate intervals. An action plan should be submitted to CSCI to address identified shortfalls in training The registered person should 30/09/06 ensure that all staff receive supervision at least six times each year. The registered person must 18/11/06 ensure that a manager is appointed to manage 11/12 Falkner Square and that a registered manager application is submitted to the CSCI. (Previous timescales of 07/02/05, 30/01/06 and 31/05/06 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA2 YA24 YA32 YA35 YA36 YA39 YA13 Good Practice Recommendations Staff should meet service users prior to their admission to number 11 where possible Domestic staff should be employed to support care team staff in maintaining hygiene standards in 11 and 12 Falkner Square. At least 50 of care staff should be qualified to NVQ Level 2. Care staff in the home must receive appropriate training Staff should be given formal recorded supervision at least six times a year. An annual development plan should be available to the management staff of the home. Staff should carry contact cards that could be issued to members of the community should they be effected by a service users behaviour to ensure that a situation can be effectively diffused without staff being at risk Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Falkner Square (11/12) DS0000025344.V331128.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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