Inspection on 21/08/07 for Falkner Square 12

This inspection was carried out on 21st August 2007.

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

The inspector found 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 18/07/06

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 12 12 Falkner Square Toxteth Liverpool Merseyside L8 7NU Lead Inspector Debbie Corcoran Key Unannounced Inspection 21 & 22nd August 2007 2:00 st Falkner Square 12 DS0000025344.V343472.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 12 DS0000025344.V343472.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 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Falkner Square 12 Address 12 Falkner Square Toxteth Liverpool Merseyside L8 7NU 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 Mrs Jacqueline Christine Emmett Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Learning disability: Code LD The maximum number of people who can be accommodated is: 6. Date of last inspection 18th July 2006 Brief Description of the Service: 12 Falkner Square is a care home registered with CSCI to provide accommodation and care for up to 6 adults with a learning disability. The home is part of a network of homes managed by Autism Initiatives. Autism Initiatives was formerly called the Liverpool and Lancashire Autistic Society and it was established in 1971. The organisation provides a variety of services to adults and children who have autism. These include residential care, day care, supported tenancies, outreach, domiciliary care, respite and educational services. Autism Initiatives is a voluntary organisation with charitable status. 12 Falkner Square is situated in the Toxteth area of Liverpool and is close to local amenities, bus and rail routes. 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 home was previously registered as 11 and 12 Falkner Square. Since the last inspection a variation to the registration has been made and number 11 is no longer included in the registration. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on an unannounced basis and over a period of approximately 7 hours over 2 consecutive days Each of the people living at the home were met at some point throughout the visit and a number of staff were spoken with. Service user plans, health and safety records and other relevant records were examined in some detail. A tour of the home was carried out. This included all areas. The manager of the home returned a quality assurance assessment to CSCI prior to this the visit and some of the information in this has been used to inform the inspection. What the service does well: The service is provided to meet the needs of people who have autism and as such routines and activities are planned with the specific needs of the people living in the home in mind. Each of the people living at the home has a plan of care. The information in the plans is specific to the needs of the person concerned. For example there may be clear guidelines on how to support a person with using public transport or when going out to a busy place. People living at the home are supported to use the local community and to pursue interests outside of the home including educational facilities. They are also well supported in using and developing their daily living skills such as personal care, cooking, shopping and housework. People living at the home are supported to remain healthy and staff support people to attend appointments on a regular basis. The staffing levels are good and as such people living at the home have a good level of one to one support. Staff carry out regular safety checks so that people living at the home are provided with a safe place to live. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Falkner Square 12 DS0000025344.V343472.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 12 DS0000025344.V343472.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): 1, 2, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose and service user guide needs to be reviewed so as to ensure accurate and up to date information on the home is available to prospective new residents and their representatives. Systems are in place for ensuring the needs of prospective service users are assessed, however, there are inconsistencies in how people have been introduced to the home. EVIDENCE: A statement of purpose which describes the services offered by the home is available. The statement of purpose needs to be updated to reflect changes at the home particularly in relation to staff numbers, staff experience and qualifications. A service users guide is also in place. This should be produced in formats suitable to the needs of the people using the service. Two people have moved in to the home since the last inspection visit. Records showed that assessment of needs information had been attained, from relevant professionals, for both of these people before they moved in. Along with attaining assessment of needs from relevant professionals Autism Initiatives have an assessment tool which is used to gather further information with regards to the person’s needs in relation autism. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 9 Staff were able to demonstrate that one of the new people who has moved to the home had the opportunity to visit the home on a number of occasions before moving in. This gave members of the staff team the opportunity to build up a knowledge of their needs and determine the appropriateness of the home in meeting their needs. They also described how the new person’s placement had been monitored to ensure the needs of the person could be met appropriately. However, for the other new person concerned there was no introduction to the home at all and the person moved in directly. During the visit it was also evident that a further new person may have been moving onto the home for emergency respite. Staff had not been provided with information on the needs of this person and it was evident from discussions with members of the staff team that staff did not seem to be fully aware of the planning involved in this or the potential impact upon the people living at the home. The manager must ensure that the referrals and admissions procedures are in line with good practice and this should include providing people with the opportunity to have introductory visits to the home before moving in. Falkner Square 12 DS0000025344.V343472.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each of the people living at the home has an individual support plan. These provide a good level of information on the person’s needs. Risks to the safety and well being of people living at the home are assessed and plans are put in place to manage these. EVIDENCE: Each of the people living at the home has a document entitled ‘about me’ and this describes the support they need in areas such as communicating, understanding, staff support, activities, meals, medication, health and safety. Each person also has a support plan which describes goals for their personal development and how to support the person with these. This may include supporting a person to develop their independent living skills, their personal care skills or learning new ways of interacting with other people. There were some good examples of information on the needs of the people using the service written as ‘guidelines’ for support. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 11 Information and support plans were looked at for two of the people living at the home. The level of information in these was sufficient to guide staff in how to support people with a good level of consistency. Support plans were all up to date. Some of the information regarding the people using the service particularly ‘about me’ information was not signed or dated, this needs to be addressed. People living at the home are encouraged to make decisions about their daily lives. Care plans include information about the person’s preferences and daily routines. A member of staff described how they encourage people living at the home to make choices and decisions about their daily lives and routines. Risk assessments are carried out with regard to the health and safety of the people living at the home. These identify potential hazards to the person’s safety and well being and include guidelines as to how to then manage the risk or prevent the risk from occurring. The risk assessments cover different aspects of the persons support. For example support with communication and expression or support with community access. The risk assessment for one of the people living at the home was not appropriate as it was a general safe working practice risk assessment. The manager must ensure that an appropriate risk assessment is carried out with this person. Falkner Square 12 DS0000025344.V343472.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported with their personal development and to pursue social and leisure activities and use the local community. The level of this should however be reviewed with each person so as to ensure equality of opportunity. EVIDENCE: Care plans include information on the skills and needs of the people living at the home. A member of staff gave examples of how support plans guide staff in supporting people to learn and develop new skills. The support plans also ensure that staff work consistently in supporting people to achieve new skills and to monitor progress in meeting targets and moving on to develop further skills. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 13 Each of the people using the service has a care plan and these include information on activities which the person likes to be involved in and includes information on the person’s social and recreational needs. Each person living at the home also has a weekly plan for activities to be used as a guide by staff. A daily record is maintained for each of the people using the service and this includes information on what activities the person has had the opportunity to be involved in. These and weekly plans were examined to assess the frequency of leisure opportunities and community access for a number of the people living at the home over the past 4 weeks. The records showed that three of the people using the service are supported to be involved in a variety of community activities on a regular basis. However, for two of the people living at the home the frequency and variety of activities was limited. The right of people to choose whether or not they get involved in activities must always be respected. However, the manager must review the access to community and leisure opportunities for each of the people living at the home to ensure equality of opportunity. In assessing the diet and meals available to people using the service menu records were examined and the availability and storage of food was checked. This indicated that people using the service have a choice of meals and food. Information on the service user’s likes, dislikes and needs with their food and meals is recorded in their personal records. Staff reported that people living at the home are supported to shop for their food and meals and prepare their meals where this is appropriate to their needs and wishes. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are supported with their individual routines and are supported to remain healthy. Some medication practices need to be improved so as to ensure the safe administration of medication to people living at the home. EVIDENCE: Each person who lives at the home has a care plan which includes information on how to meet the person’s personal care needs, physical care needs and health care needs. People living at the home are supported to visit a General Practitioner or district nurse when this is required and are supported to visit a dentist, optician etc on a regular basis. The manager must ensure that this applies to all people, as it was not possible to establish when one of the people living at the home had last visited a dentist. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 15 Care plans and other information is available to guide staff on how to support people using the service with their emotional well being. When appropriate records include guidelines for support with specific activities. For example there may be detailed guidelines for supporting a person when they are out and about in the community or if they have difficulty in managing social interactions. The medication storage and administration records were checked for two of the people living at the home. The checks identified that some of the medication practices need to be improved so that they are in line with the policies and procedures for the safe keeping and safe administration of medication. The main areas of concern noted were; medication administration records did not include information on the dose of medication prescribed. There was a double record for the administration of one particular medication. There were missing signatures on medication administration records. Medication is recorded when received and a weekly stock check is carried out. However, this was found to be inaccurate for one particular medication and this should have been picked up given the fact that the tool is an audit. There is a lack of consistency in how medication administration records are written and this could lead to mistakes in administration. The manager must ensure that these matters are addressed with immediate effect. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 16 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, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff act upon the views and wishes of the people living at the home. Some of the policies, procedures and practices around adult protection need to be tightened so as to protect people against abuse. EVIDENCE: The home has a complaints procedure which is time scaled appropriately. The statement of purpose and service user guide for the home include information on how to make a complaint and give an overview of how complaints are dealt with. There have been no complaints made since the last inspection visit and therefore how complaints are the managed could not be practically assessed. Staff who were spoken with appeared to know the needs of the people living at the home well and the way in which they described supporting people on a very individual basis indicates that they are aware of the resident’s needs and choices and listen to people when these need to be changed. Autism Initiatives has a ‘service user protection document’. This provides a guideline for staff on how to deal with a potential adult abuse allegation. This was not available at the home at the time of the visit. This should be available to staff at all times in the event of an allegation of abuse. Staff have been provided with adult protection training. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 17 The home has a ‘whistle blowing policy’ the purpose of which is to protect staff who identify and report allegations of abuse. The home has further policies and procedures aimed at protecting people who use the service and these include a physical intervention policy and a management of service users money policy. The way in which the monies of people using the service is managed was looked at for one person. The manager must ensure that appropriate procedures are fully implemented and that staff are aware of their responsibilities in accounting for monies and in attaining signatures for transactions were appropriate. The details of this were discussed with a senior member of staff during the visit. A record of key events is maintained for example incident reports and accident reports. These reports were checked and there were no particular issues identified as a result. The manager should ensure that staff date the reports of any injuries to staff. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 18 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, 25, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is room for improvement to the home so as to ensure that the people living at the home are provided with a homely and well maintained environment. EVIDENCE: The home provides accommodation over 3 floors. On the ground floor there is a communal lounge, a dinning room and a domestic sized kitchen. Each of the people living at the home have their own bedroom and these are located on both the first and second floor. All but one of the bedrooms have recently been redecorated and had new carpet fitted. Bedrooms were viewed and were presented to a suitable standard. A tour of the premises was carried out which included all areas. This identified that the following areas are in need of improvement; Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 19 • • • • • • The hallway and landings are in need of redecoration. The carpet needs to be cleaned / replaced in some parts of the main hallway. The dining room is in need of redecoration. New dining furniture is needed. The wardrobe in the dinning room should be relocated to a more appropriate area. Rubbish in the rear garden needs to be removed. In addition, the overall presentation of the home could be improved upon so as to make the home feel more welcoming and homely whilst also meeting the needs of the people using the service. People living at the home appear to enjoy spending time in the rear garden. The garden was however found to be over grown in places and had a large pile of rubbish. The garden area could be improved to provide a nice outdoor space for the people living at the home. It was reported that the manager has started to address a number of the above areas. The manager should produce a maintenance plan for the home to show this and to indicate how the environment will be maintained. Health and safety practices and procedures are carried out. These aim to ensure the home is safe, clean and free from hazards. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 20 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, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are flexible and based around the needs of the people using the service. Many of the staff have a relevant qualification in care. Staff are provided with regular supervision to look at their practice and development needs. EVIDENCE: The needs of the people living at the service have changed in that some people have moved on and new people have moved in. The staffing levels are increased as required in order to meet the needs of new people. The staff roster indicates that when appropriate people using the service are supported on a one to one basis. Information provided to CSCI prior to the site visit time showed that there are seven members of care staff on the team and of these 5 had attained an N.V.Q (National Vocational Qualification) in care. It was reported in pre inspection information that the remaining 2 members of staff are working towards attaining a relevant qualification. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 21 Information on staff training was not available due to the absence of the manager. Some records seen indicated that members of the staff team require up to date training in core health and safety skills and in adult protection. One member of staff reported that they have received adult protection training and training on mental health issues in the last 12 months. The manager should carry out an audit of staff training and ensure that all staff have up to date training. A copy of the audit should be forwarded to CSCI. Discussions with a member of the staff team indicated that staff are supporting the aims and objectives of the home in encouraging the people to make choices, develop their independent living skills, learn new skills and use their local community. The staff team has been running with a number of vacancies and there has been a reliance on agency staff to cover some of the vacant posts. It was reported that whenever possible the same agency staff are brought into the home so as to provide consistency to the people living at the home. It was reported that six new staff have been recruited. There was no recruitment and selection information available at the home for these people as their employment had not commenced. There had been no other new staff to the home since the last inspection visit and therefore the procedures for staff recruitment and selection could not be practically assessed. Staff are being provided with the opportunity of supervision meetings and team meetings take place. However, the frequency of these meetings needs to be increased to ensure that the minimum standard is achieved. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 22 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, 40, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people using the service. The quality of the service is checked on a regular basis. Policies, procedures and practices are in place to safeguard the safety and well being of people living in the home and staff. EVIDENCE: The manager has recently been registered as manager with CSCI for this service. The manager was not available at the time of the inspection visit and a senior member of staff therefore assisted with retrieving information and answering questions on some of the systems in place. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 23 The home appears to be run in the best interests of the people living at the home. There is a quality assurance process at the home which includes regular visits and audits from a representative employed by Autism Initiatives. Quality assurance also includes seeking the views of people using the service and their representatives as to the quality of the service provided. There were a number of files which included policies and procedures. However, it is recommended that the manager reviews the policies and procedure to make sure that all relevant ones are included and that staff are aware of and familiar with relevant policies and procedures. Staff are provided with training in health and safety topics and the home has health and safety policies and procedures. Fire safety and health and safety practices are adopted and checks carried out. These were found to be up to date with the exception of fire drills which need to take place on a more regular basis. Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 24 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 2 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 3 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 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 2 X 3 2 Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA9 Regulation 13 Requirement Risk assessments must be carried out in relation to the support provided to each of the people living at the home. A review of the opportunities for activities and community access provided to people living at the home should be made to ensure that these are meeting the needs of the individuals concerned. Residents’ health records should be maintained appropriately in order to evidence that residents are being supported with all aspects of their health care. Medication must be managed and stored safely and administration records must be maintained accurately and appropriately at all times. Staff must have access to appropriate policies and procedures on adult protection. Appropriate procedures must be followed for supporting people DS0000025344.V343472.R01.S.doc Timescale for action 22/09/07 2. YA13 16 (2) (m) 22/10/07 3. YA19 12 (1) (a) 22/09/07 4. YA20 13 (2) 22/09/07 5. YA23 13 (6) 22/09/07 6. YA23 13 (6) 22/09/07 Page 26 Falkner Square 12 Version 5.2 living at the home with their money. 7. YA24 23 All repairs and maintenance work as identified in the report must be completed so as to provide a well maintained and homely environment to people using the service. 22/11/07 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. Refer to Standard YA4 YA6 YA24 Good Practice Recommendations The practice for admission of new people to the service must be reviewed and should be in line with good practice. Records should be signed and dated appropriately. A maintenance plan should be produced to indicate how the home environment will be improved, refurbished and appropriately maintained. This should include improvements to the rear garden. The manager should carry out an analysis of staff training in order to ensure that all staff have relevant up to date training. A copy of this should be forwarded to CSCI. The manager should review all policies and procedures provided to staff and ensure that staff are aware of and familiar with these. The manager should review the frequency of fire drills so as to ensure they are carried out on a regular basis. 4. YA32 5. YA40 6. YA42 Falkner Square 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 12 DS0000025344.V343472.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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