Inspection on 24/11/05 for Falkner Square 12

This inspection was carried out on 24th November 2005.

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 8 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 18/07/06

Falkner Square 12 03/03/06

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 Mrs Lynne Lynch Unannounced Inspection 24th November 2005 10:30 Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 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.V268896.R01.S.doc Version 5.0 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.V268896.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Falkner Square (11/12) Address 11/12 Falkner Square Toxteth Liverpool Merseyside L87NU 0151 330 9540 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) Autism Initiatives Ms Jane Troy Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 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. 7th January 2005 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.V268896.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, started at 10.30 am and took place over seven and a half hours. At the time of the inspection there were 10 people resident within the two houses, however not all were in the building as some of the service users were on home visits. The inspector spoke with two members of staff, one service user, one visitor and the team leader on duty for 11 Falkner Square. All the people living at the home have either Autism or Aspergers and therefore have specific communication needs and therefore discussion with these individuals was limited. The team leader of 12 Falkner Square was not present. Assessment information and some of the written policies were viewed. Medication recording, storage and administration were evidenced and a full tour of both buildings was conducted. What the service does well: What has improved since the last inspection? What they could do better: The environment must be adequately maintained to ensure the home provides service users with comfortable surroundings. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 6 The registered person must make adequate arrangements in order that all staff receive appropriate and adequate training in relation to managing challenging behaviour. The registered person must make adequate arrangements for training in respect of protection of vulnerable adults. Records of all staff employed should be available in the home and meet Schedule 2 of the National Minimum Standards. The registered person must ensure that a manager is appointed to manage 11/12 Falkner Square and that a registered manager application is submitted to the CSCI The registered provider must conduct their own inspection visits on a monthly basis and forward a copy of their findings to the Commission for Social Care Inspection. The registered person must ensure that an up to date electrical test by a suitable qualified person is carried out. The registered person must ensure that a test of the fire alarm system is carried out weekly with a record of such tests being maintained. It is recommended that the staff who have responsibility for delivering direct care be involved in initial assessment procedure, as it would further ensure that the prospective service users needs can be fully met. A domestic staff should be employed to support care team staff in maintaining hygiene standards in 12 Falkner Square. At least 50 of care staff should achieve NVQ Level 2 by 2005. 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. The team leaders require clearer guidance and additional support to enable them to manage the home effectively. 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. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 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.V268896.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prior to moving into the home, a full assessment takes place, which ensures that needs are met. EVIDENCE: 12 Falkner Square There have been no new admissions to this unit since the last inspection. The Assessment was found to be acceptable at the last inspection with the service manager of the organisation undertaking an assessment of the persons needs prior to them being admitted to the home. The assessment is used as a basis for initial care planning. 11 Falkner Square Two service user files were viewed in respect of assessment. Both files were found to have good information, however one of the files did not have any supporting information from other agencies. The Team Leader explained that there were issues in relation to routinely obtaining these documents particularly from placing authority social workers. She also advised that members of the clinical team, which includes a psychologist and a language therapist, now carried out the assessment. Guidelines were seen in the home in respect of the assessment process and support plans. One service user spoken to said he did not choose to live at Falkner Square but likes it now. On entering the home service users are encouraged to complete a document stating, “what I want from Falkner Square”. Out of the two files viewed only one showed a visit being made to the Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 9 home by the service user. The other file advised that on psychiatric advice it was felt a pre visit would not be in the person’s best interest. No members of staff from the home are involved in carrying out this assessment therefore the inspector advises that the staff who have responsibility for delivering direct care are involved in this procedure as it would further ensure that the prospective service users needs can be fully met. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected at this visit EVIDENCE: Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users rights are respected and they are encouraged to take responsibility in their own lives. EVIDENCE: Staff within the home were observed throughout the day and were seen to be actively encouraging each person to carry out independent living skills in relation to their abilities. Communication between staff and service users was seen to be appropriate. Service users privacy and dignity were respected; staff were seen to knock on bedroom doors and the service user spoken to confirmed that this was always the case. Service users were spoken to by staff with their preferred name being used. The service user spoken to confirmed that he received his own mail and asked staff for support when needed. During the day one service user requested to spend time in his room this request was respected however he was asked if it was ok for staff to check with him if he felt ok periodically and he agreed to this. Later in the day he was encouraged to come downstairs, as staff were concerned regarding his health. T Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 12 he service user spoken to on 11 Falkner said “we all make our own meals and do our own washing staff are there to help you if you need them”. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication procedures demonstrate due care and attention and the staff include service users in this procedure EVIDENCE: Medication in the home is well managed. Prescriptions are seen and then faxed to the pharmacy with the originals being sent on. All medication is booked in and signed for. The majority of medications are in a monitored dosage system. Administration records were completed satisfactorily. Three of the service users on 11 Falkner Square sign their own medication records. Good records are maintained for medication being transferred from the home and the inspector observed a relative being asked to sign for medication they were taking out of the home. Medication being returned to the pharmacist is recorded and signed off by the pharmacist. Patient information leaflets are kept in the home on file. The medication room is small which poses a risk for staff with one gentleman due to his unpredictable behaviour therefore a risk assessment is in place and the medication is taken to him in a separate locked box. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People are confident that their views and concerns would be listened to. Limited staff training potentially leaves staff and service users at risk. EVIDENCE: Staff on 12 Falkner Square were unable to locate the complaints procedure when asked. The team leader on 11 Falkner Square provided this for the inspector. The procedure was thorough and covered all areas of making a complaint with timescales, however the document on display did not carry the correct contact details for the Commission for Social Care Inspection and this needs amending. The document also contained names for contact staff which is now outdated and also needs amending. Complaints are recorded and dealt with in an appropriate manner both the service user and relative spoken to were aware of how to make a complaint. There have been no complaints made to the home since January 2005 and the Commission has received no complaints since the last inspection. The home also has a copy of the Autism Initiatives comment, compliment and complaint brochure. The home has a copy of Liverpool City Councils procedures in relation to adult protection for reference. The company has a designated adult protection coordinator and appropriate policies are in place in relation to whistle blowing and dealing with aggressive behaviour. The team leader advised that three staff have attended training in respect of the Protection of Vulnerable Adults and three staff have completed training in respect of positive intervention training which still leaves a significant number of staff not trained in this area whilst supporting a difficult and potentially challenging client group. The training matrix was not available at the inspection due to it being updated so this information could not be evidenced. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30 The environment is poor, many areas of the home are badly neglected including service users bedrooms there is a failure to adequately maintain the home to provide service users with comfortable surroundings EVIDENCE: A full environmental check was carried out for both 11 and 12 Falkner Square. 12 Falkner Square was found to be dirty in many areas carpets and floors had much surface debris. The domestic post for 12 Falkner Square is currently vacant. Due to the assessment process of service users and the focus upon encouraging services users to be involved in cleaning routines a domestic is not employed at 11 Falkner Square and cleaning duties are shared between the service users and staff. Staff advised that they tried to carry out domestic duties alongside care tasks but this was not always possible. It was disappointing to note that none of the requirements identified in respect of the environment in the previous report have been addressed. Further deterioration in fact was noted particularly in the following areas. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 16 No 12 The painted walls were marked in the ground floor corridor and stairs leading to the first floor, entrance hall wallpaper ripped. The dining room wallpaper had a number of rips above the radiator and marks on the wall. The first floor corridor carpet had some staining and an iron burn. G’s room had a missing washbasin door. The ground floor lounge wallpaper was damaged and the room was sparse, the gas fire had been disabled and there was only a small radiator to heat the room. D’s bedroom stain remains on the ceiling following a leak. 1st floor shower room damage to wallpaper near show due to damp, ceiling damaged due to a possible leak. P’s room damage to ceiling, mirror missing from wall with exposed plaster. First floor bathroom/toilet – expel air requires cleaning clogged up with dirt, cobwebs hanging from ceiling, bath side panel warped and damaged. 2nd floor N’s room walls require redecorating, very sparse room furniture old and inappropriate for bedroom, carpet in room very badly stained, radiator rusting, paintwork very dirty. 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. No 11 The first floor hallway carpet was stained in various places and was lifting at the join which was found to have been sellotaped down, still poses a risk. The stair landing rails and stairway walls were significantly marked. The stair carpet was found to be very stained. The ground floor corridor carpet was found to be worn near areas around the office and kitchen Shower room 1st floor, tiles were found to be loose and taped on. These need replacing, a very damp smell was noted in this room this could be attributed to the flooring around the shower being mouldy and in need of replacing. Top stairs carpet creasing in several areas if left unattended will become worse and pose a risk of tripping. Stair carpet leading to the attic are badly stained. T’s room carpet is badly stained this needs replacing. Two walls on the 1st floor had holes in them. The lounge walls need repainting; the ceiling is stained and requires attention. A cooker in the kitchen is still out of order and has been for a considerable amount of time, thus restricting the cooking facilities available, the ceiling is damaged and the towel rail has been pulled off the wall. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 17 The general standard of accommodation particularly bedroom areas are poor the inspector appreciates that some individuals can cause damage, however this does not excuse the non-action in this area despite requirements made. Standards are not being met and further deterioration is noted. Staff advised that requests for redecoration and repairs have not been acted upon. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 The detail of training provided could not be fully evidenced. Concerns were raised regarding the lack of availability of training places available. Staff do not have sufficient management support. No clear records were available to evidence if robust recruitment procedures had been adhered to. EVIDENCE: Recruitment records for staff working in the home were not all available. No records were available for the last five staff recruited therefore the inspector was unable to ascertain whether recruitment procedures had been followed and Criminal Records Bureau Clearance obtained. The Team Leader was advised that as per Schedule 2 of the National Minimum Standards these documents must be available for inspection. The team leader advised that these records are still at the Autism Initiatives Human Resource Dept and that she had been unable to collect these due to needing to provide management cover in the home. One file was in the home and was viewed and was generally satisfactory except for insufficient information in respect of past employment. Staff spoken to advised that they received supervision from the team leaders and these were planned on a two monthly basis with an annual appraisal. Records in respect of staff supervision were good, however not all staff had received the planned supervisions. The Team Leaders in the home are supervised by the service manager. The Team Leader on duty had only received two supervision in the last 12 months. This is not good practice and Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 19 raises concerns as to the support and guidance being given particularly with the limited management contact and management vacancies in the home. Training records in the home were not clear. The organisation provides the home with a training programme and staff are nominated to undertake the training. However via discussions with staff on duty it was evident that there are issues on occasion in relation to providing staff cover for staff to complete the training. There was no current training matrix available to ascertain what staff had achieved. Staff advised that there was a programme of training and that they had been supported to attend courses. However it was also felt that at times due to limited places much training could not be accessed. There has been no progress with NVQ training with only one staff member qualified to NVQ 3 standard. Staff who were due to start this training in September have now been put back to Jan 06. Therefore 50 of care staff will not have achieved this by the date given in the National Minimum Standard. Induction training is in place and is thorough. The induction process is worked through over a period of six months and consists of five modules covering generic and service specific issues at present the Team Leaders are taking responsibility for all inductions. Despite a previous requirement there are still only 3 members of staff who have received training and attended the two day course in positive intervention. The inspector was unable to ascertain the level of mandatory training received by staff due to no clear records being held Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Vacancies in the management team need to be filled. Clearer guidance and additional management support is needed to improve upon the maintenance of records and management of Health, safety and welfare to ensure that the resident’s rights and best interests are safeguarded. EVIDENCE: There still remains no registered manager at 11/12 Falkner Square and there has not been one for some considerable time. Two Team Leaders are in post. Both team leaders should have two deputy managers each however three of these posts are vacant. The lack of managers and management support is having an obvious effect on the service with a lack of records being maintained and limited access to and support for the Team Leaders from the higher management team of Autism Initiatives. Service users and staff made positive comments about the Team Leader on duty and said that they are kept informed of events on a daily basis. Everyone spoken to said the Team Leaders are very much “hands on”. The Team Leader recognises that this “hands on” approach does mean that less time is available Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 21 to spend on the maintenance of records and developing systems that underpin good practice. The inspector noted that a residents meeting was due to be held on no 11 Falkner Square. Service users residing on no 12 Falkner Square would not be able to attend such a meeting staff general work from day to day with this client group. Autism Initiatives have Service users Consultative Committee, however there are no representatives currently on this committee from Falkner Square. A service user profile is completed annually to ascertain service users opinion of the service with questionnaires being sent to relatives. Autism Initiatives have the Investors In People Award. There was no annual development plan at the home. As the registered provider does not manage the home directly a responsible person is required to carry out monthly visits in order to establish the home is being run in the best interests of the residents and that satisfactory standards are being maintained. The last recorded visit in the home was 25/08/05 with a previous visiting being made in June 2004. The findings of these visits must be recorded and a copy of the record forwarded to the Commission for Social Care Inspection. Two areas under standard 42 were inspected following previous requirements made. These being the electrical certificate and weekly Fire Alarm tests. Both these were not satisfactory an electrical certificate had been obtained however this was again now out of date. Fire alarm tests had been carried out but not on a weekly basis. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 1 1 X X 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 1 X 1 1 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Falkner Square (11/12) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 1 X 2 X X 2 X DS0000025344.V268896.R01.S.doc Version 5.0 Page 23 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 make adequate arrangements in order that all staff receive appropriate and adequate training in relation to managing challenging behaviour. (Previous timescale of 07/04/05 not met The registered person must make adequate arrangements for training in respect of protection of vulnerable adults 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 dining room wallpaper had a number of rips above the radiator and marks on the wall. The first floor corridor carpet had some staining and an iron burn. Gs room had a missing washbasin door. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 24 Timescale for action 31/03/06 2 YA23 13(6) 31/03/06 3 YA24 23 28/02/06 The ground floor lounge wallpaper was damaged and the room was sparse, the gas fire had been disabled and there was only a small radiator to heat the room. D’s bedroom stain remains on the ceiling following a leak. 1st floor shower room damage to wallpaper near show due to damp, ceiling damaged due to a possible leak. P’s room damage to ceiling, mirror missing from wall with exposed plaster. First floor bathroom/toilet – expel air requires cleaning clogged up with dirt, cobwebs hanging from ceiling, bath side panel warped and damaged. 2nd floor N’s room walls require redecorating, very sparse room furniture old and inappropriate for bedroom, carpet in room very badly stained, radiator rusting, paintwork very dirty. 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 The first floor hallway carpet was stained in various places and was lifting at the join been sellotaped down still poses a risk. The stair landing rails and stairway walls were significantly marked. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 25 The stair carpet was found to be very stained. The ground floor corridor carpet was found to be worn near areas around the office and kitchen Shower room 1st floor, tiles loose taped on at the moment need replacing, very damp smell in room flooring mouldy needs replacing. Top stairs carpet creasing in several areas if left unattended will become worse and pose a risk of tripping. Stairs leading to attic badly stained. T’s room carpet badly stained needs replacing. Two walls on the 1st floor had holes in them. The lounge walls need repainting; the ceiling is stained and requires attention. A cooker in the kitchen is still out of order and has been for a considerable amount of time, thus restricting the cooking facilities available, the ceiling is damaged and the towel rail has been pulled off the wall. The general standard of accommodation particularly bedroom areas are poor the inspector appreciates that some individuals can cause damage, however this does not excuse the non-action in this area despite requirements made. Standards are not being met and further deterioration is noted. Staff advised that requests for redecoration and repairs have not been acted upon. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 26 4 YA34 19 schedule 2 8 and 9 5 YA37 6 YA39 26 7 YA42 23 8 YA42 23 Records of all staff employed should be available in the home and meet Schedule 2 of the National Minimum Standards. The registered person must ensure that a manager is appointed to manage 11/12 Falkner Square and that a registered manager application is submitted to the CSCI. (Previous timescale of 07/02/05 not met) The registered provider must conduct their own inspection visits on a monthly basis and forward a copy of their findings to the Commission for Social Care Inspection. The registered person must ensure that an up to date electrical test by a suitable qualified person is carried out. The registered person must ensure that a test of the fire alarm system is carried out weekly with a record of such tests being maintained. 30/11/06 31/01/06 31/12/06 31/12/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations It is recommended that the staff who have responsibility for delivering direct care be involved in initial assessment procedure, as it would further ensure that the prospective service users needs can be fully met. The homes complaint procedure should contain the contact details for the Commission for Social Care Inspection and contact names for the organisation should be updated. A domestic staff should be employed to support care team staff in maintaining hygiene standards in 12 Falkner DS0000025344.V268896.R01.S.doc Version 5.0 Page 27 2 3 YA22 YA24 Falkner Square (11/12) 4 5 6 7 8 YA30 YA32 YA35 YA36 YA39 Square. The home requires an intensive cleaning programme to ensure areas previously neglected are in a position to be easily maintained. At least 50 of care staff should achieve NVQ Level 2 by 2005. Care staff in the home must receive appropriate training and clear records be maintained of qualifications held. 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. Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Falkner Square (11/12) DS0000025344.V268896.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!