Inspection on 05/07/06 for Atkinson Grove Respite Bungalow

This inspection was carried out on 5th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Atkinson Grove Respite Bungalow 30/04/07

Atkinson Grove Respite Bungalow 23/02/06

Atkinson Grove Respite Bungalow 13/09/05

Atkinson Grove Respite Bungalow 03/11/04

Atkinson Grove Respite Bungalow 11/06/04

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 Atkinson Grove Respite Bungalow 3 Atkinson Grove Huyton Knowsley Merseyside L36 7RS Lead Inspector Miss Diane Sharrock Unannounced Inspection 5th July 2006 10:45 Atkinson Grove Respite Bungalow DS0000037680.V295248.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 Atkinson Grove Respite Bungalow DS0000037680.V295248.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. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Atkinson Grove Respite Bungalow Address 3 Atkinson Grove Huyton Knowsley Merseyside L36 7RS 0151 480 5673 0151 480 5673 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) Knowsley MBC - Health & Social Care Headquarters Miss Judith Glynis Bailey Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 3 YA with LD or up to 3LD (E) To have a mimimum of 1 waking night staff each night. To have a temporary variation for two named Service Users requiring Nursing Care The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. The Service may accommodate a named service user in the category LD on the condition that they be found accommodation elsewhere by 10 July 2006.(this condition is no longer in use) Date of last inspection Brief Description of the Service: Atkinson Grove is owned and managed by Knowsley Social Services. The Responsible Individual is Mrs Anita Marsland. Knowsley Social Services have appointed a Manager Judith Bailey who has worked at the unit for many years. The home is a purpose built bungalow with three single bedrooms, The unit offers respite facilities to Service Users living in the Huyton, Halewood, Knowsley and Kirby areas. The service offers personal care in a residential setting and staff access the local District Nursing team to provide any additional Nursing/ clinical procedure. At present two Service Users bring their own Nursing staff during their stay at the Bungalow and the District Nurse provides input for other Clinical needs. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection at Atkinson Grove. The inspector met three Guests residing at the Bungalow and the 2 staff on duty. A detailed tour of the premises took place and Resident care plans and various other records were inspected.. A selection of comment cards were left. All areas of the inspection and findings were discussed with the Manager at the end of this inspection. Previously the home had been granted a variation to accommodate an extra Resident, this person has now moved and the staff are in the process of renovating this room to its previous use as a “staff sleep in room.” Until the room is suitable for its purpose the manager explained that 2 waking staff are in place to support the guests during their stay. Due to unforeseen circumstances the manager had not been able to submit the pre inspection questionnaire back to CSCI prior to this inspection, the Manager has agreed to complete this form and send to CSCI following this inspection. This questionnaire has still not been submitted to CSCI following the completion of this report and must be submitted to CSCI as a matter of priority. What the service does well: What has improved since the last inspection? The Manager described a recent Team building day 30/6/06 that most staff attended and the benefits of these events to the team. The minutes of the day described how the team plan to move and develop the project forward and how they plan to achieve the national minimum standards, the staff also developed and had input to their own development plan for the project. The care plans have been completely developed and staff are in the process of transferring all relevant information to these care records, a lot of work has been carried out to develop these records which will evidence all parts of the Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 6 standards once they are completed and used as day to day records for all of the guests. The homes manager has implemented weekly Guests meeting which staff aim to support staff in planning their stay and implementing their requests and choices for things such as activities and trips out. The manager has liaised with her companies own personnel section and now has continued input and information to assure her that staff personnel records kept at head office have all necessary records and checks to meet the care home Regulations 2001. What they could do better: Full feedback was given to the Manager during and on conclusion of this inspection. Some areas of improvement were noted however other areas of concern were noted to need action taken and further evidence to be in place to meet most standards. Some concerns noted were repeated from previous inspections. The continued issue for requirements needs addressing by senior managers of Social Services, so that support and developments are enabled to be structured and measured to achieve compliance with all of the care home regulations and national minimum standards. 1) Activities and support need developing and implementing as per guest’s requests and as how the project originally performed in meeting its own philosophy over 18 months ago. 2) Various procedures and records need a company review to improve on present practice and to identify steps to improve current practice, reviews should cover, eg, the management of Residents finances, medicines and administration, risk assessments, care plans, and the management of complaints. etc. 3) Training records need updating and mandatory training implemented in eg abuse awareness, medications, food hygiene. 4) Staff identified that they need a new lawn mower this should be purchased and the Hoover broke and staff had to buy a temporary one until a suitable replacement was purchased, this should now be provided for the home. 5) Maintenance and suitable contractor checks should be in place for all fire appliances and mobile hoist, in-house checks on the fire alarm system should be implemented. All appropriate checks on the building and equipment should be reviewed to ensure all necessary management of the home has taken place to safeguard all present. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 7 6) The manager must organise staff photographs for their personnel files as some do not yet have them in place. 7) A maintenance, decoration and refurbishment programme should be developed to identify areas needing attention including a rolling programme of necessary work and repairs, including the garden areas that look neglected with fencing that needs replacing and gardens that need maintaining. 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. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 8 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 Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 9 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): 1 The Statement of Purpose is now displayed on the notice board. Quality in this outcome Area is, Good, this judgment has been made using available evidence including a site visit to the service. EVIDENCE: The home have displayed a statement of purpose on the notice board by the front entrance which gives Guests details about the bungalow and the project. Further work should now take place to develop this document so that it is specific to the needs of the Guests and is user friendly based on their capacities to access this document. The Service should also develop and implement a service User guide again one that is developed and caters for the differing needs of Guests. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6/7/9 There continues to be progress made in the care records which will eventually meet all parts of the standards once the documents are used wholly by all staff. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: Some care plans were case tracked and some had plans of care available. The company have developed all care records and transferred all plans to newly revised formats, which have detailed sections that staff are in the process of transferring over to. The companies’ own documents for finances, menu plans and activity plans were found to not be complete or used for sometime. The developments and transfer to the new documentation was discussed at the homes recent staff meeting on the 30/6/06 and staff had also included it in the homes development plan. The company have taken a lot of effort to develop Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 11 the care records so that they will be clear in how they meet individual needs and in meeting the national minimum standards. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/15/16/17 Individual activities are not implemented at present, activity plans were not completed and had not been developed regardless of Service Users requests. Family members are kept informed and involved with regular contact. Menu plans had not been completed. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The Staff have now developed weekly Guests meetings which enable all guests to make their requests and take some steps in planning their stay while staying at the bungalow. One care plan case tracked identified that one guest gave a list of things and activities that they would like to do the following week and in reviewing the daily records it was noted that this person had only had lunch out on one occasion in their first week and during the site visit stayed in the bungalow all day. Activity plans and menu plans had not been used similar to the findings of the last inspection. This was discussed in detail with the manager as the bungalow was now back to just 3 guests per week and should be managed with the Guests needs and requests as a priority similar to the standards and philosophy found approximately 18 months ago. The Manager Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 13 acknowledged that the Staff Team had also identified that they needed to develop and move the project on with the development of activities however this must be acknowledged by the company as something that needs measurement and monitoring with specific actions to achieve the appropriate outcomes for all Guests during their staff at the bungalow Staff were observed to have a good rapport with Guests. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 Care plans are now being developed and will hopefully be able to demonstrate individual Service Users needs and choice. The administration of medication needs complete review to improve on current practices. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The company are developing comprehensive formats for each Guests care plan and staff are in the process of transferring original documents over to the new process. Ultimately the new documents should be able to demonstrate how each Guest is supported in their individual preferences and choice while staying at the bungalow. Currently the care plans case tracked do not yet demonstrate individual needs and choices being met, its acknowledged that the transfer over to new documentation will take some time, however the company must take steps to measure the progress to ensure appropriate records are in place as a matter of priority. A sample of medications reviewed highlighted a number of issues that needed further review and attention from the company to improve on current practice. One medication records had a handwritten entry with no specific prescription for times to administer medication, one stated on the medicine label, “as directed by GP.” With no further details. Staff had tried to clarify this instruction with the GP practice but the fax sent by the practice was still unclear. This was discussed with the manager as it seemed more appropriate Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 15 to ensure that each guests medications was organised prior to their stay so that staff could safely administer the prescribed dosage of medication. Regular auditing for various procedures including the administration of medications should be developed by the company to ensure appropriate and safe practices are carried out. As an example of good practice one Guest was seen to be supported with their medication later in the day when they got up which provided a more individualised approach to their administration of their medication. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23 The management and investigation of complaints needs complete review to ensure all complaints and opinions are acted upon. Mandatory training for staff needs to be up to date to ensure all staff are trained in the protection of vulnerable adults. The management of Guests finances should be reviewed. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: Staff have been receiving training on ‘abuse awareness’ however training records were not all accessible. This training must be classed as mandatory training to enable staff to continue protecting Guests.This point was also raised at the last inspection and is of concern that it is yet again repeated in this inspection. The manager acknowledged that that mandatory training was not up to date and explained that senior management were in the process of developing a training database to enable them to organise all updated and relevant training for all staff. A complete review on the recording and investigation of any type of complaint must take place to demonstrate that all complaint are dealt with as per the companies policy and in a fair and open and transparent process. The homes complaints logging book was seen during this site visit and one complaint was noted to have been made however there was no record of any type of investigation. The manager explained that due personal circumstances she was not in a position to investigate the complaint at the time it was received, however the original complaint had been made to senior management and no investigation or record was made of a fair and even handed process to look at the concerns raised, in fact the complaint was discussed at a staff meeting Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 17 were staff comments were recorded that they wholly felt the concerns were unfounded. These comments were discussed with the manager as the absence of any record of a fair and open investigation may lead other persons to identify a biased approach to any concerns, comments or complaints made by any other party. The company must take appropriate action to ensure all persons are knowledgeable and supportive of the company’s complaints procedure and that any person is supported in raising their comments concerns or complaints. The management of Guests finances and support must be reviewed to ensure the policy / guidance carried out is consistent for all Guests. This point was also raised in the last inspection. In the new care plan format there is a section for the recording of any financial transactions, however staff are recording the management of finances in different ways. One Guest s record did not have any evidence of a receipt kept for a purchase although another Guests records did have evidence of staff keeping clear records with receipts. Regular company audits must take place to ensure an improvement to the current management and recording of guest’s finances. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24/30 The Bungalow looked comfortable, homely, tidy and clean. General management of safety issues at the bungalow need complete review to ensure the ongoing safety of everyone at the bungalow. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: During most visits to the Bungalow the environment is always noted to be clean and tidy. There are on-going maintenance issues and a maintenance programme should be developed. The front and rear gardens were noted to be in need of urgent repair and maintenance, with weeds in flagged areas, grass uncut, hedges/shrubs not trimmed and maintained, some sections of fencing missing and not repaired, the front gate was broken and seen off its hinges laid on the floor. Staff stated the lawn mower had been broken for some time and had not been replaced. Staff did say they had tried to organise a local project to come to the bungalow to help maintain the gardens however nobody had any specific times or dates Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 19 for implementing such a project. All necessary action must be provided by the company as a matter of priority to ensure a well maintained and safe garden area for all guests that stay at the bungalow, and to ensure that all necessary equipment is provided as needed. The fire log book had a last in-house record for the month of February 06 and the manager acknowledged that the recording of in-house checks was not up to date. Another gas safety certificate was noted to have a warning notice 4/5/06 stating “failure of flu flow test.”, isolated fire due to failure of flu test. The manager felt this had been attended to but there was no evidence from the contractors to state whether the company had taken any actions to ensure the safe use of the fire at the bungalow, the manager agreed to review this with the contractors and the company. General risk assessments were noted to be in need of complete review and update as some were still dated 22/5/03 and staff were unclear whether they were still regarded as live risk assessments or ones that were now out of date and not in use. General management of safety issues at the bungalow need complete review to ensure the ongoing safety of everyone at the bungalow. Atkinson Grove Respite Bungalow DS0000037680.V295248.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32/34/35/36 This standard was met in part as some staff had received mandatory training. Supervision must be developed for all staff in line with these standards. The manager had developed and audited all current staff personnel files. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: In discussion with Staff and in reviewing staff training records it was noted that mandatory training was needed for some staff especially in medications, protection of vulnerable adults and food hygiene. The manager acknowledged that the management of all staffs training and their records needed to be updated. Supervision records and their development needed further review and input to ensure that all staff receive regular supervision as per the national minimum standards. The manager has accessed all staff files and records kept at head office and has produced evidence of all necessary checks being in place prior to staff commencing employment at the bungalow including CRB checks. The only record missing from some files was the use of staff photographs, which the manager acknowledged as a simple process that she would implement and put in place. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 21 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): 37/39/42 The Bungalow has a Registered Manager, support and developments should be given to enable the home to achieve all parts of the National Minimum Standards. Risk assessments must be up to date, clear and accurate to identity actions to reduce risks. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The Bungalow has a good philosophy however it now needs support to develop the standards and achievements it strived for and achieved almost 18 months ago. The home has not always been able to demonstrate it meets the National Minimum Standards during inspections. This was discussed during this inspection with the homes Manager as a concern that the home was not showing evidence in meeting all parts of the national minimum standards. A full audit should take place identifying what actions, support and resources are Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 22 needed to support the Manager to meet the National Minimum Standards and Care Homes Regulation 2001. This point has also been raised and published in previous inspection reports. Any actions taken by the company should be measurable to ensure compliance and general improvements in the management of this unique project. Recent reviews and developments of the bungalow have seen various inputs and evidence of good practice eg weekly Guests meetings to identify individual choices and preferences, and the complete development of care plans. A previous staff meeting 30/6/06 showed evidence of senior management being in attendance and all staff being involved in developing the bungalows Annual Development Plan. The manager is still in the process of commencing her NVQ4 in management. Risk assessments must be up to date, clear and accurate to identity actions to reduce risks. During this site visit just one staff member was in attendance when the inspector called at the bungalow and 3 guests were at the home. The 2nd member of staff was mobile attending to other duty’s outside the bungalow, but later returned to the bungalow during this visit. In previous inspections the issue of managerial hours was noted as an ongoing need. The last action plan submitted by the company identified at least 14 hours a week supernumerary hours for the current manager. This must be reviewed and monitored by the company to ensure this is consistently provided and that the bungalow is not understaffed at any time which would effect individual guests needs and requests which should be demonstrated as a priority of the project and previously demonstrated approximately 18 months ago. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 23 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 3 2 X 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 1 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 X 1 x LIFESTYLES Standard No Score 11 X 12 1 13 2 14 x 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 x 1 X 2 X X 2 x Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 19 Requirement The Responsible Individual must provide pictures for all staff personnel files to meet all parts of Schedule 2 of the care home regulations 2001 Timescale for action 22/09/06 2. YA40 12 (4)(a) 16 (2) (c) 23 3. YA19 15(1)(2) (b) The Responsible Person must 22/09/06 provide suitable and safe facilities to all Guests admitted to the home and provide suitable well maintained garden areas, updated gas safety certificates and updated and recorded fire checks, and updated and current environmental risk assessments. The Responsible Person is 22/09/06 required to provide evidence that all Service Users will be provided with a detailed, accurate and appropriate care plan according to their needs including their social needs, medication needs detailing what actions will be taken to meet this regulation with an appropriate timescale of achieving the transfer to the new care records.. This is a previous inspection requirement. 4. YA35 18 The Responsible Persons must ensure that all staff have updated mandatory training including eg. Abuse awareness training, administration of medications and food hygiene.. DS0000037680.V295248.R01.S.doc 22/09/06 Atkinson Grove Respite Bungalow Version 5.2 Page 26 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 YA35 Good Practice Recommendations To provide evidence of 5 days paid training for all members of staff and ensure all training records are up to date and recorded appropriately meeting all staffs needs. This is an ongoing inspection recommendation 2. YA42 To identify and develop consistent and ongoing managerial hours for the present managerial role. This is a previous inspection recommendation. 3. YA30 To provide an updated written maintenance, decorating & refurbishment programme so that effective consultation and information can be provided for everyone. To develop ongoing and regular minuted staff and Guest meetings and develop areas of open discussions with all parties to keep them informed of all matters within the Bungalow. This is a previous inspection recommendation. 4. YA36 To continue with ongoing Staff meetings and develop the implementation of supervision as per this standard. This is a previous inspection recommendation 5. 6. YA14 YA37 To review current planning of activities and develop procedures to evidence individual needs and requests are being met. The company should carry out internal audits to identify what actions support and resources are needed to evidence that National Minimum Standards will be met including the management of care plans, complaint investigations, medication administrations, management of activities and management of Guests finances, DS0000037680.V295248.R01.S.doc Version 5.2 Page 27 Atkinson Grove Respite Bungalow management of health and safety issues and concerns at the bungalow, supervision and management and training needs of all staff, etc To take the opportunity to arrange a meeting with Representatives of CSCI to discuss the homes inspection report and its findings and the company’s actions to develop this project. Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Atkinson Grove Respite Bungalow DS0000037680.V295248.R01.S.doc Version 5.2 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. 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