Inspection on 11/09/06 for Duke Street Bungalows

This inspection was carried out on 11th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Duke Street Bungalows 09/02/06

Duke Street Bungalows 24/10/05

Duke Street Bungalows 17/11/04

Duke Street Bungalows 27/08/04

Duke Street Bungalows 04/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Duke Street Bungalows 21/23/25 Duke Street Wednesfield Wolverhampton West Midlands WV11 1TH Lead Inspector Rebecca Harrison Key Unannounced Inspection 11th September 2006 09:30 Duke Street Bungalows DS0000036162.V296546.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 Duke Street Bungalows DS0000036162.V296546.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. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Duke Street Bungalows Address 21/23/25 Duke Street Wednesfield Wolverhampton West Midlands WV11 1TH 01902-553356 01902-553356 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.wolverhampton.gov.uk Wolverhampton City Council Miss Margaret Mary Whelan Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 21 Duke St - 6 people, 23 Duke St - 6 people, 25 Duke St - 8 people as described in the Statement of Purpose. 9th February 2006 Date of last inspection Brief Description of the Service: The three purpose-built bungalows in Duke Street were opened in 1996 and are registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of twenty adults with a learning disability. The home is owned and managed by Wolverhampton City Council. The responsible individual is Mr Brian O`Leary and the registered manager of the home is Ms Margaret Whelan. The bungalows are situated close to Wednesfield Shopping Centre and other local facilities. Bungalows 21 and 23 accommodate six people in each bungalow. Bungalow 25 accommodates eight people. Bungalow 21 provides a service to people with a learning disability who are physically active. Bungalow 23 provides a service to people with a learning disability whose behaviours may challenge. Bungalow 25 provides a service to people with a learning disability who also have physical and sensory disabilities. Each bungalow provides single bedrooms and communal living accommodation. The maximum fee charged per person per week is £365.00. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 09.30a.m. and lasted just over six hours. It was carried out by talking with three service users present at the home, the manager, staff on duty, case tracking two service users, observation of some work practices, examination of a number of records and a tour of all three bungalows. 21 key National Minimum Standards for younger adults were assessed during this inspection in addition to Standards 1,5,38 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, staff and managers were very welcoming and co-operated fully throughout the inspection. Since the last inspection one complaint has been received by the home with a satisfactory outcome. No complaints have been referred to the Commission for Social Care Inspection and there has been one referral made under adult protection procedures. What the service does well: What has improved since the last inspection? Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 6 A number of rooms have been redecorated and at the time of the inspection decorators were on site decorating further rooms throughout all three bungalows to improve the environment for the people in residence. 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. Duke Street Bungalows DS0000036162.V296546.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 Duke Street Bungalows DS0000036162.V296546.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new person to the home. EVIDENCE: A Statement of Purpose and Service User Guide is in place and available to service users and their representatives. There have been no new admissions to the service since the last inspection therefore it was not possible to assess key standard 2 on this occasion. Following the loss of one service user the home has one vacancy in Bungalow 25. The manager reported that the home has recently received a referral however this is in the very initial stages. Signed terms and conditions of residency were available on both the care files and were last reviewed in September 2005. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care-planning systems are in place to adequately provide staff with the information they need to satisfactorily meet service users assessed needs. Service users are appropriately supported with decision-making processes and enabled to take responsible risks within a risk-assessed framework. EVIDENCE: Two service users were case tracked and their care files reviewed. Information was detailed and there was evidence that support plans are reviewed and updated on a monthly basis by designated key workers. Minutes of internal reviews held were available and indicate that the service user, family, support staff and day service staff attended the meetings held. It was reported that none of the current people accommodated have a social worker therefore it is the homes responsibility to undertake reviews. However appropriate referrals are made to the local team as evidenced on both files reviewed. A request for a person centred plan (PCP) for one individual was seen and the manager reported that she has sourced relevant staff training to develop PCP’s with the Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 10 people accommodated. The home has one PCP Co-ordinator who is currently off sick however three other staff are awaiting PCP training. Key workers spoken with were very knowledgeable of the individuals whom they support. They were able to provide examples of decision-making processes in addition to how they maintain and promote good links with outside agencies and family representatives. Staff spoken with shared positive examples of how the needs of individuals from ethnic minority groups are promoted within the home. It was reported that one person has an independent advocate and the families and designated key workers represent the needs of the people accommodated. Resident meetings are also held regularly. Various risk assessments seen on files evidence that people are enabled to take responsible risks, which are regularly reviewed and updated. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 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): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lead positive and active lifestyles. Family links are maintained, rights and responsibilities promoted and people provided with a varied diet in accordance with their personal and cultural preferences. EVIDENCE: It was reported that all but one person accommodated attend a variety of day services throughout the week. The person not accessing day provision is supported on a 1:1 basis by agency staff. On arrival to the home one person case tracked was waiting for her ‘Ring and Ride’ transport to attend Wednesfield Project and discussions held with her indicated that she very much enjoys attending this service. Another individual reported that she was waiting to go bowling organised through a day service. Staff confirmed that service users not wishing to attend day services are able to remain at home and be supported by staff on duty. Records seen and discussions held evidence that service users have a good community presence and lead active lifestyles. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 12 Six staff considered transport to access community activities could be improved to provide greater flexibility. One staff member reported that when day services are closed the home could do with additional staff to take service users out more, particularly the people in Bungalow 25 who have higher dependency needs. Family links are well established and people supported to maintain contact through telephone calls and visits. A parents and carers meeting is held every two months and the minutes of the last meeting held on 08.08.06 were available and evidence five families attended the meeting. It was reported that positive working relations have been developed between the home and relatives. Records seen and discussions held with staff on duty indicate that people are encouraged to develop their self-help skills as much as their ability allows. During a tour of the environment the manager was seen to knock on service users rooms prior to entry and the privacy of individuals promoted. Rules in relation to drugs, smoking and alcohol are available. Numerous signed consent forms for opening mail, furniture requirements, photographs, vaccinations were also available. Menus seen indicate that people are provided with a balanced diet and adequate fresh fruit and vegetables were readily available. Staff reported that they are looking to develop pictorial menus. The dietary needs of individuals from ethnic minorities are considered and well catered for. Preferences in relation to dietary needs and support requirements were seen on the two files reviewed in addition to a comprehensive record of foods eaten, which evidenced variety and choice. Evidence was also available of nutritional screening undertaken. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 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): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. The home has an effective system for handling, storing and managing medication which safeguards service users. EVIDENCE: Personal support requirements and preferred routines were documented on the support plans reviewed and provide staff with the necessary information for consistency and continuity of care in addition to manual handling assessments. The manager committed to ensuring support plans are more specific in relation to the level of assistance an individual requires with their personal care. Service users present at the inspection were well presented. Records of one individual case tracked stated that the person takes pleasure in deciding what clothes to put on and enjoys wearing lipstick and earrings, which was an accurate reflection of observations made. Health appointment records were available on the files reviewed and evidence that individuals have regular access to NHS healthcare facilities and the health Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 14 of individuals is closely monitored. Staff reported even minor aliments are reported to the G.P. The general practitioner visited the home in March 2006 and full health checks were undertaken and parents were invited to contribute to health assessments. Heath action plans are currently being developed. Staff spoken with demonstrated a clear understanding of peoples support requirements and considered the health and welfare of people is promoted and individual needs met. There was evidence on the files reviewed that appropriate referrals to health care professionals have been made. Medication procedures appeared satisfactory at the time of the inspection. The home uses the ‘Doset’ system and appropriate arrangements are in place for people requiring medication when off site. It was reported that all staff have undertaken accredited distance learning training on the administration and safe handling of medicines and certificates were available. None of the service users are currently prescribed controlled drugs although a facility for storage is available. Pictorial consent forms for the administration of medication were available on the files reviewed and the manager reported that only prescribed drugs are administered. It was reported that the home are currently piloting a draft procedure for the department for practical observation of administering and witnessing of medication. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are able to express their concerns, and have access to a robust, effective complaints procedure. Procedures to safeguard service users from potential abuse are in place and their rights protected. EVIDENCE: Since the last inspection the home has received one complaint and the necessary action taken and the situation resolved. No complaints have been referred to the Commission for Social Care Inspection. The local authorities guide to making a complaint for people with learning disabilities was available. Service users are supported to manage their finances, which are held at the Civic office. Procedures are in place for monitoring finances and managers audit records on a weekly basis. Security tags are used on service users wallets, receipts of all expenditure held and two signatories seen for all transactions made. The finances of the people case tracked were inspected and were an accurate reflection of the records held. Since the last inspection one referral has been made under adult protection procedures in relation to finances and a staff member is currently suspended. The local adult protection policy and procedure is available and staff spoken with confirmed that they have received training in adult protection and have access to the whistle blowing policy. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 16 It was reported that all but two support staff have undertaken training on the Management of Potential and Actual Aggression (MAPA) and dates have been sourced for the two outstanding staff and new staff. The manager reported that no service user has been subject to physical intervention. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A full tour of all three bungalows was undertaken and each home found well presented, offering spacious living accommodation to the people in residence. Bedrooms are very personalised and reflect individuality and culture. During the inspection decorators were on site redecorating a number of areas within each bungalow and the carpets in bungalow 23 were being steam cleaned. One assisted bath in bungalow 25 has been out of order for some time however managers reported that they have made every effort to ensure service users are not affected while awaiting delivery of parts. A planned maintenance scheule is in place and the manager is allocated a budget for maintenance and renewal. The bungalows are situated in large gounds and contractors are responsible for maintaining the lawns, which were in need of cutting. Discussions held with Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 18 staff and observations made indicate that the grounds could be further developed to benefit service users for example a sensory garden, herb garden, raised flower beds etc. Domestic staff are not employed therefore it is the responsibility of the support staff to ensure people are provided with a clean and safe environment to live. All three bungalows were well presented, clean and free from any offensive odours. Staff receive training in infection control procedures and cleaning schedules are in place and well maintained. Products hazardous to health are appropriately stored and data sheets available in addition to personal protective equipment, hand towels and soap. Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, well-trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Discussions held with a number of staff on duty evidence they are knowledgeable and have a very good understanding of the individuals whom they support. On the inspectors arrival at the home staff were observed to be accessible, good communicators and interacted appropriately with the three service users present. Staff spoke positively about their roles and responsibilities and appeared committed to their work and very service user focused. Staff multi-task and in addition to their support roles are responsible for all domestic and catering duties. Some staff felt that the home would benefit from employing domestic staff to provide more quality time with people. Out of forty three staff employed, twenty five staff members have gained an NVQ level 2 award or above and four staff are currently working towards their awards. Two new employees were seen undertaking induction training during their first day at the home. Their personnel files were reviewed and contained the Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 20 relevant information. It was stated that the new staff would shadow permanent staff until they have completed their induction training. Both staff had been booked to attend a training course during the week in order to acquire the skills and knowledge to support an individual diagnosed with diabetes. It was reported that no other permanent appointments have been made since the last inspection and that the home is now fully staffed. Training files seen were presented to a very high standard and each staff member provided with an individual training profile. A team plan is in place and identifies objectives for the forthcoming year. Individual training needs have been identified through Employee Performance Reviews (EPRS) and include training in hearing impairment, cultural and race awareness, lone working, makaton and person centred planning. Staff spoken with reported that they are provided with good training opportunities and are in receipt of regular supervision and team meetings. Staff stated that team work is effective and staff are employed in sufficient numbers to meet the individual needs of the people accommodated. Duke Street Bungalows DS0000036162.V296546.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, 38, 39, 41 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager, which benefits service users. EVIDENCE: Ms Maggie Whelan is the registered manager of the home and is contracted to work 37 hours per week. She reported that she holds the Certificate in Social Services (CSS), NVQ level 5 in addition to other qualifications appropriate to her role. A team of three assistant managers are employed, and hold responsibility for managing one bungalow each and are overseen by the registered manager. Discussions held with them indicate that they are well qualified and operate well as a management team. All staff on duty spoken with were very complimentary in relation to the registered managers leadership and managerial skills, her values and expectations to provide the Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 22 people in residence with a quality service. Staff stated ‘The manager is excellent, very service user focused, supportive, approachable and fair’. Quality assurance systems are in place and the manager is in the process of collating information from completed questionnaires distributed to staff, stakeholders and parents. Twenty eight completed questionnaires have been returned to date with positive comments recorded to include ‘Couldn’t ask for a better home’. ‘I cannot speak too highly of the efficient and loving care my brother receives…all members of staff deserve the highest of praise and X is fortunate to be living at Duke street’. ‘ Care could not be better, staff always friendly and helpful’. One staff member stated ‘Pity we have to wait so long to get certain courses due to being over subscribed’. Views from stakeholders include ‘Social and emotional needs of service users well met’ ‘Managers and staff work in a very person centred way’. Visits required under Regulation 26 are undertaken and reports available on site. A Service plan is also available which links into the corporate plan. Records seen throughout the inspection were presented to a high standard however the manager was advised to condense information in service user files to aid accessibility of support plans and risk assessments. Health and safety procedures appeared satisfactory at the time of this inspection. Risk assessments, accident records, temperature monitoring charts, cleaning schedules, staff training and service certificates were reviewed. Staff spoken with confirmed that they are in receipt of mandatory training in safe working practices and stated that there are sufficient staff on duty to perform any manual handling tasks required of them. All managers have received IOSH health and safety training in addition to training in risk management. The homes health and safety policy was not reviewed on this occasion. At the previous inspection it was recommended that the Registered Provider address the risk assessment identifying the need for emergency call systems. Discussions held with the manager confirmed that the situation has been addressed and monitors are now provided in the rooms of the two service users identified as requiring them, based on a risk assessment. CSCI have been notified under Regulation 37 of events affecting service users and staff and appropriate action has been taken by the home. Duke Street Bungalows DS0000036162.V296546.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 x 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 4 3 x 3 3 x Duke Street Bungalows DS0000036162.V296546.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A no previous requirements made. 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations It is recommended that person centred plans be devised with service users/representatives as soon as possible in addition to health action plans. 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