Inspection on 10/07/07 for Flat B 12 Hyde Close

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Flat B 12 Hyde Close 16/05/06

Flat B 12 Hyde Close 15/09/05

Flat B 12 Hyde Close 07/04/05

Flat B 12 Hyde Close 09/11/04

Flat B 12 Hyde Close 17/06/04

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hyde Close 12B High Barnet Hertfordshire EN5 5TJ Lead Inspector Tom McKervey Key Unannounced Inspection 10th July 2007 09:30 Hyde Close 12B DS0000010453.V341772.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 Hyde Close 12B DS0000010453.V341772.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. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Close 12B Address High Barnet Hertfordshire EN5 5TJ 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) 020 8449 0964 020 8364 8083 www.sense.org.uk Sense, The National Deafblind and Rubella Association Fiona Jennings Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 5 Date of last inspection 16th May 2006 Brief Description of the Service: 12 Hyde Close is managed by an organisation called Sense. It is a service for five adults, male or female who have sensory impairments, mobility problems and severe or complex learning disabilities. The home was purpose built and is shared by four independent flats with five residents in each flat. Each flat has its own kitchen and lounge area, two bathrooms and a toilet. All the residents have a single bedroom with a washhand basin. There is large communal garden area to which all residents have access. The laundry room is shared, with each flat having its own equipment. Each flat has a separate team of staff, which is led by a manager. At night, there is a waking member of staff in each flat and two sleeping staff are on duty for all four flats. In March 2007, each flat and manager was independently registered by the Commission for Social Care Inspection. Opposite the home, there is a specialised day service, which is separately managed. The residents have access to these facilities as well as other local community resources. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 5 Each flat has its own minibus, which accommodates wheelchairs. The home is situated in High Barnet in a pleasant residential area, and is a short walk away from shops, restaurants, pubs, and other local amenities. The area is well serviced by public transport. The stated aims of the service are to provide support in which the residents are supported to achieve their optimum potential in areas of social, emotional, developmental and educational activities, and in this way, enjoy a good quality of life. Following Inspecting for Better Lives, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. The fees for the service, which are £1736 per week, are paid by various local authorities. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed in five hours and forty minutes. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The newly-registered manager was present during the inspection and offered valuable assistance with the process. Four of the residents were in the home during the inspection, and one was at a day centre. The inspection involved a discussion with the manager and individual staff members. I was unable to communicate with the residents because of their lack of verbal skills, but I observed how the staff interacted with, and provided support to, the residents. I read a sample of residents’ case files and other documents pertaining to the running of the service. I also examined the medication records and visited all areas of the flat, including residents’ bedrooms. What the service does well: The home provides good information to prospective service users about the service it provides, and thorough needs assessments are carried out before people are admitted to the home. All the residents have a licence agreement with the landlord. There are good care plans for the residents that are person-centred and appropriate risk assessments ensure that a full range of activities in the home and the community can safely take place. The staff have an in-depth knowledge of the residents and can communicate effectively with them. There are good systems in place to ensure that the people who live in the home have access to a full range of healthcare, and medication is safely administered. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 7 The system for dealing with complaints ensures that they are investigated and responded to quickly and effectively, and staff are aware of how to protect residents from abuse. The home’s layout enables residents to have access to all areas and their bedrooms are personalised and decorated in their preferred style. The standard of cleanliness throughout the home is very good. Recruitment procedures are thorough and ensure that new staff are properly screened. The staff are deployed when service users’ needs are highest and they are trained to meet the residents’ needs. The manager provides clear leadership to the staff and provides a good model for best practice. There is good monitoring of the service by senior managers from Sense, and there are efficient systems to protect the health and safety of the residents and the staff. What has improved since the last inspection? What they could do better: Two requirements have been made regarding the following: There are worn kitchen units which must be replaced. There needs to be appropriate screening installed in the dining room/ lounge area to protect the privacy of the residents. A recommendation is made that the manager consults the G.P. about staff being authorised to administer an injection for a specific resident. It is also recommended to update the Service User Guide so that it refers specifically to Flat B. Please contact the provider for advice of actions taken in response to this Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 9 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 Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. Admissions are not made to the home until a full needs assessment has been undertaken. Residents are provided with a Licence Agreement/Contract; this sets out in detail what is included in the fee. EVIDENCE: The Statement of Purpose has been updated following the new registration of Flat B and the manager. The Service User Guide now needs to be similarly updated to focus specifically on the service provided by Flat B. This should include a summary of the Statement of Purpose and the fees charged for the service and what is covered by the fees. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 11 Each person who lives in the home has a licence agreement with the landlords who own the building and provide the major upkeep. No new people have been admitted in since 1994, but the residents’ case files include needs assessments that were completed prior to admission to the home. Care reviews are also carried out annually by care mangers from the placing authorities to ensure that the home continues to meet the residents’ needs. The manager told me that negotiations were taking place with one local authority for extra funding for a resident who has been assessed as requiring one-to-one staffing periodically. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. Each person living in the home has a care plan that includes a comprehensive risk assessment, which is reviewed regularly. The staff are skilled at understanding the residents’ wishes and how to support them. EVIDENCE: I examined three residents’ care plans. The care plans were designed to reflect the individual needs and preferences of each person. The plans included guidelines about communicating with the resident and how to interpret their behaviours. Each resident has an allocated key worker who is responsible for compiling and reviewing the care plan. Monthly reviews are documented by the key workers. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 13 The residents are non-verbal, but by discussing with the staff, I was satisfied that they are able to understand the non-verbal communications of the residents to determine their wishes and how to support them in decisionmaking. For example, residents and staff were observed interacting using objects of reference like cups, keys and items of clothing. Signing was also evident when offering choices to residents. Assessments of potential risks to residents when in the home and in the community had been carried out; for example, when bathing and when travelling in the minibus. These assessments positively contribute to the residents enjoying full lives in the community. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. People who use services are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. Help with communication skills is given by the staff team to enable residents to fully participate in daily living activities. People who use the service have the opportunity to develop and maintain important personal and family relationships The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. EVIDENCE: Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 15 One resident was at their day centre, and during the inspection, other residents were accompanied to the local shops. One person appeared to be enjoying sitting in a hammock. Four residents attend a day centre on various days during the week, and on other days, an in-house individual activity programme is drawn up and included in a “shift planner”. This identifies the staff who are allocated for each resident’s activity, which is then recorded in the resident’s daily log. Some residents help with household tasks such as preparing meals, cleaning and shopping for food. There was ample evidence in the records to show that all residents spend significant time in the local community; for example, eating out, going to the cinema and swimming. All the people who live in the home have either already had a holiday this year, or it was being planned for later this year by the key worker. The manager told me that some residents go home to their relatives for periods of time. There was evidence in residents’ care plans that their sexual needs were considered and there was written guidance for staff about this. Food shopping for that day’s meals is done each day by residents and staff, and a “big shop” is done weekly. A record is kept of the meals eaten each day. Two residents are on special diets, for which advice had been sought from a nutritionist. Residents’ records contained details of individual preferences for food. The staff described how they used pictorial and other means to prepare menus, which were varied and wholesome. There was fresh fruit available. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the varied and individual needs and preferences of the people who use services. Personal healthcare needs are clearly recorded in each resident’s plan. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: All the residents require full support for their personal care. There are extensive guidelines about how each resident prefers how this is to be provided to respect their dignity. I observed that all the residents were clean and well dressed. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 17 Emergency files have been prepared for each resident to advise medical staff about medical histories, allergies etc, in the event that they have to go to hospital. The case files I looked at, contained good records of appointments with the G.P., dentists, chiropodists and opticians. Speech and language therapist reports were also seen for some residents. Each resident has a “health action plan”, written in the first person, for regular health checks with the Community Learning Disability Team. A resident was being treated and undergoing tests for a serious medical condition. Otherwise, the manager reported that the residents were in generally good health. Monitoring charts were being recorded for a resident who sometimes exhibits challenging behaviours. There was advice from a psychologist in the case files to guide staff about this. The medication and records were checked. Following an administration error recently, the company requires two staff to administer the medication. There is a system for monitoring compliance with this. No errors were found in the administration records and the medication was found to be safely stored and accounted for. At the time of the inspection, a resident was receiving a daily injection from a District Nurse. However, the manager told me that this resident needs consistency in who provides their care and because a different nurse often visits each day, this was causing distress to the resident. I indicated to the manager that it may be appropriate for the home’s staff, in consultation with the G.P., to be trained to administer this injection, and I have made a recommendation for the manager to pursue this. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. The staff understand the procedures for Safeguarding Adults and how to report concerns. EVIDENCE: The home has an appropriate complaints procedure. No complaints have been received by the home in the past year. There is a copy of Barnet local authority’s Protection of Vulnerable Adults procedure in the home. The manager had informed the Commission for Social Care Inspection about two recent incidents that could have adversely affected the welfare of the residents. These incidents had been properly investigated and effective action had been taken as a result. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 19 The staff have attended training in the subject of protection service users from abuse, and in discussion with the staff, I was satisfied that they were fully aware of their responsibilities in this regard and knew how to report any concerns. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 29 & 30 People who use this service experience adequate outcomes. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. However, the residents’ privacy is compromised by the lack of proper screening of the lounge windows. People who use services are encouraged to personalise their bedrooms. Toilets and bathrooms for the use of people using the service are appropriately located within the home, are easily accessible and in sufficient numbers. The home is well lit, clean and tidy and smells fresh, and infection control procedures are good. EVIDENCE: Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 21 Access to Hyde Close is protected by a coded pad and visitors have to press the appropriate call button to gain entry. Flat B occupies part of the first floor of the building and has its own front door. There is a decked balcony off the lounge is protected by a safety gate and there is a fire escape to the ground. The communal garden, which is shared by all four Flats, was in a very neglected state and a requirement is made to address this. I visited all areas of the home, including residents’ bedrooms, which were tastefully decorated and individualised. Personal items were in evidence, for example, photographs and sensory equipment and toys. In one bedroom, I saw a hoist, which is required to help the resident in and out of bed. Each resident has their own bedroom, which contains a washbasin, wardrobe and other appropriate furniture. The bedroom furniture was generally in good condition and tactile symbols were on the bedroom doors to help the individual to identify their room. The bathrooms and toilets were clean and tidy and there was appropriate equipment to support the residents with using the toilet and bathing. The lounge and dining furniture was in good condition, but the kitchen units are old and in some cases, parts were loose or missing. The manager said that it had been agreed to replace the kitchen, but there did not appear to be any timescale set for this, so I am making a requirement to address this issue. There is a maintenance person employed for the building for minor repairs and there were no major maintenance issues outstanding. There were no curtains on the lounge windows. The manager said that a resident always pulls these off the wall. As a compromise, the manager has put an opaque half-screen halfway up the windows. However, this only partially screens the lounge from outside views and is not satisfactory. A requirement is made to provide proper screening to protect the residents’ privacy. A part-time cleaner is responsible for cleaning the communal areas of the building and the care staff are responsible for cleaning within the flat. At the time of this inspection, the home was very clean and tidy and there were appropriate procedures and effective controls in place to prevent infection. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 22 Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure that clearly defines the process to be followed. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. Staff meetings and supervision sessions take place regularly. EVIDENCE: Two staff have attained National Vocational Qualification level 2 and one has NVQ level 3. all new staff undergo a thorough induction, which is in a written format that has to be signed off when each module is satisfactorily completed. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 24 Staff have also attended mandatory health and safety subjects, for example, food hygiene and fire training. Courses relevant to the needs of the residents are provided, including epilepsy and “non-violent crisis intervention”. The staff rotas showed that they are deployed when the residents’ needs are highest and the staff told me that there were sufficient numbers on duty to meet residents’ needs. A member of staff had just resigned and at the time of this inspection, there was only one vacancy which was covered by regular bank staff to provide consistency and continuity of care. I examined the records of two new staff and was satisfied that proper procedures were followed in their recruitment, including interviews, references being obtained and Criminal Records Bureau checks. I saw records of formal staff supervision, and the staff to whom I spoke, said they found this process to be very valuable in supporting them in their work as carers. There are regular, minuted meetings at which the staff are able to express their views about the service. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41 & 42 People who use this service experience excellent outcomes. This judgement has been made using available evidence including a visit to this service. The manager is able to demonstrate through formal qualification, robust operational systems and professional experience and ability that she is knowledgeable and highly competent in a range of areas. Spot checks and quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. The home has efficient systems to ensure effective safeguarding and management of individual’s money including record keeping. There is full and clearly written recording of all safety checks and accidents, Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager has been in charge of Flat B for some years and has recently been registered by the Commission as such, following the separate registration of each of the flats. She has many years of experience of working with people with learning disabilities and has completed the Registered Managers Award at National Vocational Qualification level 4. She also completed a course in sign language. As part of the monitoring process, the manager works every second weekend on the rota, which is good practice. The organisation “Sense”, has recently been awarded the “Investors in people” award which demonstrates its commitment to training and developing its staff. The atmosphere in the home was relaxed and friendly. The staff told me that the manger was very efficient, provided clear leadership, and set high standards. She was described as fair and approachable in her dealings with the staff. I was informed that Sense was currently conducting an audit of the quality of its services. Senior managers carry out unannounced monitoring visits and report on a range of outcomes. The residents’ case files contain information about their personal finances, including benefit entitlement. I examined a resident’s cash box at random and found that the records were in order and matched the amount of cash available. I saw certificates of safety for the gas, electric, water and fire systems. The hoists and lift were serviced in the last year, as were the electric portable appliances. There are records of monthly health and safety audits of all areas of the home. Accidents and incidents were recorded and appropriate actions were taken to minimise these. The fire alarms were tested weekly and drills were regularly carried out. There is an up to date employers liability insurance for the service. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 27 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 3 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 2 25 3 26 3 27 X 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 3 X X 3 3 X Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 28 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 YA24 Regulation 23(2)(c ) Timescale for action The worn kitchen units must be 31/08/07 replaced. This requirement is restated from the last inspection. The previous timescale was 31/03/07. 2. YA28 12(4)(a) The dining room/lounge area 31/08/07 must be properly screened to protect the residents’ privacy. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard YA20 YA1 Good Practice Recommendations The manager should consult the G.P. about staff being authorised to administer an injection for a specific resident. The manager should update the Service User Guide so that it refers specifically to Flat B. Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hyde Close 12B DS0000010453.V341772.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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