Inspection on 15/09/05 for Flat B 12 Hyde Close

This inspection was carried out on 15th September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Flat B 12 Hyde Close 10/07/07

Flat B 12 Hyde Close 16/05/06

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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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 12 Hyde Close Barnet Hertfordshire EN5 5TJ Lead Inspector Tom McKervey Unannounced 15 September 2005 @ 10.00 am th 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 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 Stationary 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. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 12 Hyde Close Address 12 Hyde Close, Barnet, Hertfordshire EN5 5TJ Telephone number Fax number Email 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 Hilary Crowhurst for SENSE Alan Washington PC Care Home only 20 beds Category(ies) of LD Learning Disability registration, with number PD Physical Disability of places 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users do not exceed 20 adults with a learning disability and/or a physical disability. Date of last inspection 7 April 2005 Brief Description of the Service: 12 Hyde Close is managed by an organisation called Sense. It is a service for 20 adults who have sensory impairments, mobility problems and severe or complex learning disabilities. The home is purpose built and is structured in four independent flats with five service users 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 wash-hand basin. There is large sensory garden area to which all residents have access. The laundry room is shared. 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 the four flats. Opposite the home on the same site, there is a specialised day service, which is separately managed. The residents have access to the facilities in the day service as well as other local community resources. 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 usual local amenities. The area is well serviced by public transport. The stated aims of the service are to provide support in which service users can be helped to work towards their optimum potential in areas of social, emotional, developmental and educational activities, and in this way, enjoy a good quality of life. The organisation intends to register each of the flats separately, with its own registered manager. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of five hours. The purpose of the inspection was to determine what progress had been made since the last time the service was inspected, and to identify any shortfalls. The registered manager and three of the flat managers were away at a training event, and one manager was on maternity leave. The deputy managers assisted the inspection process. The inspection involved touring all the flats, talking to each deputy manager and individual staff members. The inspection also included reading residents’ case files and other documents. It was not possible to converse with the residents, because of their lack of verbal skills. However, through observation of how staff interacted with, and cared for the residents, it was possible to form conclusions about the quality of the service. What the service does well: What has improved since the last inspection? There is better communication by the home with the Commission for Social Care Inspection about incidents affecting residents. New furniture and kitchen units have been purchased in the flats, and staffing levels have improved in Flat C. There is a better structure for writing care plans, but they need to be more comprehensive. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 6 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. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 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 standard(s) 2 & 3 There is good information about residents’ wishes and aspirations to guide staff in meeting residents’ needs. EVIDENCE: One case file from each flat was sampled at random, making four in all. Good assessments of individual’ s needs were made and care reviews by social workers were carried out annually. There were excellent guidelines for staff to enable them to recognise resident’s needs and wishes, through a range of communication techniques; for example, objects of reference, gestures and facial expression. Further comprehensive information is provided in individual files referred to as “Personal passports”. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 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 standard(s) 6, 7, 8 & 9 The new care plans are better structured and easier to follow. However, the care plans are very limited and do not cover the full range of residents’ needs. There are excellent guidelines for staff, to enable them to understand residents’ needs and wishes. EVIDENCE: One care plan from each of the four flats were sampled. In all cases, a new format for writing care plans had been introduced. However, there was a very limited scope of needs addressed, which was common to all the plans seen. The case files contained examples of the resident’s likes and dislikes about a wide range of issues, and guidance about how to communicate with, and understand individual resident’s preferences. For example, staff were observed 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. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 10 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 standard(s) 12, 13 & 17 The breadth and range of activities provided enables service users to develop and maximise their potential, and they fully participate in the local community. This enhances their social and educational opportunities. EVIDENCE: Each resident has an activity programme for the week. Each flat has its own vehicle, which enables the residents to access leisure and other facilities in the community. The daily records of four residents were sampled. They contained records of attendance at day centres and leisure amenities, for example swimming sessions. Some residents also attend colleges. During the inspection, some residents were being supported by staff to do some shopping. Residents’ records contained details of individual preferences for food. The menus were varied and wholesome and there was fresh fruit available. Fridges and food cupboards contained ample quantities of food. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 11 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 12 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 standard(s) 18, 19 & 20 The health needs of service users are being met with support from healthcare professionals. Generally, the administration of medicines is safe, but improvement is needed in Flat D to ensure that residents are not put at risk from poor practice in the administration of medication. EVIDENCE: There were good records showing a wide range of appointments with consultants, G.P’s, dentists, chiropodists, audiologists, and specialists in sight and hearing problems. An appointment had been made for a psychology assessment for a resident with challenging behaviour. A recent outbreak of infection in one of the flats had been appropriately dealt with. Accidents and incidents were appropriately recorded. There were records of annual care reviews by social workers, and the manager of each flat compiles a “Purchaser’s annual review” report and sends it to the respective local authority. In Flat D, there was one Resperidone tablet had not been administered and there was a dosage not signed for. A requirement is made about this issue. The medication records were in order in the other flats. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 13 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 standard(s) 22 & 23 Residents are protected by appropriated complaints procedures and staff awareness of their responsibilities about reporting incidents of abuse. EVIDENCE: Two complaints books were sampled. There have been no complaints received at the home since the last inspection. Staff who were spoken to were aware about how to report incidents of abuse, and staff records confirmed that they had received training in adult protection this year. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 14 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 standard(s) 24, 25, 27, 28 & 30 There has been progress in the maintenance of the building and the décor of the home. However, the quality of some flooring, and kitchen and dining furniture is poor, which detracts from a safe and pleasant environment for service users. EVIDENCE: The building is maintained by Stonham Housing Association. Each flat was visited, including communal areas and bedrooms. In Flat A, the carpet in the office area, which is also used by residents, was badly stained, and there was still mould in the bathroom. In Flat C, there was a bad odour in the bathroom, and in the corridor. Some ceiling tiles were also badly stained with water. In Flat D, the floor covering in the bedroom corridor was badly damaged and needs replacing. A requirement is made to address these issues. Several bedrooms were visited. They were clean and tidy and contained personal items. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 15 Specialist equipment, for example, special beds, armchairs and hoists were available for the residents. New dining furniture had been purchased for Flat A, and new kitchen units had recently been ordered for two of the other flats. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 36 The residents needs are met by sufficient numbers of staff who receive regular supervision to support them in caring for residents. EVIDENCE: In the absence of the registered manager, it was not possible to examine staff records. However, an examination of the staff rotas showed that in each flat, there were three staff on the early shift, three on the evening shift and one member of staff awake at night. Two other staff provide support for all of the flats on a sleep-in basis. One resident has funding for one-to-one staff support to meet their special needs, and in Flat B, the rota is arranged to reflect the particular activities each day. There is also a manager on duty in each flat for five days a week. Staff who were spoken to stated that they receive regular supervision from their line managers. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 42 & 43 The residents’ health and safety is protected by good procedures and practices. Important documents and residents’ records are well structured and maintained. A business plan is required to provide the strategy for the future management of the service. EVIDENCE: On the day of the inspection, the registered manager and all the managers of the flats were at a training event, so it was not possible to examine some of the standards relating to the management of the home. A senior manager from Sense, had confirmed to the Commission, that a requirement to ensure that the manager was reinstated full-time in the home, had been complied with. However, as the manager was not present, and a rota of his duties was not available, this will be verified at the next visit. The money held on behalf of one resident was checked against the records and was found to be in order. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 18 Although it is still the intention of the organisation to separately register each manager and each flat, no progress has been made by Sense in pursuing this matter. The requirement to produce a business plan for the home is restated in this report. The Commission for Social Care Inspection had been informed about a serious fire incident in the home recently. This had involved the presence of the fire brigade and a full evacuation of the residents. The staff are congratulated for responding well to this emergency and ensuring the safety of the residents. An appropriate action plan has been put in place to prevent a reoccurrence of this incident. There were records showing that fire alarms were tested weekly and fire drills were carried out regularly. 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Hyde Close Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x 3 x 3 2 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 20 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 6 Regulation 15.1 Requirement Timescale for action 30/11/05 2. 20 13(2) 3. 24 23(2)(b) 4. 30 23(2)(d) The registered manager must ensure that care plans reflect all aspects of service users needs and assessments, objectives and actions are linked. This requirement is restated from the last inspection.The previous timescale was 30/6/05. The registered manager must 31/10/05 ensure that accurate records of the administration of medicines are maintained in Flat D The registered person must 30/11/05 address the following issues: Flat A; have carpet in the office cleaned or replaced. Flat C; replace the stained ceiling tiles. and ensure that there are no offensive odours in this flat. Flat D; replace the floor covering in the corridor. The registered person must 31/10/05 ensure that in Flat C, there are no offensive odours. The registered person must provide an annual business and financial plan for the home.This requirement is restated from the last inspection. The previous timescale was 31/5/05 31/3/06 5. 39 25 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 21 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 Good Practice Recommendations 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 22 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 12 Hyde Close 20050915 Hyde Close X00023 UN Stage 4 S10453 V244936 G59.doc Version 1.40 Page 23 - 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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