Inspection on 16/05/06 for Flat B 12 Hyde Close

This inspection was carried out on 16th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Flat B 12 Hyde Close 10/07/07

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

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 12 High Barnet Hertfordshire EN5 5TJ Lead Inspector Tom McKervey Unannounced Inspection 16 & 17th May 2006 10:00 th Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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 12 DS0000010453.V289948.R01.S.doc Version 5.1 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 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hyde Close 12 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 The National Deaf, Blind and Rubella Association Mr Alan Washington Care Home 20 Category(ies) of Learning disability (20), Physical disability (20) registration, with number of places Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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. 15th September 2005 Date of last inspection 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 divided into 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 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 these facilities 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 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. “Sense” intends to register each of the flats separately, with a registered manager in each. Following “Inspecting for Better Lives”, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and was completed in a total of eight hours. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. Since the last inspection, the registered manager had resigned and has taken up other duties for the organisation. However, he retains an overseeing role for the home and he was present at the beginning and end of the inspection. At the time of this inspection, there were three flat managers in post and there was one managerial vacancy. Two of the managers were present during the inspection and one deputy manager, all of whom assisted with the inspection process. The inspection involved a visit to all the flats, talking to each person in charge, and individual staff members. The inspector attended a staff handover, and afterwards held a discussion with the group of staff. The inspection also included reading residents’ case files and other documents pertaining to the running of the service. It was not possible to converse with the residents, because of their lack of verbal skills. However, through observation of the residents and how staff interacted with, and cared for them, it was possible to form impressions and conclusions about the quality of the service. What the service does well: Service users and their representatives are provided with information about the service, which is in written and audio form. very good There are excellent guidelines to enable staff to communicate with, and ascertain the residents’ wishes in order to meet their needs. The relationship between staff and residents is warm and caring and there is good communication between the staff and the relatives of residents. The range of activities in the community is extensive. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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 Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, & 4 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. New residents are thoroughly assessed regarding their needs, and they and their representatives, are able to visit the home before moving in. EVIDENCE: One new resident was recently admitted to the home. This resident had been transferred from another “Sense” home that was in the process of closing. The resident’s case files contained evidence of assessments by the previous home and by senior staff from Hyde Close, before admission. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 9 The home was purpose built to provide a very specialised service for people with learning disabilities and physical and sensory impairments. Upstairs accommodation is accessed by lifts that can take wheelchairs. Staffing levels in each of the flats reflects high levels of support, as required by the assessed needs of residents. Sense provides training courses on how to meet the specific needs of service users. The accommodation of residents in four separate flats, enables care to be provided in a more individualised manner. The inspector was informed that two staff had been seconded to support the resident in the previous home prior to the move and trial visits and stays had taken place in Hyde Close. This resident’s parents and sister were present during the inspection and were spoken to. They said that they had visited the home prior to the transfer and found the staff to be very helpful in making the transfer as smooth as possible. During the inspection, the relatives were given a copy of the Service User Guide and Statement of Purpose. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is a lack of consistency in the implementation of residents’ care plans in one of the flats. This could lead to staff not having full information about residents’ needs and how to meet them. The staff are skilled at understanding the residents’ wishes and how to support them, and there are appropriate risk assessments in place to protect residents from harm. EVIDENCE: Four care plans were sampled, one from each flat. The inspector was informed that Person Centred Plans were being gradually implemented. However, there was a lack of consistency in how current care plans were structured. For example, some care plans covered all aspects of the individual’s needs, but others were very limited in range. A care plan for a new resident in Flat C had not drawn up, but the care plan from their previous home was being used. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 11 A requirement is made to provide comprehensive care plans for all residents. Although the inspector was informed that Personal Centred Plans (PCP)’s, were being introduced, there was little evidence of progress. The residents are non-verbal, but staff are able to understand the non-verbal communications of the residents to determine their wishes and how to support them in decision-making. 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. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The breadth and range of activities provided enables residents to develop and maximise their potential. Appropriate measures are taken to develop and maintain contact between residents and their relatives where this is problematic. The home is well integrated with the local community, which enhances the residents’ social and educational opportunities. Meals are nutritious and varied and offer plenty of choice. EVIDENCE: Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 13 There is a programme for each resident that details activities for the week. In addition, a shift planner is used to allocate staff to residents to support their activities on a day-to-day basis. 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 gave details of attendance at day centres and leisure amenities, for example swimming sessions. Some residents also attend day centres and colleges. One resident has a book read to them in their room, and during the inspection, two residents were having a hand massage. During the inspection, some residents were out shopping and another was out for a walk with support by staff. In one flat, a personal computer has been provided for residents and two residents were observed working on it enthusiastically, supported by staff. At the tome of the inspection, a resident was on holiday in Cuba with two staff for two weeks. There is an open visiting policy at the home, but the majority of residents are taken home by their relatives. In one instance, the staff are making strenuous efforts to increase a resident’s visits to the family home, which had been a problem in the past. 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. An excellent example of communication about the day’s menu was seen in one of the Flats. This was using computer-generated laminated pictures to display on the fridge, which showed what was on the menu. Fridges and food cupboards contained ample quantities of food, which was stored safely. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality in this outcome group is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ privacy and dignity in one flat, is at serious risk by male staff supporting female residents in their personal care. Residents’ physical health and well-being is safeguarded by appointments with healthcare professionals and by the safe administration of medicines. EVIDENCE: The inspector was very concerned to be told by staff in one flat that sometimes male staff have to undertake personal care for female residents on their own when female staff are not available. It was said that help was not always available from the other flats. When asked about this issue, the inspector was told by the senior staff in the other flats that they would certainly have provided assistance but had not been asked. The inspector was assured that this practice would cease immediately. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 15 A requirement is made that personal care for female residents is only supported by female staff. There were records showing a wide range of appointments with consultants, G.P’s, dentists, chiropodists, audiologists, and specialists in sight and hearing problems. Appointments were made for psychological assessments for residents with challenging behaviour. Each resident has a profile document to go with them if they have to attend hospital in an emergency. The accident book was completed properly. One resident showed a recent history of falls, for which a referral had been made to the G.P. A recommendation is made to provide a falls monitoring chart to enable any patterns to be detected and appropriate intervention to be made. The medication standard was checked in each flat. No errors were found in the administration of medicines records and the medication was found to be safely stored and accounted for. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are protected by appropriate complaints procedures. Staff are trained in adult protection and are aware of their responsibilities about reporting incidents of suspected abuse. EVIDENCE: Each flat has its own system for logging complaints. Since the last inspection, only one complaint had been received. There was a letter from the social worker concerned, complimenting the staff about how this complaint had been dealt with and was resolved satisfactorily. Staff who were spoken to were knowledgeable about adult protection issues and how to report incidents of abuse. Staff records showed that they had received training in adult protection. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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, 25, 30 The quality in this outcome group is poor. This judgement has been made from evidence gathered both during and before the visit to this service. There is a lack of urgency by the landlord in attending to maintenance and repairs. Two bathrooms being out of use for long periods are hampering the care of the residents. In the absence of an overall manager, it is not clear who is responsible for cleanliness and maintenance of some shared areas of the home. EVIDENCE: The building is maintained by Stonham Housing Association. Each flat was visited, including communal areas, bathrooms and bedrooms. The garden at the rear of the building was very attractive. The inspector was informed that staff from one of the flats had taken the lead to develop the garden and that some residents had been involved in the work. In the corridor leading from reception, a light shade was missing. At the rear of the building, there was old furniture and builders rubble lying around, which needs to be disposed of. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 18 Flat C A week before the inspection, a bathroom was taken out of use due to being flooded form the flat above, which brought the ceiling down. This had been reported and was awaiting attention from the landlord. There was still a persistent bad odour in this bathroom, which the inspector was informed, was due to poor drainage. Flat D In the large bathroom, the floor cover had been damaged by a resident in February 06, and consequently, this bathroom had been out of use since that time. The maintenance book showed that the staff had reported the problem to the landlords every week, but this had still not been addressed. The lounge curtains had been pulled down by a resident and the staff said that a quote for more secure fixings had been obtained and was now waiting to be done. A lampshade was missing in one resident’s bedroom. In two flats, the kitchen units were damaged and the inspector was informed that there were plans to replace them this year. The inspector was informed that an advertisement had been placed for a part time cleaner for the home. At the time of the inspection, the home was generally clean and tidy, but in the reception area, there were bits of paper lying about and the area looked neglected. Requirements have been made to address all these issues. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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, 35 & 36 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient numbers of staff on duty to meet residents’ needs and residents’ welfare is safeguarded by appropriate staff recruitment procedures. There is a training and development programme for staff and they receive regular supervision to support them in caring for the residents. EVIDENCE: Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 20 The staff rotas in each flat were checked. The staff numbers varied in each flat to reflect the dependency of the residents. In all cases, there were sufficient staff on duty during the day and there was one member of staff awake at night. Two other staff provide support for all of the flats on a sleep-in basis. One resident had funding for one-to-one staff support to meet their special needs, and a new resident has two extra staff to support them while they settle in to the home. There is also a manager or deputy on duty in each flat for five days a week. Staff who were spoken to stated that they were happy with the number of staff available. The records of three recently recruited staff were examined. They showed that proper procedures had been followed, including references and Criminal Records Bureau vetting. An inspection of the staff records showed that all staff have an induction when starting work at the home. They also receive mandatory training in fire safety, food hygiene etc. Many staff have attained National Vocational Qualification level 2 and 3. There were records showing that the staff receive regular supervision from their line managers. Staff said that they valued having formal supervision. Typical comments were “ It is very useful to raise issues with my manager, for example, my training needs.” “Supervision gives me more confidence in my work with the residents.” Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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, 42 & 43 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There are good systems in place for ensuring residents’ and staffs’ health and safety. There is no clear overall leadership in the home. Management has been devolved to individual managers in each flat. However, until the flats are separately registered and clear responsibilities are defined, there is risk that important communal issues are not addressed. It is not clear how the service is to be developed, as a business plan is not available, and the views of service users or their representatives about the quality of the service, are not published. EVIDENCE: Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 22 The person who was the registered manager for the home, resigned in February 2006 when he became Sense’s locality manager. In the interim, he has a line management role for each of the flat managers. However, there is no one in overall charge of the home. There has been an elongated process of separately registering each flat and manager. As commented under the Environmental Standards, there are a number of issues that are currently shared between flats, for which responsibility has not yet been identified, and a requirement is made for this matter to be addressed. At the time of the inspection, the post of manager for Flat C was vacant, but the process of filling the post was underway. The inspector was informed that a quality assurance audit of the service had taken place this year, which included canvassing the views of residents and their representatives. However, the results of the survey were not yet available. A requirement is made for the results of the survey to be summarised and included in the Service User Guide. A copy of this information must also be sent to the Commission for Social Care Inspection. The locality manager stated that a business plan had been prepared for 2006, but this was not available at the time of the inspection. This is necessary to ensure the continued development of the service. A requirement is made for this to be sent to the Commission for Social Care Inspection. Personal money is held in each flat for residents’ use. A sample of the records showed that they balanced with the amounts of cash held. Receipts were retained for purchases mad on behalf of residents. Health and safety issues were examined. There were certificates of safety for fire, heating and water installations. Lifts and hoists and special adaptations were serviced within the past year, and portable electrical appliances were tested for safety. Fire alarms and emergency lighting were tested weekly and there were records of fire drills being carried out. There was an up to date employers liability insurance certificate on display. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 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 X 2 3 3 3 4 3 5 X 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 1 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 1 3 3 X 1 1 2 X 3 3 2 Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 24 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 YA6 Timescale for action 15.1 The registered manager must 30/06/06 ensure that a care plan is drawn up by the home’s staff for each resident, and that care plans reflect all aspects of service users needs. 12(4)(a)(b) The registered person must 30/06/06 ensure that only female staff provide personal care for female residents. 23(2) The registered person must 30/06/06 ensure that light shades are provided in all areas where they are missing. 23(2) The registered person must 31/07/06 ensure that old furniture and builders rubble is disposed of. 23(2) The registered person must 30/09/06 replace the kitchen units in two of the flats. 23(2) The registered person must 30/06/06 ensure that repairs are carried out to the two bathrooms that are currently out of use. 23(2) The registered person must 30/06/06 ensure that the offensive odour in the bathroom in Flat C is addressed. 8(1)(a)(b) The registered person must 31/07/06 apply to the Commission for DS0000010453.V289948.R01.S.doc Version 5.1 Page 25 Regulation Requirement 2. YA18 3. YA24 4. 5. 6. YA24 YA24 YA24 7. YA30 8. YA37& YA38 Hyde Close 12 9. YA43 25 Social Care Inspection for registration of the managers of the flats. This requirement is restated from the last inspection. The previous timescale for this requirement was 31/05/06 The registered person must 31/08/06 provide an annual business and financial plan for the home. This requirement is restated from the last inspection. The previous timescale for this requirement was 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations The registered person should provide a system of falls monitoring for a specific resident in Flat B. Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southgate Area Office 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 Hyde Close 12 DS0000010453.V289948.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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