Inspection on 15/07/08 for Flat C 12 Hyde Close

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Flat C 12 Hyde Close 31/08/07

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 08/11/2008.

CARE HOME ADULTS 18-65 Hyde Close 12C High Barnet Hertfordshire EN5 5TJ Lead Inspector Brian Bowie Key Unannounced Inspection 15th –24th July 2008 18.00p Hyde Close 12C DS0000069373.V364602.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 12C DS0000069373.V364602.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 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Close 12C 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 8441 5289 anita.grant@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12C DS0000069373.V364602.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 31st August 2007 Brief Description of the Service: 12c Hyde Close is managed by Sense. It is a service for adults who have sensory impairments, mobility problems and severe or complex learning difficulties. The four flats in the building at Hyde Close are registered as separate homes by CSCI and each has its own team of staff, including a manager. 12c Hyde Close accommodates 5 people in their own rooms and has a kitchen/lounge area and two bathrooms. Each person has his or her own single bedroom with a washbasin. There is a large shared sensory garden area and a patio. The laundry facilities are shared between the flats. During the daytime there is either four or five members of staff to support the residents. At night there is one waking night member of staff and a person sleeping in who is on call. The flat has two vehicles of its own to enable residents to get out and about in the community. The home is situated in High Barnet, in a pleasant residential area, close to shops, restaurants, pubs and other local amenities. The area is well served by public transport. Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 5 Sense summarised the aims of 12c Hyde Close as: ‘A Person-Centred Planning approach is used to maximise each person’s opportunities for independence, to support them in establishing relationships in the local community and to promote their rights as citizens whilst meeting their support needs.’ Following ‘Inspecting for Better Lives’, the provider must make information about the service, including inspection reports, available to residents and other stakeholders. The fees for the home are negotiated with the funding authority on an individual basis following a full assessment of need and at the time of the inspection ranged between £1795-£3,576/week. Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection is the annual key inspection and the aim is to look at how well the service is meeting the key National Minimum Standards for Younger Adults. The unannounced inspection consisted of four visits over the period of a week. Additional visits were made so that key information which was not initially available could be seen. The inspection began at teatime so that the early evening routines in the home could be observed. The manager and deputy were interviewed and assisted with the inspection. The locality manager for Flat 12c was also spoken to as part of the inspection. A member of staff showed us around the flat. All five people resident in the home at the time of the inspection were seen. Each resident has significant communication difficulties, so throughout the inspection the way in which staff communicated with and supported residents was observed, as well as how residents got on with staff. We also interviewed staff to get their views and comments on the home. Relatives and care professionals involved with the home provided written feedback on what they thought about the home. We received four surveys completed by relatives, 1 by a health professional, and 4 from members of staff. A wide range of records, including care plans, staff files and health & safety documents, were also looked at. The home’s Annual Quality Assurance Assessment also provided considerable detail about the running of 12c Hyde Close. The inspector would like to thank the staff and management team at 12c Hyde Close for their assistance with the inspection. What the service does well: The overall impression from the inspection was that the staff team works hard to support residents within a friendly and homely environment. This was confirmed by some of the positive feedback, written and verbal, that was received from relatives and professionals involved with the home. A relative of a resident commented: ‘We couldn’t ask for better care for my relative. We are very happy.’ ‘They provide a clean home, that has a good friendly atmosphere. Our relative appears happy and is well fed. They have a lovely bedroom and an adapted back garden suitable for wheelchair users.’ Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 7 The home has an established and stable team of staff that demonstrated a good knowledge of the people living in the home, with staff able to recognise the individual needs of residents and respond appropriately to them. The residents were observed to be very relaxed within their home environment. There are detailed and helpful guidelines to enable staff to communicate with the people living in the home and to help determine and meet the needs of residents. The people living in the home have a good relationship with the staff and feel comfortable and confident to express their wishes using a range of communication to which the staff respond appropriately. The residents are supported to go to a range of leisure activities based on their individual interests and this enables them to have participation in the local community. Some of the people living in the home have close contact with families and friends and this is promoted by the home. The home is comfortable and spacious and the residents each have a single bedroom that is personalised to their taste. There is also an attractive sensory garden at the rear of the flat. The home has access to two vehicles which enables residents to get and about regularly. What has improved since the last inspection? What they could do better: Arising from this inspection there are eight specific areas that must be improved. Sense must ensure that 12c Hyde Close has an up to date and accurate Service User Guide, containing all the required information, so that all key parties are informed about the service provided and know what to expect from it. The manager must ensure that there is clear evidence in the care planning process that actions agreed at placement reviews have been followed up by the home, as well as reviewing medication procedures in the home in order to ensure residents are protected in this area at all times. The manager must ensure that an audit is made of current training needed by staff with an action plan and schedule to achieve this. Sense must ensure that an application is submitted to CSCI for a registered manager to be in place at 12c Hyde Close. It is also essential that rigorous management systems are in Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 8 place at 12c Hyde Close so that key information is available at all times for inspection including the home’s records in relation to health and safety which must be accurate and up to date. The manager must ensure that there are regular fire drills at 12c Hyde Close that are in line with Sense’s procedures for this flat. It is important that these areas are acted on in line with the timescales given so that the recent improvements in the home can be maintained and extended. It is planned to carry out a further inspection of the home by the end of March 2009 to check on progress being made. Three recommendations are made to improve care practice further in the home. Sense should review the existing care planning formats being used so that all parties are clear what a care plan looks like and consists of. Staff should be given more guidance and training in the area of personal and sexual relationships so that they can support residents more effectively in this area. Finally Sense should review its fire safety procedures at 12c Hyde Close so that it is clear which procedures and responsibilities are specific to the flat and which are generalised across the four flats at Hyde Close. At the conclusion of the inspection the management team indicated that they were keen to follow up all areas for improvement and recommendations made and that they were committed to a process of continuously raising standards within the home. 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. The summary of this inspection report can be made available in other formats on request. Hyde Close 12C DS0000069373.V364602.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 12C DS0000069373.V364602.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information about the home is available so that residents and families know what they can expect from 12c Hyde Close. People moving into the home can be confident that their needs and wishes will be fully assessed and an appropriate plan for meeting these needs will be drawn up. As a result their needs are met. EVIDENCE: At the outset of the inspection key documents were not available or were out of date. However by the end of the inspection a revised and updated statement of purpose had been produced that is clearly written and contains detailed information about 12c Hyde Close. A new brochure about the flat had also been produced in an attractive and user-friendly format. Elements of the Service User Guide that gives all key parties essential information about 12c Hyde Close were available, including some information in audio format, but had not been collated into an information pack as required. Sense must ensure that 12c Hyde Close has an up to date and accurate Service User Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 11 Guide, containing all the required information so that all key parties are informed about the service provided and know what to expect from it. The files for 3 of the residents were looked at and indicated that before they moved in a full assessment had been received from Social Services. A care plan had then been drawn up by the home showing how these needs were to be met. All five residents indicated from observation that they were settled at 12c Hyde Close. At the most recent placement review the social worker had noted in relation to one resident: ‘This individual seems to be settled at 12c Hyde Close and they are doing well as they are familiar with their environment and they are used to the layout of the building. Their cultural needs are met at the home.’ Hyde Close 12C DS0000069373.V364602.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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide detailed information so that in general the needs of residents are met. However residents lack the protection of care plans that systematically follow up actions agreed at annual reviews. The staff team at 12c Hyde Close is good at finding ways for residents to make as many decisions for themselves as possible. Residents are protected by risk assessments that are comprehensive and indicate clearly how risks to the safety of residents are reduced, whilst still promoting independence. EVIDENCE: At the outset of the inspection care plans were in a variety of formats, with some not accessible to the management team. It is recommended that Sense Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 13 reviews the existing care planning formats being used so that all parties are clear what a care plan looks like and consists of. By the end of the inspection considerable work had been carried out on the care plans. As a result they are now in a person-centred format that is visually attractive and much easier to use. For each resident there is a significant amount of detailed information relating to their health needs, their communication needs and their behaviours. All of the four residents whose case notes were inspected have complex behaviours. These people have behavioural guidelines describing how the staff should most appropriately support them when they are angry or distressed. These guidelines were clear and helpful. Care plans record the cultural and religious needs of residents. One placement review had noted: ‘ ‘The resident’s cultural needs are met at the home.’ Each resident had had an annual review in the past year that had agreed follow up action to be taken. However it was not clear from the records looked at whether all actions had been followed up and whether they had been implemented through the individual’s care plan and monthly reviews. The registered manager must ensure that there is clear evidence in the care planning process that actions agreed at placement reviews have been followed up by the home. The residents’ independence is being promoted by staff at 12c Hyde Close who offer them choice in choosing activities they enjoy and assisting them to develop in all aspects of their daily living skills. Throughout the inspection residents made choices about when they got up in the morning or went to bed, when they had their meals, what they ate, and whether they went out or not. As a result residents feel they have more control over their lives and this is contributing to their life at 12c Hyde Close being a positive experience for them. Residents’ files contain a variety of detailed risk assessments in order to ensure each resident’s safety, whilst promoting independence wherever possible. These included guidelines for staff when supporting people in the community so that resident could get out and about to local shops, whilst identifying ways of reducing any possible dangers to their safety, or the safety of others. Hyde Close 12C DS0000069373.V364602.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is good at enabling residents to get out and about so that they lead as ordinary a life as possible. Staff support residents to keep in close contact with friends and family, as well as respecting their rights and encouraging them to act responsibly. Residents enjoy their meals and benefit from being offered a diet that is healthy and reflects their cultural preferences. EVIDENCE: During the inspection residents were involved in a range of activities, both inside and outside of the flat. These included going to a local park, to the shops and local cafes. At home staff supported residents to do some gardening in the sensory garden area, to help with some domestic tasks and to use specialist equipment and aids to provide various types of sensory Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 15 stimulation. Residents also go out to various clubs and make use of some of the sessions at the specialist day centre run by Sense opposite 12c Hyde Close. In addition there are regular outings, including trips to the seaside and theme parks. During the inspection residents went out and about into the community to a variety of locations. One resident has their own car and goes out regularly with staff. Residents also go off on holidays in small groups or on their own with staff support. The experience of the residents at 12c Hyde Close therefore is that they are part of their local community. Surveys from relatives confirmed that families of residents have good working relationships with staff at the home. Residents in some cases are having regular contact with their families. Staff interviews indicated that staff have had some training in supporting people with personal and sexual relationships, but would benefit from more guidance in this area. This was supported by the home’s own assessment of this area in their annual quality assurance assessment. It is recommended therefore under the staffing section of this report that staff are given more guidance and training in this area. Observation throughout the inspection indicated that staff treat residents with respect and are patient when encouraging residents to do something. One relative had commented: ‘We couldn’t ask for better care for my relative.’ The vulnerability of the residents means that throughout the home various methods of safeguarding them are used. Some of these amount to environmental restraints, such as locking some doors. In the light of new legislation and amendments in the form of the Mental Capacity Act and the Deprivation of Liberty Safeguards the manager should review existing arrangements and procedures in order to identify any changes needed and ensure that these arrangements are properly recorded. The home has a varied menu that is changed regularly. Residents were observed enjoying their meals, with assistance provided by staff as needed. Healthy eating is encouraged with regular weight checks made. A placement review had noted about one of the residents: ‘They like their ethnic meals, which are spicy. They go out to the restaurant. Their ethnic needs in this area are catered for by the home.’ Throughout the inspection residents had opportunities to eat and drink out in the community as well as at home. Staff files showed that staff have food hygiene certificates. Hyde Close 12C DS0000069373.V364602.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are good at meeting the physical and emotional health needs of residents. As a result residents feel more at home and relaxed at 12c Hyde Close. The residents are not fully protected by arrangements regarding medication in the home. EVIDENCE: ‘We couldn’t ask for better care for my relative. We are very happy.’ This was the comment of one relative and reflected the positive feedback from relatives about the care provided at 12c Hyde Close. Residents indicated by their actions and behaviour that they felt relaxed and comfortable in their home. A keyworker system is in place to ensure that residents get the support Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 17 they need that is appropriate to their individual situation. Staff spoken to knew about the individual needs of each resident. The care plans are detailed and set out clearly how staff should respond to the individual needs and wishes of residents, with guidelines about areas of risk. As a result residents have felt supported in their home and have become more independent than previously. For example residents now take a greater part in the daily running of the home including tidying up and helping to maintain the garden. ‘The home is good at looking after vulnerable individuals and providing necessary care.’ This was the comment of a health professional who has regular contact with the home. Health needs are responded to with evidence seen of referrals made to other relevant professionals. During the inspection a nurse called in to check arrangements for some dental treatment a resident was having in hospital. Interviews with staff showed that staff had a very good knowledge of the health needs of each resident. We sat in on the staff handover meeting. Key information about current health issues in relation to residents was shared and appropriate action agreed. Residents have health action plans that set out their health needs and how they should be responded to. Each individual resident has a separate medication cupboard and record in their bedroom. In some cases the information on the resident’s medication profile did not match up to what was written on the medication administration record. This information was corrected in the course of the inspection. Since the previous inspection an incident had taken place regarding failure by a staff member to give out administration correctly. This had been reported to CSCI and appropriate taken by the home. The operation manager had identified a need for a full review of medication arrangements in the home in order to ensure that medication arrangements are effective at all times. The manager must review medication procedures in the home in order to ensure residents are protected in this area at all times. Hyde Close 12C DS0000069373.V364602.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and their representatives can be confident in the complaints procedures in the home that make sure their concerns are responded to whilst at 12c Hyde Close. The residents benefit from safeguarding adults procedures that make sure that they are safe and secure whilst at 12c Hyde Close. EVIDENCE: The complaints record showed that there had been no complaints since the previous inspection. An appropriate format is available to record complaints. Sense have a general complaints procedure that people can use to raise concerns. Surveys from relatives indicated that they felt able to raise concerns with staff at the home. Staff spoken to said they had received training on the protection of vulnerable adults and knew what to do if an incident of abuse occurred or an allegation was made. This was confirmed in staff interviews. The home has a copy of the London Borough of Barnet’s adult protection procedure, as well as their new leaflet ‘Say no to abuse.’ In addition Sense have their own detailed policy and procedure on protecting vulnerable adults. Sense also run an ongoing Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 19 training programme that includes how to safeguard adults. This area is also covered in the induction programme that all new staff have to attend. I looked at the personal finances for two residents. The organisation has finance officers who organise each resident’s welfare benefits. The spending money is passed to each individual as needed and held in a separate cash tin in the flat. The records of expenditure, with receipts were correct for the two people whose finances were checked. As a result residents are protected by the arrangements the home has in place in relation to safeguarding adults. Hyde Close 12C DS0000069373.V364602.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): 24,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at 12c Hyde Close enjoy an attractive and comfortable living environment that add to their quality of life, with a good standard of cleanliness and hygiene maintained in the home. EVIDENCE: One relative commented: ‘They provide a clean home, that has a good friendly atmosphere. Our relative appears happy and is well fed. They have a lovely bedroom and an adapted back garden suitable for wheelchair users.’ Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 21 These comments were confirmed over the course of the inspection. We went round the flat and gardens with the care staff. The rear garden is very attractive, with a new and improved sensory area that encourages and facilitates the residents to go into the garden and enjoy this area. During the inspection residents would also help to maintain this area. During the inspection residents were observed feeling and finding their way around the flat so that they could get to the different areas as independently and safely as possible. The living environment facilitates this freedom of movement and adds to the residents’ quality of life. The bedrooms are very nicely personalised and have lots of sensory stimulation, for example, aromatherapy and hanging mobiles. Each bedroom has a sensory sign on the door to enable people to identify their room. The bedrooms are individually furnished and some have a couch or comfy chair so people can spend time in their bedrooms. One resident has mobility problems so appropriate lifting equipment was available when they needed hoisting. The kitchen area has been refitted with new dining room furniture in place. During the course of the inspection both bathrooms were redecorated and brightened so they became more attractive and inviting areas. The main bathroom is awaiting a major refit so that it can be modernised and reequipped. Sense must ensure the large bathroom is refurbished, with advice from an appropriate care professional obtained to ensure the new bath meets the needs of the people living in the flat. The manager explained that Stonham Housing Association maintains the building and in some cases larger pieces of work are now overdue. The home was very clean and tidy throughout the inspection. Sense has effective policies and procedures for infection control and staff have been trained in this area. The home has a maintenance person with responsibility for all the flats at Hyde Close. Where appropriate residents are also encouraged to assist with tidying up in the flat. Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 22 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the committed, competent and experienced team of staff at the home. Residents are protected by the home’s rigorous recruitment procedures for new staff. Residents enjoy a good quality of life because staff in general have the training and support they need to provide a good standard of care. However training records need to be improved so that residents can be confident all staff at all times have undertaken all essential training. EVIDENCE: The staff rota was checked and staff on duty observed. The staff team consists of a manager, deputy manager and a team of thirteen full-time and part-time carers. There is a minimum of four staff on duty during the two daytime shifts and at night there is one waking member of staff and a person sleeping in who is on call. These numbers are sufficient to meet the needs of the people living in the home. Four of the staff have completed an NVQ level 2 in care and Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 23 other staff have started this qualification. Most staff have worked in the flat for over a year and some have worked at 12c Hyde Close for several years. One member of staff had written on their feedback form: ‘We’re good at employing a diverse group of people as we have a diverse group of service users and we all work together and exchange and understand other cultures. ‘ There is therefore in place at 12c Hyde Close an experienced, competent and diverse team of staff who support the residents well. During the inspection agency staff were used on a number of shifts. The manager said that the team of bank staff run by Sense had been increased and that as a result there is now less use made of agency staff. She was hopeful that this would reduce further with the appointment of new staff to their existing two vacancies. It is recommended that Sense expands further its team of bank staff so that use of agency staff is minimised, given the importance to the residents that staff supporting them are aware of their very specialised needs. Staff files were looked at and contained the information needed to make sure that all new staff in the home have had the appropriate checks made, including obtaining written references and satisfactory CRB (Criminal Records Bureau) disclosures. As a result residents are protected by the procedures 12c Hyde Close has in place when recruiting staff. Staff turnover at the home has been low, with most staff having worked at the home for a number of years. The training schedule arranged by Sense provides a rolling programme for staff to access as required. Staff undertake a wide range of essential training courses, including safeguarding adults, medication, first aid, food hygiene and health and safety. In addition more specialised courses are provided to reflect the particular needs of the residents at 12c Hyde Close. These include communication, challenging behaviour, orientation and mobility and skills teaching. As a result staff are more effective in how they support residents, as confirmed by the feedback received from both relatives and professionals involved with the home. Staff interviews indicated that they have knowledge of person-centred planning, with many elements of this approach in place in the home and training provided. The record kept of training undertaken by staff is not up to date and therefore it was not possible to be sure which of the mandatory training for staff, such as health & safety and first aid, had been undertaken or where it staff needed refresher training. Staff sickness in relation to training staff within Sense had contributed to this situation. However it is essential that training information is available and up to date in order to ensure that staff have undertaken all essential training, and where necessary had refresher training. The manager Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 24 must ensure that an audit is made of current training needed by staff with an action plan and schedule to achieve this. Feedback from staff indicated that they are aware of personal and sexual relationship issues in relation to residents and have had training in this area in the past. Staff said they would value more training in this area so that they were more confident in how they supported residents in this area. The manager confirmed this would be helpful. It is recommended therefore that staff have further training in supporting people with learning disabilities with personal and sexual relationships. Hyde Close 12C DS0000069373.V364602.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): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home which is improving but needs to run more effectively to ensure residents are well supported at all times. Sense has good systems in place to ensure that the home responds to and acts on comments and suggestions from all key parties about how the home is run so that there is a process of continuous improvement at 12c Hyde Close. The home has good procedures in place in relation to health and safety, but these are not always fully implemented so that residents are not always fully protected. EVIDENCE: Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 26 In February 2008 a new manager, Anita Grant, was appointed at 12c Hyde Close, who has considerable experience in managing care homes. The locality manager confirmed that an application would be made for her to become the registered manager once her probationary period had been satisfactorily completed. In view of 12c Hyde Close not having a registered manager for some time Sense must ensure that an early application is submitted to CSCI for a registered manager to be in place at 12c Hyde Close. The manager acknowledged that when she started at 12c Hyde Close there was a considerable amount of work needed to ensure there were effective management systems in place. The inspection took significantly longer than is usual because a good deal of necessary information was not available at the start of the inspection or was incomplete. Some of this related to areas that had been highlighted at the previous inspection for improvement, including care plans. By the end of the inspection key information had been made available. In some cases information was inaccurate or out of date, such as medication profiles or employer’s liability certificate, and had to be corrected. It is essential therefore that rigorous management systems are in place at 12c Hyde Close so that key information is available at all times for inspection and is accurate. Sense has a variety of systems in place to ensure that the quality of service is continuously reviewed and improved. The locality manager for 12c Hyde Close visits the home monthly and reports on how the home is running and areas to be improved. Written feedback from relatives about the home was positive. Staff meetings are held regularly so that staff can contribute their ideas on the running of the home. The home was awaiting the comprehensive annual Sense audit of the service. The manager had completed the AQAA (Annual Quality Assurance Assessment) that provides detailed information about the running of the service and areas needing improvement. As a result 12c Hyde Close is run in a way that aims to improve further the service on offer and is responsive to the key parties involved, including residents, relatives and staff. A range of records was looked at, including health and safety and fire safety. At the outset of the inspection these records were not always available, accurate and up to date. For example there had bee a gap in the daily recording of fridge and freezer temperatures. By the end of the inspection this situation had improved. However the manager must ensure that the home’s records in relation to health and safety are available, accurate and up to date at all times. The home had current certificates covering gas, electricity, and portable appliance testing. A fire evacuation procedure is in place and displayed around the home. A fire safety risk assessment is in place and kept under review. Fire safety procedures covering the four flats were in the process of being reviewed at the time of the inspection. As a result there was some confusion about where the responsibility lay for arranging regular fire drills. As a result 12c Hyde Close had not had a daytime fire drill in 2008. The Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 27 manager must ensure that there are regular fire drills at 12c Hyde Close that are in line with Sense’s procedures for this flat. It is further recommended that Sense reviews its fire safety procedures at 12c Hyde Close so that it is clear which procedures and responsibilities are specific to the flat and which are generalised across the four flats at Hyde Close. Fire drills should take place at 6 monthly intervals. It is recommended that given the needs of the current group of residents that drills are held at least quarterly so that residents become very familiar with this situation. The manager agreed this was appropriate and indicated he would implement this in future. Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 28 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 2 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 2 36 x 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 3 3 2 x 2 X 3 X X 2 x Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 29 No 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 YA1 Regulation 5 (1) Timescale for action Sense must ensure that 12c 31/08/08 Hyde Close has an up to date and accurate Service User Guide so that all key parties are informed about the service provided and know what to expect from it. Requirement 2. YA6 15 (2) (c ) The manager must ensure that 31/08/08 there is clear evidence in the care planning process that actions agreed at placement reviews have been followed up by the home in order to ensure residents’ needs are met. 13 (2) The manager must medication procedures home in order to residents are protected area at all times. review 30/09/08 in the ensure in this 3. YA20 4 YA24 23 (2) 9a) & (f) 5. YA35 18 (1) (a) Sense must ensure the large 31/07/09 bathroom is refurbished, with advice from an appropriate care professional obtained to ensure the new bath meets the needs of the people living in the flat. The manager must ensure an 30/09/08 DS0000069373.V364602.R01.S.doc Version 5.2 Page 30 Hyde Close 12C audit is made of current training needed by staff with an action plan and schedule to achieve this so that residents are supported by staff who have been appropriately trained. 6. YA37 8 (1) Sense must ensure that an 30/09/08 application is submitted to CSCI for a registered manager to be in place at 12c Hyde Close in order to ensure there are proper management arrangements at 12c Hyde Close. The manager must ensure that 31/08/08 the home’s records in relation to health and safety are available, accurate and up to date at all times so that residents are fully protected at all times. The manager must ensure that 31/08/08 there are regular fire drills at 12c Hyde Close that are in line with Sense’s procedures for this flat. 7. YA42 17 (3) (a) & (b) 8. YA42 23 (4) (c) (iii) & (e) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that Sense reviews the existing care planning formats being used so that all parties are clear what a care plan looks like and consists of. It is recommended that staff have further training in supporting people with sensory impairments with personal and sexual relationships. It is recommended that Sense reviews its fire safety DS0000069373.V364602.R01.S.doc Version 5.2 Page 31 2 YA35 3 YA42 Hyde Close 12C procedures at 12c Hyde Close so that it is clear which procedures and responsibilities are specific to the flat and which are generalised across the four flats at Hyde Close. Hyde Close 12C DS0000069373.V364602.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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