Inspection on 31/08/07 for Flat C 12 Hyde Close

This inspection was carried out on 31st August 2007.

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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Flat C 12 Hyde Close 15/07/08

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 12C High Barnet Hertfordshire EN5 5TJ Lead Inspector Jane Ray Key Unannounced Inspection 31st August 2007 08:45 Hyde Close 12C DS0000069373.V343894.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.V343894.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.V343894.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 8364 8083 www.sense.org.uk Sense, The National Deafblind and Rubella Association vacant post Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12C DS0000069373.V343894.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 New service registration 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 which, although always managed separately, were originally under one registration but now, each flat has its own registration. This is the first inspection of 12c Hyde Close under its own registration. 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. The staff team work two day shifts and at night, there is one waking night and one sleep-in staff member. The residents access a range of community resources. The flat has its own Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 5 minibus and one person also has his own vehicle. 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. The stated aims of the service are to provide support to the residents to achieve their optimum potential in social, emotional, developmental and educational activities, and enjoy a good quality of life. Following ‘Inspecting for Better Lives’, the provider must make information available about the service, including inspection reports, available to service users and other stakeholders. The fees for the home range between £1727-£3495 a week. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 31 August 2007 and the 3 September 2007 and was unannounced. The inspection lasted for seven hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to observe the support given to four of the five current people living in the flat. The inspector was also able to spend time talking to the manager, deputy manager as well as the four members of care staff who were working in the home. The inspector did a tour of the premises and also looked at a range of records including service users records, staff files and health and safety documentation. The home had provided the inspector with a completed selfassessment as part of the inspection. What the service does well: The home provides a high standard of care and support to a group of people with a range of complex and challenging needs. The staff team demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs and how to respond appropriately to them. The residents were observed to be very relaxed within their home environment. There are excellent guidelines to enable staff to communicate with the people living in the home, to help determine and meet their needs. 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 access 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 has a well established and stable team of staff. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 7 The home is comfortable and spacious and the residents each have a single bedroom that is personalised to their taste. The home also has access to a vehicle that is helpful in facilitating some of the community activities. What has improved since the last inspection? What they could do better: There are fifteen requirements from this inspection. In order to enhance the daily lives of the residents it is required that they are supported to access more structured activities in line with their individual interests. Their care plan goals need to be clear and achievable and they need to be supported to all have an annual review meeting to which relatives and care professionals are invited at which any agreed action is recorded. The residents also need to be supported to all have their primary healthcare checks on a regular basis. Medication administration can be improved by ensuring the administration of creams is recorded, ensuring medication does not run out and arranging medication refresher training for all the staff. The staff also need to carry out their key-worker role more fully as this will allow them to ensure each persons individual needs are fully met. In terms of the environment in the flat, the kitchen needs to be replaced as it is falling apart, the bathroom needs to be refurbished and a bath provided that is easy for people to get in and out and one resident needs a new bed where staff can safely assist with his moving and handling. There are a number of areas for improvement in staff management including ensuring they all have a record of their recruitment checks, ensuring they have a confirmed contract, having regular staff supervisions and team meetings and having an accurate record of each member of staffs training. For health and safety to be complete the water needs a legionnaires check and the hoist needs a maintenance check arranged. Finally the service needs a permanent manager who has completed the registration process. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 8 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.V343894.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.V343894.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): Standards 1,2,3,4 and 5 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they are appropriately assessed and that the service can meet their needs. EVIDENCE: I looked at the statement of purpose and service user guide. The statement of purpose contains all the appropriate information. The service user guide is in a user-friendly format, including an audio version and clearly explains what the home will provide. Four service user case notes were inspected and these all included a contract between the home and the resident and these had been signed as needed by the resident or an appropriate representative. The four case notes I inspected all had comprehensive assessments in the form of individual person centred guidelines prepared by the staff in the home. These provided a good summary of the needs of each person and linked with the care plans. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 11 The last person who moved into the flat arrived over a year ago. The staff explained that there had been a detailed transition process and the resident had been able to meet the staff in his previous home and visit the flat. Detailed information had been provided to the service by the previous home and had incorporated reports from care professionals. The staff spoken to said they had received training on meeting the needs of the people living in the home. This was reflected in the training programme. The staff spoke very positively about the induction and ongoing training that prepared them to support people with a sensory impairment and provided them with the experience such as communication skills to carry out this role. Hyde Close 12C DS0000069373.V343894.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): Standards 6,7,8 and 9 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to express their views on how they wish to lead their lives but the care plans need to be more focused with regular review meetings. EVIDENCE: I inspected four case notes for the people living in the home. Each person has an individual care plan, but these tend to include a number of broad statements about what each person will be supported to achieve without a clear explanation of how this will happen in practice. This means that it is hard to get a clear understanding of how each person is being supported to make progress in their lives. Two of the four people living in the flat did not have a record of a review meeting with their care manager and other significant people in their lives in Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 13 the last year. For the two people who had been supported to have a review meeting there was no record of any actions agreed at these meetings. The staff were asked about their roles as key workers but whilst they all knew who they supported they did not feel they carried out these roles fully. Staff said they often did not go with the resident to healthcare appointments, may not attend their review meeting and had not been involved in preparing the persons care plan. 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. The four residents whose case notes were inspected all included individual risk assessments covering all areas of potential risk and these identified what action the home would take in response to the identified risks whilst at the same time promoting each persons independence. Examples of this include supporting one of the people living in the home to put petrol in his vehicle and supporting the residents to participate in a number of sporting activities. Throughout the inspection the people living in the home were observed interacting with the staff and making decisions concerning their daily lives through the use of gestures, body language and facial expressions. This included choosing where they wanted to sit and when they wanted to eat or drink. The staff also described how two of the people living in the flat are able to clearly indicate when they want to go to bed. It was very positive to observe the staff communicating very effectively with the people living in the home through speech and touch. The people living in the flat do not currently access an advocacy service. Hyde Close 12C DS0000069373.V343894.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): Standards 11,12,13,14,15,16 and 17 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to participate in domestic activities in the home and to enjoy community based leisure activities. There is scope to access a wider range of activities including some regular structured sessions. EVIDENCE: The staff explained that one person attends a day centre on a full time basis. The other residents do not have structured activities but enjoy going out for walks, for lunch and for a drive. In addition there are regular outings that have recently included a music festival, a theme park, a boat trip and a visit to Hatfield House. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 15 It was noticed from reading the residents case notes that some of them enjoyed activities such as swimming, trampolining and ice-skating and yet there was very little evidence of these activities taking place. It would enhance the lives of some of the residents if they had access to some more structured sessions according to the individual interests of each person. The staff explained that none of the people living in the flat regularly attend a place of worship but one of the residents enjoys listening to and singing along with hymns. The staff explained that holidays are planned on an individual basis and that it is hoped that two of the residents will be travelling abroad to Portugal later in the year. The staff explained that most of the people living in the home have contact with their families. They are made welcome in the home or the residents are supported to go to their family homes. One of the residents was due to have a visit from his parents at the weekend. It was observed that there was a comfortable atmosphere in the home with the staff communicating appropriately with the residents. The people living in the home were observed to be relaxed with the staff. I was able to observe that the routine is flexible for the residents and that some choose to get up early and others got up later. The home has menu prepared each week by a senior support worker and the staff explained that they follow the menu quite closely. There was plenty of fresh fruit and vegetables available in the kitchen. Lunch was prepared during the inspection and was nutritious. The staff explained that the residents do not have any specific dietary requirements although one person does not eat sugary food and everyone needs help to cut up their food. The staff said that they do not prepare food to meet the specific cultural needs of one of the residents but had observed that all of the people living in the flat enjoyed food with stronger flavours. Hyde Close 12C DS0000069373.V343894.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): Standards 18,19 and 20 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to receive healthcare input but some primary healthcare checks need to take place. Medication systems within the homes are organised but staff need to ensure they are followed accurately. EVIDENCE: I observed during the inspection that the people living in the home were given support with their personal care based on their individual needs. The staffing provision allows there to be same gender care. The residents were all adequately dressed and groomed. The staff explained that some of the residents have their hair cut at the local hairdressers and some use a hairdresser who comes to the flat. The people living in the home were observed participating in domestic activities in the home including being supported by staff to assist with cleaning their bedrooms. Their individual care guidelines also included information for staff on how they could support each person to develop their independent Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 17 living skills. The staff were also able to describe how they support the residents to carry out their domestic activities. The healthcare records were inspected for the four people living in the home. They had all been supported to access the GP. Three people had no record of seeing the dentist since October 2005 and one person had no record of seeing an optician since being admitted to the home even though his pre-admission information said he would need input for cataracts. In addition the residents receive input from a number of other healthcare professionals including the nurse from the learning disability team, physiotherapist, the wheelchair service and the neurologist. There was a clear record of healthcare appointments that had been attended. A summary is also available for each person to be used in the event of a healthcare emergency. Each individual resident has a separate medication cupboard and record in their bedroom. These were inspected for three people. The medication entering the home and being returned to the pharmacist is recorded appropriately on the medication administration record. Some of the residents have PRN medication and guidelines are in place in the case notes for when these should be administered. The medication record was not being signed when cream was administered. One person was prescribed Movicol and this medication was not available in his medication cabinet. Another person was prescribed lactulose and there were blank spaces on the medication administration record. The staff training records were inspected for seven staff and three had a record of receiving medication training in 2003. The manager explained that medication training is being arranged but there is no date available yet for when this will commence. Hyde Close 12C DS0000069373.V343894.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): Standards 22 and 23 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the correct training and procedures are in place to protect them from the risk of being abused. EVIDENCE: I looked at the complaints record and saw that there had been no complaints since the previous inspection. An appropriate format is available to record complaints and this monitors the time taken to resolve the complaint. The complaints procedure was also inspected and this is available in the statement of purpose and in each service users case notes. I spoke to four care staff who all said they had received training on the protection of vulnerable adults and also on how to work with residents with complex challenging behaviours. They demonstrated a good understanding of both these areas. The individual staff records did not include certificates to confirm this training had taken place but I was able to see the ongoing training programme that covered both these topics. Staff who needed to update this training had been identified. I looked at the personal finances for two service users. The organisation has finance officers who organise each persons DSS benefits. The spending money Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 19 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. Hyde Close 12C DS0000069373.V343894.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): Standards 24,25,27,28 and 30 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are benefiting from an environment that is clean, tidy and homely. Work is needed to replace the kitchen and modernize the main bathroom. EVIDENCE: I toured the flat and gardens with the care staff. The rear garden is very attractive, with sensory features and plants as well as a table and chairs. 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 person in the flat has a large Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 21 double bed in his room, but the staff are finding it hard to position themselves correctly so they can move and handle him safely when he needs to get up. The manager said that alternative beds are being considered but have not yet been ordered. A new bed that is suitable for staff safety needs to be obtained with advice from a care professional such as a physiotherapist. The kitchen needs to be replaced and it could be seen that some of the cupboards are broken. The main bathroom needs to be updated especially the old bath which again is difficult to use for people with mobility issues. Advice from an appropriate care professional needs to be sought 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 whilst minor maintenance work happens in a timely manner the ongoing larger jobs are now overdue. The home was very clean and tidy. A cleaner comes in regularly but staff do most of the cleaning on a rotational basis. There are very good policies and procedures for infection control and staff have been trained in this area. The home now has a new maintenance person with responsibility for all the flats at Hyde Close. Hyde Close 12C DS0000069373.V343894.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): Standards 32,33,34,35 and 36 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a stable team of staff who know them well. Staff need to be supported to work to a high standard through the use of team meetings and regular supervision. 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 are four staff on duty during the two, day time shifts and at night there is one sleeping and one waking member of staff and these numbers are sufficient to meet the needs of the people living in the home. All the staff have worked in the flat for over a year and some have worked for several years. Very little use is made of agency staff as the team is fully staffed and members of the team can usually cover sickness and leave. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 23 The manager explained that four of the staff have completed an NVQ in care and four have started the qualification. This means that over half of the staff team are appropriately qualified or are undertaking the appropriate qualification. The record of this qualification is not available in their individual training record. The recruitment checks for all the staff are held at the Head Office but only one of the six staff whose records were inspected had a checklist available to confirm these checks had been completed. Copies of the contracts of employment were not available in any of the staff records. The record of staff team meetings was inspected and this had only taken place once since the beginning of the year. The induction records were inspected for three staff. They had all completed the Sense induction programme and the staff spoken to said they had found this was excellent and provided a good preparation for working with people who have a sensory impairment. The training programme arranged by the company was also inspected up to the end of the year and this provides a rolling programme for staff to access as required. The problem however was that the manager did not know what training each member of staff had undertaken and when this had been completed. The staff supervision records were inspected for three staff. None of the staff had received supervision on a regular basis. Staff spoken to during the inspection expressed frustration at the difficulties they experienced in contributing to discussions about the running of the service. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 24 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): Standards 37,38,39 and 42 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an acting manager but systems for management need to be fully implemented in the home in order to maintain standards of care. The health and safety of the people living in the home is protected by the appropriate measures being in place although a water legionnaires check needs to take place. EVIDENCE: An acting manager has been recruited to manage the service. He has worked for Sense for a number of years and knows the systems used by the organisation to effectively manage the services. He does however acknowledge that in this flat not all the systems are being fully implemented at the time of Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 25 the inspection, particularly in relation to staff management. The organisation needs to ensure a registered manager is in place for this flat. The latest quality assurance information was inspected. The manager explained that this exercise took place in March 2007 when questionnaires were sent out to relatives and care professionals but unfortunately there was no response. There was however an internal audit that included a staff consultation exercise and this produced a number of areas for the service to improve and an action plan has been prepared. The health and safety training records were inspected for all staff. Unfortunately as mentioned in the staffing section of the report these records are not comprehensive and therefore it is not possible to tell who needs to receive training. The internal training programme did show that there are courses available in some of the topics such as food hygiene and first aid whilst some topics such as fire safety are not available in the programme that runs for the next few months. The fire safety measures were inspected. The fire appliances and fire alarm had been serviced. Weekly fire alarm and emergency light checks and monthly drills are recorded as taking place. A fire safety risk assessment is available. A fire safety emergency plan is also available. The current certificates were available to confirm the maintenance for the gas system, electrical installations and portable electrical appliances. There was no record of a legionnaires check, taking place. There are two hoists available for one resident and these were installed about a year ago, but no appointments were made for an annual maintenance check. The record of accidents and incidents was inspected and these are all recorded appropriately and stored in each residents case notes. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 3 x x 2 x Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 Regulation 15(1) Requirement The registered person must ensure all the residents have a care plan with clear and achievable individual goals. The registered person must support each resident to have an annual review meeting with their relatives and other care professionals. The actions agreed at this meeting must be recorded and incorporated into their care plan. The registered person must support the residents to enjoy more structured activities such as swimming and other sports in accordance with their individual interests. The registered person must ensure all the residents are supported to have regular dental and optical checks. The registered person must ensure medication procedures are followed including completing the MAR sheets for creams, ensuring medication does not run out and enabling all the staff to refresh their medication training. DS0000069373.V343894.R01.S.doc Timescale for action 31/10/07 2. YA6 15(2) 31/10/07 3. YA11 16(2)(n) 31/10/07 4. YA19 13(1)(b) 31/10/07 5. YA20 13(2) 30/09/07 Hyde Close 12C Version 5.2 Page 28 6. YA26 13(5) 7. YA27 13(5) 8. 9. 10. YA28 YA33 YA34 23(2)(b) 21(2) 19(1)-(5) 11. YA34 17(2) 12. YA35 18(1)(c) 13. YA36 18(2) 14. YA37 8(1) 15. YA42 13(4) The registered person must ensure that one resident has a new bed that also allows the staff to safely move and handle him. The registered person must ensure the main bathroom is refurbished and a new bath provided that is easier and safer for people to get in and out. The registered person must ensure the kitchen is replaced. The registered person must ensure that regular staff team meetings take place. The registered person must ensure that all staff have evidence in their staff records that all the necessary recruitment checks have taken place. The registered person must ensure that all the staff have a contract of employment and evidence of this is in their staff record. The registered person must ensure that for all the staff working in the service, that there is a clear record of the training they have received, with copies of certificates. The registered person must ensure that all the staff have access to regular individual supervision. The registered person must ensure a permanent manager is appointed and completes the registration process. The registered person must ensure health and safety checks are completed including a legionnaires check and arranging for the hoists to have an annual service. 31/10/07 31/12/07 31/12/07 30/09/07 30/09/07 31/10/07 31/10/07 31/10/07 30/11/07 31/10/07 Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 29 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 The registered should ensure that the staff are able to perform their key working role fully. Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hyde Close 12C DS0000069373.V343894.R01.S.doc Version 5.2 Page 31 - 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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