Inspection on 17/07/07 for Flat D 12 Hyde Close

This inspection was carried out on 17th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Hyde Close 12D High Barnet Hertfordshire EN5 5TJ Lead Inspector Tom McKervey Key Unannounced Inspection 17th July 2007 10:00 Hyde Close 12D DS0000069374.V341775.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 12D DS0000069374.V341775.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 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Close 12D 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 Anne Dennison Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12D DS0000069374.V341775.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 Brief Description of the Service: 12 Hyde Close D is managed by an organisation called Sense. It is a service for five adults, male and female who have sensory impairments, mobility problems and severe or complex learning disabilities. The home was purpose built and is shared by four independent flats with five residents in each flat. Each flat has its own kitchen and lounge area, two bathrooms and a toilet. All the residents have a single bedroom with a washhand basin. There is large communal garden area to which all residents have access. The laundry room is shared, with each flat having its own equipment. Each flat has a separate team of staff, which is led by a manager. At night, there is a waking member of staff in each flat and two sleeping staff are on duty for all four flats. In March 2007, each flat and manager was independently registered by the Commission for Social Care Inspection, and Flat D was registered as a “new service”. Opposite the home, there is a specialised day service, which is separately managed. The residents have access to these facilities as well as other local Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 5 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. Following Inspecting for Better Lives, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. The fees for the service, which are £1736 per week, are paid by various local authorities. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed in four hours and forty minutes, and was the first inspection since Flat D was registered as an independent service. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The registered manager was present throughout my visit and offered valuable assistance with the process. All five of the residents were in the home most of the time during the inspection, although some went out to shops at various times of the day. The process involved a discussion with the manager, two individual staff, and other staff members at the shift handover. I was unable to communicate with most of the residents because of their lack of verbal skills, but I observed how the staff interacted with, and provided support to them. I read residents’ case files and other documents pertaining to the running of the service. I also examined the medication records and visited all areas of the flat, including residents’ bedrooms. What the service does well: The home provides good information to prospective service users about the service it provides, and thorough needs assessments are carried out before people are admitted to the home. All the residents have a licence agreement with the landlord. There are good person-centred care plans for the residents and appropriate risk assessments ensure that a full range of activities in the home and the community can safely take place. The staff have an in-depth knowledge of the residents and can communicate well with them. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 7 There are good systems in place to ensure that the people who live in the home have access to a full range of healthcare, and medication is safely administered. The system for dealing with complaints ensures that they are investigated and responded to quickly and effectively, and staff are aware of how to protect residents from abuse. The home’s layout enables residents to have access to all areas and their bedrooms are personalised and decorated in their preferred style. Recruitment procedures are thorough and ensure that new staff are properly screened. The staff are deployed when service users’ needs are highest and they are trained to meet the residents’ needs. The manager provides clear leadership to the staff and provides a good model for best practice. There is good monitoring of the service by senior managers from Sense, and there are efficient systems to protect the health and safety of the residents and the staff. What has improved since the last inspection? What they could do better: Four requirements are made in this report relating to maintenance and repair issues and re-provision of furniture to improve the comfort and wellbeing of the residents. The wardrobe door in a specific resident’s room needs to be repaired for their safety. The lounge carpet must be thoroughly cleaned or replaced. The lounge/dining area is in need of redecoration. The worn settees and armchairs must be replaced. I have made two recommendations; Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 8 That the Service User Guide for residents and their representatives is updated to specifically refer to Flat D, rather than to the whole building. That Sense considers providing the staff with training in British Sign Language training to enhance their communication skills with the people who live in 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 12D DS0000069374.V341775.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 12D DS0000069374.V341775.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, 3 & 5 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. There is a Statement of Purpose that is specific to this home, and the residents that live there. The home’s structure and layout are appropriate for this group of residents. Admissions are not made to the home until a full needs assessment has been carried out. The residents have a Licence Agreement/Contract that sets out in detail what is included in the fee. EVIDENCE: The Statement of Purpose has been updated following the new registration of Flat D and the manager. The Service User Guide now needs to be similarly updated to focus specifically on the service provided by Flat D. This should Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 11 include a summary of the Statement of Purpose and the fees charged for the service and what is covered by the fees. Residents’ files contained a licence agreement from the landlords who own the building and who are responsible for the upkeep of the building. The home was purpose built and is shared by four independent flats with five residents in each flat. Each flat has its own kitchen and lounge area, two bathrooms and a toilet. All the residents have a single bedroom with a washhand basin. There is a passenger lift to the first floor and there is large communal garden area. The people who live in the home are able to access all areas of the home. No new people have been admitted in the past few years, but the residents’ case files include needs assessments that were completed prior to admission to the home. Care reviews are being carried out every year by care mangers from the placing authorities to ensure that the home continues to meet the residents’ needs. The residents’ relatives are invited to attend these reviews. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person living in the home has a care plan that includes a comprehensive risk assessment, which is reviewed regularly. The staff are skilled at understanding the residents’ wishes and how to support them. Management of risk is positive, addressing safety issues whilst aiming for a better quality of life. EVIDENCE: I sampled three care plans, which were person-centred and written in the first person. Clear guidance was documented for staff about how best to meet the Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 13 residents’ needs. This included how to communicate with residents who are non-verbal. Each people who lives in the home has a key worker who writes a review each month of the care plan and monitors their progress. I observed the staff interacting with the residents. The staff appeared to have a very good relationship with them and demonstrated their ability to understand the residents’ wishes and how to support them in decision-making. For example, staff were observed using objects of reference like cups, keys and items of clothing. The staff have had training in Makaton, and some signing was also being used when offering choices to residents. The manager and the staff all stated that they wished to have training in British Sign Language, which they believed would provide a broader range of communication with the people who live in the home. However, they said that there were funding issues about this. Nevertheless, I am making a recommendation that Sense considers this. I was informed that one resident had chosen the colour scheme for their bedroom. 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 home’s vehicle. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use services are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The residents’ rights to privacy and dignified care is respected. The staff support the residents with communication to enable them to fully participate in daily living activities. People who use the service have the opportunity to develop and maintain important personal and family relationships The meals are balanced and nutritious and cater for the varying cultural and dietary needs of the individuals using the service. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 15 EVIDENCE: All five residents were present in the home during this inspection, but at various times they went out, accompanied by staff to the shops or across to the nearby Anne Wall Centre. This facility is used by many people with learning disabilities from care homes and people who live in the community. It provides sessions for swimming, Jacuzzi, trampoline and there is a canteen that service users from the home can use. Sense has provided an electric massage chair in the home, which I was told is very popular with the residents. All the residents spend considerable periods of time in the community and each person has a holiday every year. In some cases, the holidays are taken abroad. Some residents visit their families at home and relatives are invited to attend care reviews. The staff have regular contact by phone with relatives who live some distance from the home. An activity programme is drawn up for each resident and is included in a “shift planner”. This identifies the staff who are allocated for each resident’s activity, which is then recorded in their daily log. Some residents help with household tasks such as preparing meals, cleaning and shopping for food. I observed a resident being supported by a staff member, cleaning the dining tables after lunch. I observed that the verbal communications and discussions among the staff, included the residents, and ensured that they were not excluded. Staff were seen knocking on residents’ doors and when supporting the residents with personal care, this was done discreetly to protect their privacy and dignity. The manager told me that she has made approaches to the Barnet Advocacy Scheme to provide representation for the residents, and at the time of the inspection, she was awaiting a response. Menus are decided on a day-to-day basis and food shopping is done each day by residents and staff for that days meals. Residents’ records contained details of individual preferences for food. A record is kept of the meals eaten each day. Pictures of meals help the residents to decide what they want to eat. The meals were varied and wholesome and there was fresh fruit available. On the day of the inspection, a Jewish resident was being supported to go out for a Kosher sandwich. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 16 Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the varied and individual needs and preferences of the people who use this service. Personal healthcare needs are clearly recorded in each resident’s plan. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: The care plans contained comprehensive guidance for staff about how each resident prefers to be supported in their personal care and other activities. The guidance detailed how to interpret and respond to, residents’ non-verbal communications. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 18 There were good records of healthcare appointments attended by residents, which included the G.P. and the Community Learning Disability Team. Specialist referrals were made to speech and language therapists and in one case, to Sense’s specialist in sensory impairment to advise on “tactile markers” for a resident who is blind, to help with their orientation around the home. One resident displays some challenging behaviours from time to time. A chart is used to monitor this behaviour, which the manager said helps to identify key triggers. Two staff are deployed to support this person when going out. The manager told me that she is pursuing additional funding from the placing authority to finance this. At the time of the inspection, all residents were reported to be in good health and they looked well cared for, clean and well dressed. The medication standards and records were checked. The company requires two staff to administer and check the medication. There is a system for monitoring compliance with this. No errors were found in the administration records and the medication was safely stored and accounted for. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. The staff understand the procedures for Safeguarding Adults and how to report concerns. EVIDENCE: The home has an appropriate complaints procedure. No complaints have been received by the home in the past year. Previous complaints and concerns had been dealt with satisfactorily. There is a copy of Barnet local authority’s Protection of Vulnerable Adults procedure in the home. The staff have attended training in the subject of protecting service users from abuse, and in discussion with the staff, I was satisfied that they were fully aware of their responsibilities in this regard and knew how to report any concerns. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 & 30 People who use this service experience adequate outcomes. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. People who use services can personalise their rooms. Toilets and bathrooms for the use of people using the service are appropriately located within the home, are easily accessible and in sufficient numbers. The home is clean and tidy, and there are systems in place for the control of infection. EVIDENCE: Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 21 The building is owned and maintained by Stonham Housing Association. There is a lift to the flat from the ground floor, which accommodates wheelchairs. All areas of the flat are easily accessible to all the people who live in the home. I visited the communal areas, bathrooms and bedrooms. New curtains had been provided in the lounge/diner. The lounge/dining area was not very presentable; the carpet is old and was badly stained and the walls need redecoration. The lounge furniture is also very old and needs replacing. The manager told me that it has been agreed to replace the carpets and furniture but there was no firm timescale for this to be done. A requirement is therefore made to address these issues. There were pictures on the walls which contributed to a homely feeling. There is an attractive decking area outside the lounge for people who live in the home to use in the good weather. There is a gate guarding the stairs from this area for the safety of the residents. The bathrooms and toilets were fully functioning and had locks on the doors to safeguard privacy. There are appropriate aids and adaptations in the toilets and bathrooms for people with mobility problems. The bedrooms I visited were individually decorated and personalised with residents’ personal possessions. In one bedroom, a knob had come off a wardrobe door, leaving the screw exposed. A temporary repair was made by the staff to protect people from injury and I was assured by the manager that this would be addressed by the maintenance person the next day. A requirement is made to ensure that this is repaired. There is a policy in place regarding control of infection and staff were observed wearing disposable gloves and aprons when supporting the residents with personal care. With the exception of the lounge carpet, the flat was clean and tidy and there were no offensive odours. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 22 Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people using the service. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. The service has a good recruitment procedure that clearly defines the process to be followed. Supervision sessions are regular and staff find them helpful. EVIDENCE: Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 24 The staff rotas were checked. The rota correctly identified the staff who were on duty that day. The staff rota is designed to ensure that staff are available at the busiest times of the day when the residents need most support. There is one member of staff awake at night on Flat D and two other staff provide support for all of the flats on a sleep-in basis. At the time of the inspection, six staff had attained National Vocational Qualification level 2 and other staff were currently in the process. I examined staffs’ records. All new staff undergo a written induction which includes training in mandatory health and safety subjects. Other courses provided by Sense include epilepsy, crisis intervention and care planning. Staff who were key workers for the residents, described their roles as advocates for the people who live in the home and they had specific responsibilities for a resident’s care plan and activities. The records of new staff contained evidence that they had undergone interviews, had supplied references, and had been properly screened by the Criminal Records Bureau. I saw records of formal staff supervision. The staff to whom I spoke, said that supervision was helpful in providing an opportunity to say what they want about their work and discuss their specific training needs. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. There is organisational monitoring of the service by the organisation. The residents’ best interests are safeguarded by good systems for managing their personal finances. The home works to a clear health and safety policy that aware of. all staff are fully Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager is registered with the Commission for Social Care Inspection. She has attained the Registered Manager Award and is an assessor for the National Vocational Qualifications. She has been the manager of Flat D for four years and has long experience of working with people with physical and learning disabilities. The atmosphere in the home was business-like but relaxed and staff appeared to have a warm relationship with the residents and with each other. The staff said that there was a good team spirit and that the manager set high standards for the care of the residents. I saw a document that was part of the organisation’s quality assurance audit. The manager told me that a more comprehensive audit involving service users, was currently underway and the results would be published in the near future. Senior managers carry out unannounced monitoring visits and report on a range of outcomes, for example the environment, residents’ money and health and safety issues. Staff meetings are held each month and a record is kept of the content of the meetings. None of the residents are able to manage their finances. A senior manager from Sense acts as their appointee. The residents’ case files contain information about their personal finances, including their entitlement to benefits. I examined a resident’s cash box at random and found that the records were in order and matched the amount of remaining cash in the box. There are certificates of safety for the gas, electric, water and fire systems. The hoists and lift were serviced in the last year, as were the electric portable appliances. There are records of monthly health and safety audits of all areas of the home. Accidents and incidents were recorded and appropriate actions were taken to minimise these. The fire alarms were tested weekly and drills were regularly carried out. The employers liability insurance is up to date. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 28 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. 2. 3. 4. Standard YA24 YA24 YA24 YA24 Regulation 13(4)(a) 16(2)(c) 23(2)(d) 16(2)(c) Timescale for action The wardrobe door in a specific 31/08/07 resident’s room must be repaired for their safety. The lounge carpet must be 30/09/07 thoroughly cleaned or replaced. The lounge/dining area must be 30/09/07 redecorated. The worn settees and armchairs 30/09/07 must be replaced. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA8 Good Practice Recommendations The manager should update the Service User Guide so that it refers specifically to Flat D. Sense should consider training for staff in British Sign Language to enhance their communication skills with the people who live in the home. Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hyde Close 12D DS0000069374.V341775.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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