Care Home: Flat B 12 Hyde Close

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What the care home does well The home provides good information about the service which can be provided in several formats to enable prospective service users to assess if the home is suitable for them. All the residents have a licence agreement with the landlord. The manager provides clear leadership to the staff and provides a good model for best practice. There are good care plans that are person-centred, 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 who are non-verbal. This knowledge enables the staff to communicate effectively with the people who live in the home. There are good systems in place to ensure that the residents have access to a full range of healthcare, and medication is being safely stored and 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. The standard of cleanliness throughout the home is very good. 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. 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? New kitchen units have been installed to provide better storage and cooking facilities for the residents. A new assisted bath has also been provided for people who prefer a bath to a shower. The garden has been completely restructured in a way that enables residents to enjoy sensory experiences. What the care home could do better: A requirement has been made to provide a soap dispenser and a waste bin in the toilet to promote good hygiene. "Sense" should review the layout of Flat B to see if a private area could be provided for residents to see relatives and where the manager could meet with staff confidentially. CARE HOME ADULTS 18-65 Hyde Close 12B High Barnet Hertfordshire EN5 5TJ Lead Inspector Tom McKervey Key Unannounced Inspection 25 September 2008 9:15 th Hyde Close 12B DS0000010453.V371992.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 12B DS0000010453.V371992.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 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Close 12B 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 8447 4042 020 8364 8083 Fiona.Jennings@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Fiona Jennings Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Hyde Close 12B DS0000010453.V371992.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 10th July 2007 Brief Description of the Service: 12 Hyde Close 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, sensory garden, 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. 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 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 Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 5 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. The fees for the service are on average, £1900 per week, which are paid by various local authorities. Following Inspecting for Better Lives, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. Hyde Close 12B DS0000010453.V371992.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 2 Stars. This means the people who use this service experience good quality outcomes. This unannounced inspection was completed in six hours. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The inspector was assisted by an expert by experience. This person is independent of the Commission for Social Care Inspection, but has personal experience of receiving services. The expert by experience assisted by assessing the environment, residents’ activities and staff/resident interactions. The expert-by-experience’s comments are included where appropriate, in the body of this report. The registered manager was present during the inspection and offered valuable assistance with the process. Prior to the inspection, the manager sent valuable information to the Commission in a document called an Annual Quality Assurance Audit, (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. This information was discussed with the manager for clarification and where the information could be improved, this was pointed out. There are references to the AQAA in appropriate sections of this report. Four of the residents were in the home during the inspection, and one was on holiday. The inspection involved a discussion with the manager and individual staff members. It was not possible to converse with the residents because of their lack of verbal skills, but we observed how the staff interacted with, and provided support to, the residents. Residents’ case files and other documents pertaining to the running of the service were examined as well as medication records. All areas of the home were visited, including residents’ bedrooms. What the service does well: The home provides good information about the service which can be provided in several formats to enable prospective service users to assess if the home is suitable for them. All the residents have a licence agreement with the landlord. The manager provides clear leadership to the staff and provides a good model for best practice. There are good care plans that are person-centred, and appropriate risk assessments ensure that a full range of activities in the home and the community can safely take place. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 7 The staff have an in-depth knowledge of the residents who are non-verbal. This knowledge enables the staff to communicate effectively with the people who live in the home. There are good systems in place to ensure that the residents have access to a full range of healthcare, and medication is being safely stored and 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. The standard of cleanliness throughout the home is very good. 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. 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: 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 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 8 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 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 9 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): 2&3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including examining case files and considering the layout of the home. The residents can be confident that each person living in the home has a comprehensive risk assessment of their needs, which is reviewed regularly. The environment is laid out in a way that enables residents to access all areas of the home, even if they have mobility problems. EVIDENCE: At the time of this inspection, five people were living in the home, all of whom have lived there since 1994. The residents’ case files include needs assessments that were completed prior to admission to the home. Care reviews are also carried out annually by care mangers from the placing authorities to ensure that the home continues to meet the residents’ needs. The manager informed us that one resident receives additional funding from their local authority for one-to-one staffing to meet their specific needs. 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, sensory garden, to which all residents have access. The laundry room is shared, with each flat having its own equipment. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 10 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. The expert by experience found that; “The flat was very accessible, with an open space off the shared living area where the manager had her office. This made the manager very accessible to all residents and staff. Residents unable to climb stairs, use a stair lift to reach their flat. Although none of the residents self propelled their own wheelchair, in the event of future residents being able to do so they might have difficulty managing this system”. (Please see further comments under Standard 24). Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 11 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 excellent outcomes in this area. This judgement has been made using available evidence including looking at care plans and observation. Each person living in the home has a care plan that includes a comprehensive risk assessment, which is reviewed regularly. This enables residents to have as high a quality of life as possible. The staff are skilled at understanding the residents’ wishes and how to support them in their preferred manner. EVIDENCE: Three residents’ care plans were examined in detail and at random. The format for the care plans has evolved to become more person-centred to reflect the individual needs and preferences of each person. The plans are written in the first person and include guidelines for staff about how to communicate with individual residents and how to interpret their behaviours. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 12 None of the residents are able to communicate verbally, but through discussion with the staff and observing them, it was evident that the staff have an excellent understanding of each person. Each resident has an allocated key worker who is responsible for compiling and reviewing their care plan. Monthly reviews of the plans are summarised and recorded by the key workers. The expert by experience observed that; “Staff used different articles of reference to communicate with residents eg objects that individuals could handle to indicate something specific was going to happen”. Residents and staff were observed interacting using cups, keys and items of clothing. Signing was also evident when offering choices to residents. Assessments of potential risks to residents when in the home and in the community were documented. These assessments positively contribute to the residents enjoying full lives in the community. The residents are supported by the staff in carrying out household tasks such as, doing their laundry, cleaning their rooms and shopping and cooking. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 13 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 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including looking at menus and residents’ records. People who live in the home can be confident that they are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The staff have good communication skills which enable residents to make their choices known. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. EVIDENCE: At the time of the inspection, four residents were present in the home. One person was abroad on holiday with their relatives. An activity plan is prepared for each resident for each shift. The day’s activities are discussed by staff at their handover between shifts. On some days, residents attend day centres and colleges, otherwise, a full programme is provided in the home. This included household tasks, but also outings to Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 14 restaurants, cinema and swimming. These activities are recorded in each person’s daily log. The home acquired a grant from the Calvert Trust which enabled a resident to enjoy an outdoor activity weekend of outdoor sports. All the residents have had a holiday this year, accompanied by staff. During the inspection, we observed a resident being given a back and shoulder massage by a staff member. Other similar activities included nail polishing and enjoying a foot spa. The expert by experience found that; “Residents were involved in different activities both in the community and at home. Residents usually went out at least once every day. They attended different college courses according to their likes including horticultural activities, swimming, aromatherapy, foot spa treatments, walking. Service users might also go out for lunch. Some residents like to go and visit other service users in the neighbouring flats or make use of the sensory garden that has recently been installed. Residents went shopping at least once a week and were involved with the weekly cleaning of their room; this might involve observing what was going on. Comments such as x prefers coffee, y doesn’t like to wear pink or red, indicated to me that the residents were making choices about their everyday lives and staff respected these choices”. The manager was able to obtain the services of an advocate who successfully argued for one-to-one funding for a resident who had specific needs. The manager told us that the advocate was also instrumental in obtaining more input from the Community Learning Disability Team for another resident. The daily records showed that all residents spend significant time in the local community; for example, going for trips in the minibus, eating out, going to the cinema and swimming. In the AQAA, the manager said she intends to contact other residential homes in the area to hold joint social evenings to facilitate the residents making new friends. There was evidence that some residents go home to their relatives for periods of time, including overnight stays and weekends. There was also evidence in the care plans that residents’ needs for sexual expression were addressed and there was written guidance for staff about this. Food shopping is done each day by residents and staff, and a “big shop” is done weekly. A record is kept of the meals eaten each day. Two residents are on special diets, for which advice had been sought from a nutritionist. Residents’ records contained details of individual preferences for food. The staff described how they used pictorial and other means to prepare menus, which were varied and wholesome. There was fresh fruit available. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 15 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 looking at residents’ health records. Residents can be confident that their personal support is provided in accordance with their individual needs and preferences. They can also be assured that the staff administer medication safely so that residents’ health and wellbeing is maintained. EVIDENCE: All the residents require full support for their personal care. There are extensive guidelines in each case file about how each resident prefers personal care to be provided, which respects their dignity. During the inspection, it was noted that all the residents were clean and well dressed. Emergency files have been prepared for each resident to advise medical staff about medical histories, allergies etc, in the event that they have to go to hospital. Each person has a Health Action Plan in place and there is a form for recording all appointments with the GP and other healthcare professionals. In the AQAA, the manager states she is trying to arrange with health personnel to allow residents who might be frightened about appointments, to visit the clinic and Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 16 feel the instruments beforehand to minimise any anxieties. This is an excellent idea and is an example of good practice. The expert by experience’s concluded that, “From observation, it would appear that residents were in good health, in a calm environment, and well cared for and respected. Staff were aware how service users indicated their choices, these were respected and therefore service users had a degree of control and choice over their living conditions”. Monitoring charts were being used to record incidents when a resident sometimes exhibits challenging behaviour. Residents’ medication and administration records are stored together in a locked wall cupboard in each person’s bedroom. No errors were found in the administration records and the medication was found to be safely stored and accounted for. One resident receives a daily injection from a District Nurse. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 17 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): Both 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. Residents can be confident that a full record of complaints is kept if they express concerns and this includes details of the investigation and any actions taken. The staff understand and follow the procedures that are in place to safeguard residents’ welfare. EVIDENCE: The home has an appropriate complaints procedure. We noted that the complaints log showed that there were no complaints in the past year. There is a copy of Barnet local authority’s Protection of Vulnerable Adults procedure in the home, and staff records showed that they had been trained in safeguarding residents. The majority of staff have also received training in sexuality and relationships. Earlier this year, the manager alerted Barnet Social Services and the Commission for Social Care Inspection about two incidents that could have adversely affected the welfare of the residents. Meetings were held to consider these incidents which led to effective action being taken, including updating risk assessments where appropriate. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 18 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): All these standards were assessed. 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 provides an environment that meets the specific needs of the people who live there, but there is a lack of space which prevents residents and staff from being seen in private. People who live in the home are encouraged to personalise their bedrooms and toilets and bathrooms are easily accessible. EVIDENCE: Access to Hyde Close is protected by a coded pad and visitors have to press the appropriate call button to gain entry to any Flat. Flat B occupies part of the first floor of the building and has its own front door. There is a decked balcony off the lounge leading to a fire escape. There is a lack of private space in the home. The office area doubles up as an activities area containing a large hammock which is used by some residents. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 19 The expert by experience reported that; “There was no private space for staff supervision. Supervision took place in a shared office outside of the flat or in one of the sleep over rooms. Likewise there was no private space for residents to meet with friends and family other than in their bedrooms”. We recommend that Sense reviews the environment to see if a private area can be provided in Flat B. Extensive work has been carried out to develop the communal garden into a sensory area. This is a very valuable asset to the home which is shared by all four Flats. We visited all areas of the home, including residents’ bedrooms. These are tastefully decorated to reflect each individual’s personal taste. Personal items were in evidence, for example, photographs and sensory equipment and toys. One bedroom has a hoist to help the resident in and out of bed. Each bedroom contains a washbasin, wardrobe and other appropriate furniture. The bedroom doors have tactile symbols to help residents to identify their own rooms. The bathrooms and toilets were clean and tidy and there is a new assisted bath, which was about to brought into commission. In the AQAA, the manager states she would like to have sensory equipment in the bathrooms to make bathing a more pleasant experience for the residents. It was noted that in one of the toilets, there was no soap nor a waste bin for paper towels. A requirement is made to address this. The lounge and dining furniture was in good condition and new kitchen units have been installed. This was a requirement at the last inspection. There is a maintenance person employed for the building who does minor repairs. At the time of the inspection, there were no major maintenance issues outstanding. The manager stated that the response times for repairs has greatly improved this year. There were no curtains on the lounge windows because a resident always pulls these off the wall. An opaque screen on the windows screens the lounge from outside and affords some protection for residents’ privacy. A part-time cleaner is responsible for cleaning the communal areas of the building and the care staff are responsible for cleaning within the flat. At the time of this inspection, the home was very clean and tidy and there were no offensive odours. The home has an appropriate procedure in place regarding control of infection. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 20 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 looking at staff records. The residents can be confident that there are sufficient numbers of staff on duty at all times who are well trained and supervised. This ensures that the residents are well supported. They can also be assured that proper recruitment procedures are followed to safeguard residents’ interests. EVIDENCE: Seven permanent staff and two bank staff have attained National Vocational Qualification level 2 and one has NVQ level 3. Two more senior staff are currently working towards NVQ level 4. All new staff undergo a thorough written induction when they start working at the home. “Sense”, has achieved the “Investors in people” award which demonstrates its commitment to training and developing its staff. Staff records show that they have also attended mandatory health and safety subjects, for example, food hygiene and fire training. Courses relevant to the needs of the residents are provided, including epilepsy and “non-violent crisis intervention”. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 21 The staff rotas are flexible to ensure that sufficient numbers are available when residents’ needs are highest to support them in their activities. The staff told us they were satisfied with the staffing levels in the home. Vacancies that arise from time to time are covered by regular bank staff to provide consistency and continuity of care. The records of new staff were examined. These showed that proper procedures were followed in their recruitment, including interviews, references being obtained and Criminal Records Bureau checks. There were also records of formal staff supervision, and the staff who were spoken to, said they found their supervision to be very valuable in supporting them in their work as carers. There are regular, minuted meetings at which the staff are able to express their views. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 22 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 & 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including discussion with the manager and staff and looking at records. The residents can be confident that they live in a home that is well managed by someone who is experienced and qualified to run the service effectively. The service is committed to enabling residents to develop their skills and achieve their potential. The residents’ health and safety is protected by regular checks and frequent monitoring by senior management. EVIDENCE: The manager has been in charge of the home for several years and is registered by the Commission. She has many years of experience of working with people with learning disabilities and has completed the Registered Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 23 Managers Award at National Vocational Qualification level 4. She also completed a course in sign language. The atmosphere in the home was relaxed and friendly. The staff told us that the manger was very efficient, provided clear leadership, and set high standards. She was described as fair and approachable in her dealings with the staff and residents. Senior managers carry out unannounced monitoring visits each month and complete a report on their findings. These reports are available for inspection in the home. Sense conducts an annual audit of the quality of its services throughout the organisation. This document was also available for inspection. The residents’ case files contain information about their personal finances, including benefit entitlement. There were 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. There is an up to date employers liability insurance for the home. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 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 3 26 3 27 3 28 2 29 3 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 4 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 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 X 3 X Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 25 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 YA30 Regulation 16(2)(j) Requirement A soap dispenser and waste bin must be provided in the toilet to ensure good hygiene. Timescale for action 31/10/08 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 YA24 Good Practice Recommendations “Sense” should review the environment in the home to see if an area could be provided so that people can meet in private if necessary. Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Hyde Close 12B DS0000010453.V371992.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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