Inspection on 20/02/06 for Queen Elizabeth House

This inspection was carried out on 20th February 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Elizabeth House 10/10/08

Queen Elizabeth House 27/10/06

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Queen Elizabeth House National Society for Epilepsy Chesham Lane Chalfont St Peter Bucks SL9 ORJ Lead Inspector Christine Sidwell Announced Inspection 20th February 2006 09:30 Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address National Society for Epilepsy Chesham Lane Chalfont St Peter Bucks SL9 ORJ 01494 601300 01494 601300 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) martineau@epilepsynse.org.uk The National Society for Epilepsy Andrew Ferguson Care Home 16 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Queen Elizabeth House is a purpose built home providing care for people with physical disabilities or learning disabilities, who also have epilepsy. It is one of a number of homes on one site at Chalfont St Peter and is managed by the National Society for Epilepsy. There are 12 rooms, which have been designed to meet the needs of the disabled, and also have ensuite facilities. There are lounges and dining rooms and residents can use the facilities of the site, which include a therapy service and small shop. The village of Chalfont St Peter is a bus or taxi ride away as are the nearest shopping centres. The home is staffed by qualified nurses and carers and residents have the support of a multidisciplinary team including specialist consultant neurologists, psychologists and other therapists. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report records the findings of the first inspection carried out at the home since it was registered in October 2005; the inspection was announced. The lead inspector was Christine Sidwell who was accompanied by Mrs Rosemarie James Regulation Manager. The home was assessed for compliance against all the key standards and others as appropriate. The inspection involved meeting with the manager, staff and residents, a tour of the home and looking at a selection of policies, procedures and records. Both inspectors were made to feel very welcome. Thanks go to the manager and her deputy who facilitated the inspection process. What the service does well: What has improved since the last inspection? Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 6 This was the first inspection of a newly registered service. 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. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The assessment procedures work well giving residents and staff the confidence that resident’s needs could be met if they choose to move to the home on a permanent basis. EVIDENCE: Residents are admitted to the home by way of a multi disciplinary team assessment and assessment by the manager of the home. Records were seen to confirm that the last resident to move to the home had been visited by the home manager at his school and that a full assessment of his needs had been undertaken. Most residents are funded by their local Primary Care Trust (PCT). There was evidence in the files that those residents who have a care manager had a care needs assessment. Potential residents stay at the home for a sixweek trial period, to enable a full assessment of their needs. This is followed by a multi disciplinary team review, which includes the resident and their family. The assessment documentation takes account of potential resident’s cultural and faith issues. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The care plans and risk assessments give staff the knowledge that they need to care for residents. Residents are supported to make as many decisions as is possible within the constraints of communal living and their disabilities. EVIDENCE: Four care plans were selected at random and looked at in detail. They are comprehensive and contain evidence of multi disciplinary working. They had been reviewed monthly and the daily entries were signed and dated. There was evidence in the plans seen that residents had risk assessments appropriate to their needs. The plans also held a suggested daily guide as to when medication and other interventions were to be undertaken. This was to prevent residents being disturbed frequently and to allow them the opportunity for activity and relaxation in between necessary clinical interventions. Each resident has a named nurse and key worker. The named nurses spoken to were knowledgeable about their residents. There was evidence in the plans that residents and their families have been involved in drawing up their plans. The residents spoken to said that they were able to make decisions about their day to day lives although it was not always possible for them to have complete Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 10 freedom to determine who will be caring for them or how they will spend their day. One family member has requested an all male team to care for his son. Whilst there are male carers on the team it may not be possible to accommodate this wish as there are insufficient to ensure that there is a male carer on duty at all times. One resident said that she would like to be able to go out more. No residents manage their own monies. Risk assessments are undertaken to support residents when they go out or participate on activities on the NSE site. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The ability for residents to take part in local community events is limited by the isolation of the site, although the staff endeavour to ensure that residents have the opportunity to go out on a regular basis. The staff were observed to be caring and supportive to residents, promoting their dignity and wellbeing. The residents are offered a varied diet at times suited to them thus ensuring mealtimes are an enjoyable experience. EVIDENCE: The residents in the home have profound disabilities and are unable to work. There are community activities on site and residents can go to the local shops and town centres on the site bus or in a taxi. The finance office of the National Society for Epilepsy, and their care managers, help residents and their families with benefits. Resident’s integration with community life is hindered to a certain extent by the isolation of the site. The staff confirmed that they assist residents if they wish to out in the evening or at weekends. The home has been open a short time and systems are being consolidated at present. The manager said that plans for annual holidays and outings will be made later in the year. There is open visiting and some residents are in close contact with their families. The staff were seen to respect residents privacy and dignity and Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 12 were speaking to residents in a friendly and supportive manner. Residents have unrestricted access to all areas of the home. The home work to a 4 week rotating menu. On the day of the inspection the residents had a choice of cereals and toast for breakfast with a full cooked brunch for those wishing to eat a little later. Lunch was a choice of sandwiches, salad with cooked meat and cheeses, crisps and pickles, cake or yogurt. A selection of fresh fruit was also on offer. The evening meal was chicken and gravy with boiled potatoes or rice, a selection of vegetables. Apple crumble was the desert. In addition to this drinks and snacks are available around the clock. The day’s menu is on display in the dining room. Special diets are catered for. Staff are reminded to defrost food in the fridge and not on top of a work surface as was the case on the day of the inspection Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal support for residents is given in a way in which they prefer although every effort must be made to ensure that residents are cared for by carers of the same sex when this is their expressed wish. Resident’s healthcare needs are met, maximising their abilities. Medication policies and procedures work well, ensuring that residents receive their medication in a safe and timely way. EVIDENCE: The care plans seen described how resident’s preferred to be moved and the residents spoken to said that most staff understood their needs. The times for getting up and going to bed are flexible, as are meal times. All residents require full support to meet their personal hygiene needs. They were all wearing their own clothes on the day of the inspection. Those that needed it had specialist wheelchairs and equipment for supported nutrition. One lady who is of the Muslim faith has been allocated female care workers in line with her wishes. The manager said that whilst it was normally possible for all female residents to be cared for by female carers, if that was their wish, it was is not always possible for male residents to be cared for by male carers. This is the expressed wish of one family and every effort should be made to accommodate this. Residents have the support of a multidisciplinary team based on the site. There is also an advocacy service on the site, although the manager said that this was not used at present in the home. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 14 There was evidence in the care plans that residents had seen the general practitioner. They had had ‘flu’ jabs. There is a need for the multidisciplinary team with the residents and their families to agree what routine health screening should be undertaken for each resident. There was evidence in the care plans that residents had access to routine outpatient appointments. Their care is reviewed weekly by the local general practitioner and their epilepsy care by the visiting consultant neurologist. The health professionals who returned the comment cards distributed as part of the inspection said that they were able to see residents in private. Residents consent to medication was recorded in the care plans. No residents self administer medication at present. Residents medication is stored in locked boxes in their rooms and the medication records administration charts were found to be completed correctly. The nurses spoken to said that no medicine was administered covertly. The controlled drugs were stored and administered correctly and the correct records kept. There is an on site pharmacist, from whom medication advice may be sought. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Resident involvement in the drawing up of care plans and the monthly resident meetings ensure that residents’ views are listened to and acted upon. The NSE’s policies and procedures and staff training on adult protection provide the means by which residents can be protected from abuse, neglect and self-harm. EVIDENCE: Monthly resident meetings are held and minutes are taken. The minutes for the meeting held in January were up on the notice board in the dining area. The minutes showed a wide variety of topics were discussed evidencing that residents are fully consulted about things that affect their lives and that they are listened to. During the inspection staff were observed attempting to communicate with a resident recently admitted to the home using sign language in a form he could understand. They were successful in determining he would like his favourite snack of cheese on toast (provided) and that he did not want to go out for a walk as had been suggested. The advocacy service Peoples Voices visits the NSE site regularly and the times for this are advertised in the NSE’s magazine In site. Resident involvement in the drawing up of care plans has been recorded under Standard 7. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 16 Protection of Vulnerable Adults training is part of the induction programme. Further courses on this topic are included in the NSE’s overall training programme. A joint protocol for the investigation of Adult Abuse between Bucks Adult Social Care and Thames Valley Police was on file. The NSE has their own complaints procedure that all staff are trained to follow. Copies of the procedure are included in the Service User’s Guide; a pictorial form is available. The procedure includes timescales for responses and the contact details of the Commission for Social Care Inspection (CSCI). At the time of this inspection the Commission had not received any complaints about the service in the time since it has been registered. Two complaints had been received ‘in house’. The records about these complaints were made available for inspection purposes. The records showed that appropriate action and follow up had been undertaken. Whether or not to report to the Commission under a Regulation 37 was also indicated. The organisation’s finance department holds funds pertaining to residents centrally. The disadvantage of this is that staff have to think ahead and plan to draw money out on behalf of a resident if a trip out shopping was planned for example as the finance department is not open all of the time. These records were not looked at during this inspection. Small amounts of cash are held at the home for the residents. The records and cross check were satisfactory. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 An inspection of the premises showed that the residents live in a safe and well maintained environment. The residents have a choice of homely communal facilities where they can pass the time of day. Although the home has its own garden QEH is situated in extensive grounds that the residents can make use of. Toilet and bathing facilities have been designed to meet the needs of the residents this home is registered to accommodate. A variety of aids and adaptations are available to maximise residents’ independence. Bedrooms are spacious and equipped to meet resident’s needs. Residents are encouraged to bring in personal possessions to help personalise their bedrooms. The layout of the home and the homely fixtures and fittings mean the residents live in safe and comfortable surroundings. Standards of cleanliness were good with no unpleasant odours detected. EVIDENCE: Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 18 Queen Elizabeth House is a new purpose built home designed to accommodate adults with complex epilepsy and a range of physical disabilities. The home is in two halves each virtually mirroring the other. Bedrooms are extremely spacious and all have en suite shower and toilet facilities. Tracking is fitted in both the bedroom and en suite areas to assist movement and handling. Additional disabled toilets and two Arjo baths have been provided should the residents prefer to use them. Each dining area has a kitchen where snacks and hot drinks can be prepared. The main meals of the day are prepared in the homes main kitchen, which is again spacious and domestic in style. Doorways and corridors have been designed with a wheelchair user in mind. Because the home is not yet full only one lounge area is currently being used. It too is spacious and there is a range of domestic style furniture fixtures and fittings. However, the room still lacks a really homely feel, this will come with time when the ‘clinical newness’ of the room has worn off. Because the home has only recently been constructed the fabric of it is in good order. There was only one area of redecoration / repair needed and that was where the end of a bed had been allowed to come in contact with a wall when the bed was being adjusted. The deputy manager confirmed the redecoration and repair would be included in the snagging list of works that follow a new building construction. At the time of the inspection the home was clean throughout with no unpleasant odours detected. There are fully equipped laundries on both sides of the home. They contain industrial sized washing machines (with a sluice facility) and tumble dryer. The laundry floors are impermeable to water and are coved to the wall for easy cleaning. Appropriate measures appear to be in place to dispose of clinical waste with the use of large pedal bins lined with yellow bags. Hand washing facilities are available. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 A team of qualified nurses together with experienced support workers have been recruited to provide the levels of care needed for the resident group. The organisation follows recruitment practices as detailed in the National Minimum Standards and Regulations ensuring any staff members employed are suitable to work with vulnerable people. The organisation, the manager and his staff team have a positive attitude to training thus ensuring residents needs are met by appropriately trained staff. Regular staff supervision sessions are undertaken meaning the staff are well supported in their roles. EVIDENCE: With QEH being a new establishment, it presented the opportunity for the recruitment of a completely new staff team. The manager has recently added RGN to his impressive list of qualifications that includes the Registered Managers Award. A team of qualified nurses have been recruited and are on duty 24hours a day. Two nurses from India are working at the home while undertaking their adaptation training. Experienced support workers have been recruited from Poland and Lithuania, these staff members have undertaken Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 20 nurse training in their own country. As a result the staff team as a whole are very experienced and competent to carry out the work they do. Observations made of staff practice on the day of the inspection confirmed that this was so. The organisations recruitment records are held centrally and managed by the HR department. The Commission has agreed with the NSE that these records be inspected twice a year. It is confirmed that at the inspection carried out in December 05 all the records examined were in order. The training records for the home were made available for inspection purposes. Courses already undertaken and those booked included: Basic Life Support Food Hygiene Awareness Basic Fire Awareness Challenging Behaviour Epilepsy Awareness Medication Management Key Worker Training Basic Foot Care Infection Control & MRSA During supervision, (1 to 1’s are held every five weeks) training is discussed and the supervisee is responsible for drawing up and maintaining their own development portfolio. Records were seen to confirm this. NSE induction training for new employees lasts a minimum of three days. In addition to this the new staff member will undertake movement and handling training and training in POVA. Once this has been completed satisfactorily the new employee can take up their post. However, further induction training pertaining to working at QEH then begins. There is no set time for the completion of this programme of training but progress is monitored during supervision sessions and the probationary period will not be signed of until all necessary work has been completed. Again records confirming this were shown to the inspectors. The manager ensures all his staff team are up to date with their knowledge of the organisations policies and procedures. He will regularly put a policy / procedure around for circulation and staff has to sign to say they have read and understood it. Records were seen to confirm this. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The manager is experienced in the care of people with epilepsy and physical disabilities and in the management of a care home and has established the home to best meet the needs of residents. The health and safety policies and procedures should protect residents and staff. The home’s quality assurance systems are in place but would be enhanced by seeking the views of residents, their families and other stakeholders about the quality of care offered, on a regular basis. EVIDENCE: The registered manager is a registered general nurse and holds the National Vocational Qualification in Management at Level 4. he has had three years experience of managing a care home. He has qualifications and experience in caring for people with learning disabilities and epilepsy. The staff spoken to said that the atmosphere in the home is open. Regular staff meetings are held and minutes were seen to confirm this. Training records were seen to confirm that the manager has updated his knowledge and skills in the last year. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 22 The National Society for Epilepsy (NSE) has an internal quality assurance system. The home manager meets monthly with the service manager to undertake a quality review of the service. Independent quality assurance visits are undertaken and reports are sent to The Commission for Social Care Inspection for Social Care Inspection. In addition to this the manager undertakes a home audit of care plans , medication and the environment. The care plan audit and action plan seen by the inspector was an example of good practice. Resident’s meetings are held regularly and provide an opportunity for residents to give their views. At present surveys are not undertaken to ascertain the view of residents, their families or other stakeholders about the quality of the service, either by the home or the organisation, and this should be considered. The home has only been open for less than six months and it is not possible at present for the manager to demonstrate that there is a year on year development plan for each service user. The poster telling residents and visitors about the forthcoming inspection was in the main entrance of the home. There are moving and handling policies and procedures in place. Records showed that staff have had training in moving and handling. Specialist hoists are available and residents have their own hoist slings to prevent cross infection and to ensure that residents are safe. There is a fire risk assessment and records showed that most staff, although not all, have had fire training and that regular fire drills have been undertaken. The NSE hold regular one-day first aid training and the manager said that a member of staff who has completed that training is on duty on every shift. There is a Health and Safety policy in place. COSHH substances are kept in a locked cupboard. Colour coded mops were evident. The temperature of bath water is checked and records were seen to evidence this. Protective gloves and aprons were available to staff and the use of an antibacterial gel was observed. Routine maintenance of equipment has been undertaken. Generic risk assessments are in place. There is an accident book and internal reporting procedures should residents or staff suffer an accident. There is a clinical incident reporting policy. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 X Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 24 N/A 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 Standard YA13 YA17 Regulation 16 16 Requirement Individual activity plans must be drawn up with residents. Staff are reminded that frozen food must only be defrosted in a fridge and not on a worktop surface as was evident at the inspection. The views of residents, family, friends and advocates and of other stakeholders (eg other professionals) should be sought on a regular basis and the outcomes shared with The Commission for Social Care Inspection. Timescale for action 30/06/06 21/02/06 3 YA39 24 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA18 YA19 Good Practice Recommendations Every effort should be made to enable residents to be cared for by members of the same sex if that is theirs or their families wish. The manager should agree with residents, their families DS0000065482.V275691.R01.S.doc Version 5.1 Page 25 Queen Elizabeth House and the multidisciplinary team, the annual health screening that is appropriate for each resident. Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Elizabeth House DS0000065482.V275691.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!