Inspection on 10/01/06 for Queen Elizabeth Walk (57)

This inspection was carried out on 10th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Elizabeth Walk (57) 27/08/08

Queen Elizabeth Walk (57) 19/12/07

Queen Elizabeth Walk (57) 20/03/07

Queen Elizabeth Walk (57) 03/03/06

Queen Elizabeth Walk (57) 02/12/04

Queen Elizabeth Walk (57) 20/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (57) 57 Queen Elizabeth Walk Hackney London N16 5UQ Lead Inspector Kristen Judd Unannounced Inspection 10:45 10 January 2006 th Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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 Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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 Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Walk (57) Address 57 Queen Elizabeth Walk Hackney London N16 5UQ 020 8809 3817 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) yadvoezer@btconnect.com Yad Voezer Mrs Jacqui Biren Care Home 8 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Agreed room may be used for respite care. Agreed residents may have relatives/friends to stay overnight in respite room and not in their own bedr Agreed room may be used for respite care. Agreed residents may have relatives/friends to stay overnight in respite room and not in their own bedrooms One Service user with Mental Health needs may be accommodated for a period of six months from the date of this certificate and thereafter reviewed by CSCI on a three monthly basis. 2nd December 2004 2. Date of last inspection Brief Description of the Service: 57 Queen Elizabeth Walk is a Jewish Orthodox care home for seven females with a learning disability and one respite bed. The care provider is Yad Voezer (A Helping Hand), an orthodox Jewish charitable organisation, managed in accordance with strict Torah guidelines. All areas of daily life, including food (Kashrus requirements), Shabbos (Sabbath) traditions, festivals, religious rituals etc. are culturally observed. Yad Voezer aims to “ensure that despite a learning disability, people are given the maximum opportunity to enjoy their lives to the full.” A range of activities is offered within and outside of the home. These include opportunities for employment, day care, Hebrew lessons, religious instruction, art therapy, music therapy, keep fit and computer training. Service users independent living skills, spiritual needs and personal development are actively promoted. There are additionally strong links with the local orthodox Jewish community. The home is a large family type property situated in a quiet residential area in Stoke Newington. The home offers access to local amenities, transport and relevant support services, to suit the lifestyle needs of service users and the purpose of the home. Restricted permit parking is in operation. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which started at 10.45am. This inspection followed up the requirements made at the announced visit held on 2nd December 2005. The inspector spoke with service users, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There have been seven requirements made following this inspection. Verbal feedback was given to the registered manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: 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. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 6 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 Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 7 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): 1&5 The inspector believes that staff are clear about the service provision and what assistance is expected to be provided to service users. However documentation such as the service user guide must accurately reflect the service to enable service users to be accurately informed. EVIDENCE: The home’s statement of purpose covers the aims and objectives of the home, and the additional aspects as listed in Schedule 1 of The Care Homes Regulations 2001. The service user guide has been developed; the format has been improved and is more suitable for service users with learning disabilities. However the document requires further amendment as it does not indicate that complaints can made to outside agencies such as social services or the Commission for Social Care Inspection directly. Additionally the guide has not been individually developed to accurately reflect the individual home. The words and pictures should provide the service users with an accurate description of the individual service being provided. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 8 The organisation has developed a written contract / statement of terms and conditions with the home. Contracts cover such aspects as conditions; trail periods, fees, conditions, visitors, health and complaints. Contracts are available in the service user rooms however it was noted that these have not been signed by service users or a representative. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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): 6,7,8,9&10 The inspector believes that staff are aware of service users needs. However all of the service users needs must be reflected in the individual service users plans and be supported by comprehensive risk assessments to demonstrate how those needs are to be met effectively. EVIDENCE: A sample of the service user plans were examined during the inspection. Each file examined contained all the relevant personal information. Service user individual plans highlight the issues/needs, the aims and actions. Identified needs are highlighted covering daily living skills, personal care, activities, religion and health. Generally individual service plans are good however it was noted that some of the individual needs required reviewing, as this had not been done in excess of a year. The registered manager must ensure that all service users plans accurately show how the service user’s needs in respect of health and welfare are to be met. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 10 Through the tracking of care the inspector was not satisfied that the all risks which were highlighted in the care plan, had been comprehensively assessed. Two of the service users plans indicated that the individuals suffered from epilepsy and indicated some risks however this had not been formulated in to a risk assessment. Additionally one service users file indicated that the service user has some episodes of anger, which must also be assessed and a risk assessment implemented. The registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. There was evidence that service users are involved in the day-to-day running of the home, participation in activities of daily living and involvement in choice of daily activities. Service users were observed during the inspection undertaking such tasks. One service user was observed assisting with instruction to prepare the meat for supper. Service user house meetings are held weekly generally on a Sunday evening. Minuets were seen, each service user is asked individually to contribute to the meeting. Service users are encouraged and supported to take an active part in the daily routines, such as cleaning their rooms, making snacks and beverages, preparing the house for the Sabbath. It was evident from observations made during the inspection that service users have choice and control over their daily lives. Service users are free to come and go from the house as they choose. The confidentiality policy has been amended as previously required. The inspector was informed that the all records in regards to the service user are kept secure and confidential in a locked office. Through interviewing the staff the inspector is satisfied that service users information is handled in a confidential manner and that staff have a clear understanding of confidentiality. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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): 11,12,13,14,15 &17. The inspector observed and was satisfied that staff provide service users with support to make choices and provide them the opportunity to lead independent lives. EVIDENCE: This care home is an orthodox Jewish home and all service users are from orthodox Jewish families. The home is culturally appropriate to the needs of the service users. The inspector was satisfied through observations made during the inspection that staff encourage service users to be involved with many activities and organisations outside the home. This is one of the homes strengths. On the day of inspection service users were attending day services, music therapy, swimming sessions, shopping in the local area, knitting, cleaning their own rooms, laundry and food preparation. Staffing was at a level to support all of the activities. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 12 The inspector was satisfied that they are encouraged by staff and management to participate in the local community. The inspector was informed that holidays are arranged for service users who wish to attend annually. This year service users were taken to a hotel in Bournemouth. Staff provide the service users with the assistance with their finances if required. Service users have their own building society books and cash is kept in individual lockable boxes in their own rooms. Service users record with assistance their finances in individual books. One of these was seen at the time of inspection. The registered manager discussed the importance of encouraging the service user independence in this area. The registered manager stated that they mainly use taxis for the service users. They do have the use of the organisations mini bus however the registered manager stated that they only occasionally use this facility. The registered manager stated that all service users have a freedom pass and are on the electoral role. The registered manager stated that family and friends are always welcome in the care home. Evidence was seen of family contact. Details of family and friends were evidenced on the individual service plans. The inspector was informed that families could visit them in their own bedrooms or the communal areas of the care home. The registered manager stated members of the community are invited to share Shabbos (Sabbath) as they would in their own homes. There are three meals offered daily when service users are present in the home, with additional drinks and snacks. The registered manager informed the inspector that the menus are planned with the service users at the house meetings on Sundays. Evidence was seen in the minutes of the residents’ house meeting of meals being discussed. Any changes are recorded on the menu sheets. Menus were examined and found to be international, culturally appropriate and nutritious. Service users assist in meal preparation on a rota basis. During the inspection lunch consisted of fresh salad, and tuna with pitta bread and the evening meal being prepared was fresh chicken with potatoes and fresh vegetable. All food purchased whether for the home, clubs, holidays or outing must hold a hescher (certificate of Kashrus) of Kedassia or one of equal standing. Milk and meat sections of the kitchen were clearly separated. Food stores were seen during the inspection. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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& 20 It is the inspector’s view that service users are well supported by staff to ensure that physical and emotional needs are met. EVIDENCE: The inspector was satisfied through observations made that the service users continue to be supported to maintain their personal identity and choice. Service users’ require a range of support with personal care from just supervision to assistance with all aspects of personal care. The inspector was satisfied that the registered manager and staff are fully aware of service users’ needs and makes appropriate referrals when required. All service users files contained documented medical appointments to GPs, dentist, the local hospital and occupational therapist. The inspector was informed that staff have completed the Health Action plans for individual service users. This document is being implemented in all of the organisations homes. It provides a comprehensive overview service users health needs. The inspector saw evidence of the draft forms, which were in the process of being typed at the head office. The inspector felt, through speaking to both staff and service users that the staff treat service users with respect. The inspector was satisfied through Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 14 indirect observation that the staff are very flexible with regards to the day-today running of the home. Staff were observed during the inspection encouraging service users to make decisions and complete tasks for themselves when appropriate. Staff were observed interacting with all of the service users throughout the inspection. The interaction was positive and there is clearly good relationships between staff and service users. Service users were seen to move around the home without any restrictions. The inspector was satisfied that staff were fully aware of service users medical needs. The medication storage was in good order. Service users medication is provided in doset boxes. The home appropriately stores medication in a locked cabinet. The inspector completed three spot checks on generic package medication, one error was found. Additionally one service user who had been admitted on a one-week respite placement had several medications but no records of amounts had been recorded in the home. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 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): 23 It is the inspectors view that the service user rights are protected however there must be accurate records maintained in relation to service users income and how that income is spent. EVIDENCE: Policies and procedures for dealing with allegations of abuse are in place. It also includes the procedure of responding to allegations or suspicions of abuse. The procedure covers immediate respond and action, how to alert management, who to notify, protection, and formal investigation. The guidance covers the importance of accurate recording. Clear time scales are indicated. The registered manager informed the inspector that there have been no allegations in regards to abuse within the home. Concerns have been raised at previous inspections regarding to the procedure of the service users Disability Living Allowance being used by the organisation to go towards the funding of the mini bus. The inspector saw how the registered manger records the trips undertaken by service users by taxi or other modes of transport. This information is then entered centrally onto a spreadsheet. The registered manager must forward the end of year account of the benefits and evidence how the funds are spent on accessing the community. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 16 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): 24,27,28, 29 &30 The inspector is satisfied that the home is suitable for it purpose and is maintained to a high standard of cleanliness. EVIDENCE: The home is located in a quiet residential road in Stoke Newington. It is a large terraced town house and blends unobtrusively into the neighbourhood. The home offers access to local amenities, transport and relevant support services to suit the personal and lifestyle needs of service users and the purpose of the home. The premises were found to be safe, comfortable, bright, homely, clean and free from offensive odours. There was sufficient lighting, heating and ventilation on the day of inspection. The home has sufficient numbers of toilet and bathroom facilities conveniently located on each floor throughout the home to meet service users needs in keeping with this standard. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 17 The ground floor bathroom has tiles missing and needs decoration however the inspector was informed that this bathroom is being refurbished and the bath is being replaced with a walk in shower by the end of March 2006, as such requirements have not been made at this time. The service users have access to the entire home with the exception of the individual rooms of others. All the communal areas are accessible including the garden area, which has a patio area. Service users are encouraged to assist in the kitchen with tasks such as laying the table and cooking with assistance. There is an interconnecting and dining room. The house was found to be very homely. Evidence of service users artwork was on display. The lounge has an aquarium, keyboard, television, video, computer and a library for service users use. Communal areas additionally displayed photographs of service users engaging in various activities and culturally reflective pictures of Israel and quotations in Hebrew The home has ramps leading to the entrance of the home and at the rear of the building leading to the garden. Service users were found to have the specialist equipment needed to maximise their independence. The home does not however have a passenger lift. During the inspection the home was free from odour. The home was of adequate cleanliness and hygiene. There is domestic support for a few hours daily. Service users are supported by staff to maintain their own rooms. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 18 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): 33 &34 It was the inspectors view that the home has a stable, experienced and effective staff team who work well together to provide an excellent level of care to service users. However the staff files must evidence all relevant pre employment checks have been completed appropriately. EVIDENCE: Rotas indicated that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. The home always has at least 2 members of staff on duty during the day. At nighttimes there is one waking night. An on call rota is available for staff support. On the day of inspection four staff members were on duty. Staff were allocated to enable the service users to undertake trips and individual activities. One service user was escorted to a swimming session; others were taken shopping and to day care services. The home is well staffed to meet the individual needs of service users. The registered manager also issues staff with a daily responsibility checklist, which covers laundry, hygiene, kitchen and cooking responsibilities; this provides clear direction for staff. Through observation and discussions with staff they demonstrated a good understanding of their roles and responsibilities, and good knowledge around Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 19 individual service users needs. Staff assist service users with domestic tasks in the home dependant on their individual assessed need. Staff were observed to interacting with service users in a relaxed and respectful manner, and there was evidence that good relationships have been built up with service users Minutes for staff meetings were seen the content of the meeting was good, items that were discussed and action plan was recorded clearly stating who was responsible. The head office deals with all recruitment and this is where the main personal files are stored. Files were made available for inspection. Four personnel files were examined; two files did not contain photographic identity, two contained only one reference. Criminal Bureau checks were in place for all of the staff. It therefore remains an outstanding requirement that the registered manager must ensure that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. This matter must be addressed as a matter or urgency. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 20 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): 38, 41&42 The inspector believes that the home is run by a registered manager who is competent to run the care home in line with its statement of purpose. However there are issues with regard to some of the homes recordings not being up to date, these issues must be addressed. EVIDENCE: Through interviewing the registered manager, the inspector was satisfied that the home is managed in an open and positive way. The inspector continues to be satisfied that the registered manager is competent and experienced to run the care home in line with its stated purpose. All the staff and service users were friendly, open and appeared comfortable within the care home. The home’s records are generally well kept, recording is clear and all records are formatted well. However the individual service plans require some work to Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 21 ensure that all the service user needs are reviewed regularly and risk assessments must be updated. Additionally staff files must contain relevant documentation. These requirements have been made under the relevant standards. The monthly-unannounced monitoring visits are untaken; and copies are forwarded to the Commission. Service users and staff meetings are being held and copies of the minutes were available for inspection. Relevant documentation was in place regarding the health and safety requirements, certificates were seen. Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queen Elizabeth Walk (57) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 3 x DS0000010281.V270442.R01.S.doc Version 5.0 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5.1 Requirement The registered manager must ensure that the service users guide reflects the service provision accurately. Additionally the complaints procedure must indicate that complaints can be made directly to the Commission. The registered manager must ensure that all service users have agreed and signed contracts in place. The registered manager must ensure that all service users have a written plan as to show how the service user’s needs in respect of health and welfare are to be met. Each plan must be reviewed in line with the organisational policy. The registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. Timescale for action 31/03/06 2 YA5 17 31/01/06 3 YA6 15.1.2 28/02/06 4 YA9 13 28/02/06 Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 24 5 YA20 13.2 6 YA23 25.3(c) The registered manager must 31/01/06 ensure that arrangements are in place for the recording, handling, safekeeping and safe administration of all medications in the care home. The registered manager must 14/04/06 forward the end of year account of the benefits and evidence how the funds are spent on accessing the community. The registered manager must ensure that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. (Timescale of 28/2/05 not met) 28/02/06 7 YA34 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Elizabeth Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Walk (57) DS0000010281.V270442.R01.S.doc Version 5.0 Page 26 - 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!