Inspection on 19/12/07 for Queen Elizabeth Walk (57)

This inspection was carried out on 19th December 2007.

CSCI found this care home to be providing an Adequate service.

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 9 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) 20/03/07

Queen Elizabeth Walk (57) 03/03/06

Queen Elizabeth Walk (57) 10/01/06

Queen Elizabeth Walk (57) 02/12/04

Queen Elizabeth Walk (57) 20/09/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (57) 57 Queen Elizabeth Walk Hackney London N16 5UQ Lead Inspector Robert Sobotka Unannounced Inspection 19th December 2007 09:30 Queen Elizabeth Walk (57) DS0000010281.V356418.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 Queen Elizabeth Walk (57) DS0000010281.V356418.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. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 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 vacant post 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.V356418.R01.S.doc Version 5.2 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 bedroom. 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. 20th March 2007 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.V356418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate quality outcomes. This inspection visit took place over one day and was unannounced. During this visit, the inspector spoke the home manager and several members of staff working in the home. He also looked around the premises and viewed various records. This inspection was undertaken with help from an Expert by experience, who visited the home with his Support Worker. She spoke to the people who use the service and undertook a tour of the premises. Prior to this inspection the home was asked to complete the Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. The aim of this unannounced inspection was to check the home’s compliance with the National Minimum Standards and the Care Homes Regulations. The inspector would like to thank service users and staff for contributing to this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the manager has ensured that the complaints procedure in the service user’s guide has been amended. The organisation has appointed a new home manager, who has established a good rapport with the service users and staff working in the home. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 6 The recommendation that the service users’ Health Action Plans contain information of annual checks has now been met. What they could do better: There were 2 requirements, which remain unmet from the last inspection and have therefore been repeated. These were: - The registered manager must ensure that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. - The registered manager must ensure that all staff have regular, recorded supervision sessions at least six times a year. In addition the following 7 statutory requirement and 2 good practice recommendations were made following this inspection visit: - The registered person must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the preadmission assessment and statutory reviews have been taken into consideration. - The registered person must ensure that individual risk assessments are reviewed on a regular basis in order to minimise any risk to people who use the service. - The registered person must ensure that appropriate systems are in place for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. - It is required that more robust systems for managing service users’ finances are set up within the home, in order to protect service users from abuse. - The registered person must ensure that carpets are replaced in communal areas. - It is required that an application is submitted to the Commission for the home manager to be formally registered. - It is required that the home’s electrical appliances are tested, in order to ensure with the health and safety law. - It is recommended that the home purchase a cordless phone, so that the service users are able to use it in the privacy of their rooms, should they wish. - Lampshades should be provided in each service user’s bedroom. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 7 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. Queen Elizabeth Walk (57) DS0000010281.V356418.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 Queen Elizabeth Walk (57) DS0000010281.V356418.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): 1, 2, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the necessary information they need to make an informed choice about the home. EVIDENCE: The home had an up-to-date statement of purpose and the service user’s guide in place, which cover the its aims and objectives of the home and additional aspects listed in relevant sections of the Care Homes Regulations 2001. Both documents contained relevant information to allow service users to make an informed choice whether to live in the home. Since the last inspection the manager has ensured that the complaints procedure in the service user’s guide has been amended. There have been no new admissions to the home since the last inspection. The standard relating to the assessment process could not therefore be fully assessed. Files of existing service users contained appropriate pre-admission assessments. Following discussion with interviews with members of staff working in the home and the home manager and review of the documentation kept in the home and feedback from the expert by experience , the inspector was satisfied that the needs of those accommodated in the home were being met. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 10 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, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was required to improve individual care plans. Service users were also encouraged to take part in planning their care and contributed to other aspects of life in the home. Appropriate risk management systems were in place, however they must be regularly reviewed. EVIDENCE: As part of this visit, the inspector viewed care plans of four service users accommodated in the home. The new home manager stated that a format of care plans was being reviewed. The manager must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the pre-admission assessment and statutory reviews have been taken into consideration. In the Annual Quality Assurance assessment, the Home Manager stated that the new individual key worker system has been introduced and service users meet with their keyworkers on a regular basis. Weekly service users’ meetings are also organised. Minutes from these were available for inspection. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 11 Each filed viewed contained appropriate risk assessments, however these must be reviewed on a regular basis in order to minimise any risk to people who use the service. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged and supported to become part of the local community and develop and maintain friendships and family links. They enjoyed the food offered in the home. EVIDENCE: Following discussions with staff working in the home, direct and indirect observation, feedback from the Expert by experience, and review of documentation in the home, such as care plans, the inspector was satisfied that people who use the service were supported and encouraged to take part in appropriate leisure activities. Some of the observations by the Expert by experience were: • Lady told us that she is able to go out on transport; she is assisted by a key worker. • Lady told us she is able to have her friends come to visit her in the home when they wish to. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 13 • • • • • • • • • • • • • • • • • • • • • • • • • • • Staff told us cooking is carried out by the ladies with support from staff. Lady told us she is able to spend quality time in her room if she chooses. Staff were seen to be very helpful and friendly towards the ladies and the ladies seemed happy with the staff support. Hobbies are encouraged by staff. We observed lots of Art work displayed around the home. Creative art is done in the home and at the day centre the ladies attend. Clothes are washed by Ladies who are able to do so. The ladies rooms are very personal; we observed lots of their own personal belongings in the rooms. Lady told us she was able to choose her own clothes every day. Lady told us she was able to talk to staff if she was not happy with anything. Lady told us she was able to choose her holiday to Bournemouth/Wales. Lady told us she chooses to go to clubs locally. Staff told us the ladies choose a limousine to go to see the lights in London. We observed the ladies to be very happy during our visit. The home is keep very clean and tidy. Staff told us the ladies do housework and preparation of the food. We were told the ladies attend a Jewish day centre for meals. Ladies go to a local garden centre and they choose to eat in the restaurant there. We were told the ladies help in the garden and enjoy gardening. Ladies are very happy with living in the home. Lady told us they were able to choose when they go to bed. Staff told us Ladies wake up at 8:00am if they have a programme to follow. Ladies are given a choice if they wish to have shower or bath. One lady told us she likes having a shower best. Lady told us she felt safe living in the home. We were told all ladies attend the synagogue. Lady told us she uses cream to keep her skin in nice order. One lady told us she exercises. Ladies attend the local Doctors if unwell; ladies go to a local Dentist. Lady told us she is able to choose what she eats. The inspector noted that throughout the inspection staff working in the home communicated with the service users in a respectful and sensitive manner. Those who live in the home enjoyed food offered to them. All food purchased whether for the home, clubs, holidays or outing must hescher (certificate of Kashrus) of Kedassia or one of equal standing. Mils and meat sections of the kitchen were clearly separated. Food stores were checked during this inspection, all of which were clean and tidy and foods were appropriately stored. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 14 Queen Elizabeth Walk (57) DS0000010281.V356418.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of this inspection, the home was appropriately meeting service users’ emotional and physical health. Improvements were required to the home’s medication systems. EVIDENCE: The home continues to meet the needs of the residents living there. The service users appeared well at the time of the inspection. All personal care required by the people who use the service is carried out by female staff. The examined files showed the home’s commitment to facilitate the service users’ access to community health resources. Each person was registered with a General Practitioner. All service users had “Health Action Plans” in place, which were incorporated into their care plan. The recommendation that the service users’ Health Action Plans contain information of annual checks has now been met. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 16 The home’s medication systems were checked during this inspection. They were generally well maintained, however it was noted that staff did not always appropriately sign for the medication administered to the service users, this required improvement. During cross checking medication stocks, the inspector came across some Paracetamol tablets without original packaging and dispensing label in one of the service user’s boxes. The registered person must ensure that appropriate systems are in place for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The home manager was advised by the inspector that in accordance with change in legislation, a cupboard is required to be installed for the storage of Controlled Drugs. The cupboard must meet the requirements of the Misuse of Drugs Regulations 1973. Queen Elizabeth Walk (57) DS0000010281.V356418.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): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate complaints systems were in place. Improvements to the home’s financial systems are required to ensure that service users are protected from abuse. EVIDENCE: There have been no complaints made to the home since the last inspection. As previously mentioned, the service user’s guide has been amended to indicate that complaints can be made to the Commission directly. The organisation’s complaint procedure was displayed on full view on the service users’ notice board. The home manager stated that an open and honest atmosphere is encouraged within the service and people who use the service are supported to discuss any issues at their weekly meetings. The home’s accidents and incident records were inspected and were found to be appropriately maintained. The home had appropriate policies and procedure in place in relation to the adult protection issues. Staff have received Adult Protection Training within the Learning Disabilities Awards Framework induction programme. During the course of this visit, the inspector requested to see two of the service users’ financial records and their money tins. It was noted that neither of the tins contained accurate amounts of money and that records were not kept fully up-to-date. These concerns were raised during this inspection visit with the home manager and as a result an adult protection meeting was called, due to suspicions of financial abuse within the home. During the adult Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 18 protection strategy meeting hosted by the London Borough of Hackney, it was agreed that more robust systems for managing service users’ finances were required in the home to ensure that service users are protected from potential financial abuse, as at the time of this inspection visit they were found to be inadequate and therefore being open to potential abuse. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a generally safe and clean environment, however some of the communal carpets required replacement. Lampshades should be provided in each service user’s bedroom. Cordless telephone should also be provided to afford service users more privacy. EVIDENCE: The following observations were made by the Expert by experience: • • • There are only Ladies living in the care home. The home is has very good wheelchair access. Ladies are welcome to use the entire home and the facilities. • Ladies are able to take telephone calls and use the telephone. Some Ladies have their own mobiles. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 20 It is recommended that the home purchase a cordless phone, so that the service users are able to use it in the privacy of their rooms, should they wish. As part of the visit, the inspector undertook a tour of the premises. The home was generally well maintained and homely, however it was noted that carpet in communal areas has become worn and required replacing. The home manager informed the inspector that quotes and measurements were being obtained for the replacement carpet. The home manager stated that residents’ bedrooms are decorated to their individual choice and people who use the service were fully involved in consultations regarding the decoration of communal areas. The inspector noted that some of the service user’s bedrooms did not have any lampshades. These should be provided in each room. The ground floor is fully accessible at both back and front of the premises and one of the bedrooms (located on the ground floor) is occupied by a person using a wheelchair. A house keeper is employed to ensure all laundry is completed appropriately and to a high standard, to oversee cleaner, monitor health and safety checks, including hygiene checks are monitoring stock control regarding cleaning materials. The location of the service offers access to local shops, transport and local community activities. During a tour of the premises, the home manager stated that she had plans to involve service users in maintaining flower beds and the home’s greenhouse. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 21 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, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff who are committed to providing good quality of care. Sufficient staffing levels were in place. Staff recruitment processes and frequency of formal staff supervision sessions required improvement. EVIDENCE: As part of this visit, the inspector checked staff duty rosters, which evidence that there were sufficient staffing levels in place to meet the assessed needs of the service users accommodated in the home. There are at least 3 members of staff on duty during the day. At night time there is one person doing waking night and one person working sleep-in. Those members of staff who spoke with the inspector were able to demonstrate good knowledge of each service user’s needs. Staff were observed to be working with the people who use the service in a relaxed and respectful manner. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 22 The home employs a number of Jewish staff to meet the religious needs of the people who use the service and to supervise and host Shabbos and Holy Holiday arrangements. Those who spoke with the inspector said that they were satisfied with training offered to them. The Yad Voezer’s head office deals with all recruitment and this is where the main personal files are kept. As part of this visit the inspector checked personnel files of 3 members of staff. Although there has been an improvement in ensuring that all information required by law was in place in respect of each member of staff working in the home, the organisation was unable to find a Criminal Records Bureau disclosure or a letter from the Organisation’s umbrella body confirming that they had received a satisfactory CRB disclosure in respect of one member of care staff. The inspector was presented with that person’s CRB number, which was seen as insufficient. It is required that the organisation obtains a new CRB disclosure in relation to that person as a matter of urgency. Confirmation that the check has been applied for must be forwarded to the Commission. The requirement in relation to the recruitment procedures and therefore been repeated and must be met without any further delay. Further failure to comply with the regulation will result in the Commission considering an enforcement action against the provider. Although some improvements were noted in the frequency of staff supervision, further improvements are required in order to ensure that the National Minimum Standards are being met and that staff receive at least six supervision sessions annually (or pro rata for part-time staff). The requirement regarding staff supervision has therefore been repeated. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 23 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, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An application for the new manager to become formally registered with the Commission must be submitted without delay. Appropriate quality assurance systems were in place. Health and safety in the home was generally maintained, however the home’s portable electrical appliances must be tested without delay. EVIDENCE: Since the last inspection visit, the organisation has employed a new home manager. She has settled in the home well and positive comments were received by the inspector from staff working in the home. The home manager stated that she had passed her probation period and would be applying to the Commission to become the registered manager. She has worked with adults with learning disabilities in her previous job and has completed National Vocational Qualification Registered Managers Award and NVQ Level 4 in Care, Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 24 which are required in order to manage a residential care home. It is required that an application is submitted to the Commission for the home manager to be formally registered. Appropriate quality assurance systems were in place. The monthlyunannounced monitoring visits are undertake and copies from those are forwarded promptly to the Commission. Service users and staff meetings are being held and copies of the minutes were examined during this inspection. Health and safety checks were undertaken on a regular basis, however it was noted that the home portable appliances were last tested in June 2006 and were due for retesting in June 2007. It is required that the home’s electrical appliances are tested, in order to ensure with the health and safety law. The home was appropriately insured for its purpose. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA34 Regulation 19(1) Requirement The registered manager must ensure that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. (Previous timescales of 28/2/05 and 23/04/07 were not met.) The registered manager must ensure that all staff have regular, recorded supervision sessions at least six times a year. (Previous timescale of 23/04/07 was not met). The registered person must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the preadmission assessment and statutory reviews have been taken into consideration. The registered person must ensure that individual risk assessments are reviewed on a regular basis in order to minimise any risk to people who use the service. The registered person must ensure that appropriate systems DS0000010281.V356418.R01.S.doc Timescale for action 31/01/08 2. YA36 18(2) 29/02/08 3. YA6 15(1) 29/02/08 4. YA9 13(4) 29/02/08 5. YA20 13(2) 15/02/08 Queen Elizabeth Walk (57) Version 5.2 Page 27 6. YA23 17(2) Schedule 4.9, 20 23(2)(d) 8; Care Standards Act 2000 23(2)(c) 7. 8. YA24 YA37 9. YA42 are in place for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. It is required that more robust systems for managing service users’ finances are set up within the home, in order to protect service users from abuse. The registered person must ensure that carpets are replaced in communal areas. It is required that an application is submitted to the Commission for the home manager to be formally registered. It is required that the home’s electrical appliances are tested, in order to ensure with the health and safety law. 31/01/08 31/03/08 31/01/08 15/02/08 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. 2. Refer to Standard YA26 YA26 Good Practice Recommendations It is recommended that the home purchase a cordless phone, so that the service users are able to use it in the privacy of their rooms, should they wish. Lampshades should be provided in each service user’s bedroom. Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Queen Elizabeth Walk (57) DS0000010281.V356418.R01.S.doc Version 5.2 Page 29 - 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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