Inspection on 20/03/07 for Queen Elizabeth Walk (57)

This inspection was carried out on 20th March 2007.

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

The inspector found 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 3 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) 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

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 20th March 2007 10:00 Queen Elizabeth Walk (57) DS0000010281.V333020.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.V333020.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.V333020.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 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.V333020.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 bed 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. 3rd March 2006 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.V333020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and followed up the requirements made at the unannounced visit conducted on the 19th March 2006. The inspector spoke with service users, staff and the acting manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There have been 3 requirements and 1 recommendation made following this inspection. The service has also been awarded 3 commendations. The inspector wishes to thank the acting manager, 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. The summary of this inspection report can be made available in other formats on request. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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.V333020.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector is satisfied that the home is able to meet service users needs in line with the homes Statement of Purpose. 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. There is a service user guide in place; the previous inspection noted that the document required further amendment as it does not indicate that complaints can made to outside agencies such as social services or to the commission directly. The acting manager provide the inspector with copies that belonged to service users that still indicate that the complaint must go through the organisational procedure in the first instance. It therefore remains s an outstanding requirement that the registered manager must ensure that the complaints procedure in the service user guide be amended as stated in this report. This requirement will be reinstated with a new timescale for compliance. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 8 There have been no new admissions to the home since the previous inspection. The inspector is satisfied that service users are admitted only after a full assessment has been undertaken. Following assessment the service users care plans are developed. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector believes that staff are aware of service users support needs in line with assessed needs and how those needs such be met. The inspector is satisfied that service users are supported to make day-to-day decisions when needed. EVIDENCE: The inspector viewed three service user files during the inspection. Each file examined contained service user basic information that contained all the personal information as stated in Schedule 3 of the Care Homes Regulations. Files contain a photograph of the service user and basic information profiles. 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. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 10 the tracking of care it was noted plans clearly reflected the individual service users needs. For example one plan was very clear about how to provide personal care even indicating what products to be used. The mobility care plan stated what equipment was to used and made reference to the risk assessment in place. The inspector cross reference two service users care plans and the monitoring that was required, one was in regard to weight and another was in regard to food and fluid intake. Monitoring records were in place and up to date. Risk assessments were seen on the individual service user files inspected. The assessments highlight the risk, which assess whether the activity should be considered .The risk assessments also highlight what action to be taken. The inspector was satisfied that the care plans are developed to minimise risk without imposing inappropriate restrictions on the service users. Through observations made during the inspection and discussions with staff there was evidence that service users have control over their daily lives. For example service users are able to get up and go to bed when they choose, and choose their own clothes to wear, and are involved in making decisions through the weekly house meetings. Service users are heavily involved in the day-to-day running of the home. For example, service users are supported by staff to cook each week for all the service users Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The inspector continues to be satisfied that staff provide service users with support to make choices and provide them the opportunity to undertake a wide range of activities both inside and outside the home. 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 ethos of the home is to promote all the service users to be independent and to maintain and develop their social and daily living skills. The inspector continues to be satisfied through observations made during the inspection that staff encourage service users to be involved with many activities and organisations outside the home. For example the service users daily records clearly indicated that service users attended trips to the theatre, visited family, and were escorted on shopping trips. Extra staff are on duty to support the trips out. As highlighted in previous inspection this continues to be one of the homes strengths. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 12 On the day of inspection service users were escorted on shopping trips for new clothes for ‘Passover’. During the inspection service user were receiving manicures, playing games and listening to music. Service users were active throughout the inspection and were being supported to prepare their individual bedrooms for ‘Passover’. Service users are also assisted to complete daily living tasks such as cleaning their own rooms, laundry tasks and cooking. Service users’ are fully involved in the day-to-day routines of the home as part of their identified care planning objectives and in relation to their learning disabilities. Service users are offered a key to their own bedroom, which can be locked. Through observation and discussion with staff, it was positive to note that daily routines and house rules do promote independence and individual choice for the service users. Staff were observed to communicate in a respectful and sensitive manner. There are three meals offered daily when service users are present in the home, with additional drinks and snacks. Menus are planned with the service users at the house meetings on Sundays. Menus were examined and found to be international, culturally appropriate and nutritious. Service users assist in meal preparation on a rota basis. On the day if inspection lunch was appetising and made with fresh ingredients, and there was plenty of choice for service users. The service users spoken to clearly enjoy the food offered to them. 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 all of which were clean and tidy and foods were appropriately stored. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. 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. It continues to be the inspector’s view that service users are well supported by staff to ensure that physical and emotional needs are met. The inspector noted that all medication records were deemed correct. EVIDENCE: The inspector was satisfied that staff are fully aware of service users’ needs and that appropriate referrals are made when required. Staff present at the time of inspection were able to inform the inspector of the health concerns of particular service users and were fully aware of the health professional involvement and how care was to be provided. Care plans indicate that service users are encouraged to manage their own personal care as much as possible, although staff will prompt and remind service users about personal care as appropriate. The inspector was satisfied through observations made that the service users continue to be supported to maintain their personal identity and choice. All service users were appropriately dressed on the day of inspection. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 14 There was evidence that service users personal needs are reassessed and changes in needs are clearly recorded on the service users individual plan of care with detailed information as to how those needs are to be met. The inspector was satisfied that staff are fully aware of service users’ needs and makes appropriate referrals when required. One of the service users needs are extremely high however there was evidence on the service users file regarding liaison with health professionals and appropriate referrals have been made. The service user has suitable equipment in place to enable staff to meet her needs. The home has Health Action Plans for service users in place this provides a very clear picture for the service users health needs, what appointments have been undertaken and any issues that may need following up. This form would benefit from being updated with the details of annual checks and when they are completed/due. The inspector is satisfied that referrals are made to relevant health professional such occupational therapist. The format provides a comprehensive overview service users health needs. 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 medication storage was in good order. Service users medication is provided in dosset boxes. The home appropriately stores medication in a locked cabinet. The inspector completed several spot checks on generic package medication all were deemed correct. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have received Adult protection training and through discussions with staff they appeared to know how to respond correctly to allegations. EVIDENCE: There is a complaints procedure/policy in place. As previously stated the service user guide requires further amendment as it does not indicate that complaints can made to outside agencies such as social services or to the commission directly. It currently indicates that the complaint must go through the organisational procedure in the first instance. This has been made a requirement under standard 1. 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. Staff have received adult Abuse training within the LADAF induction programme. In previous inspections concerns have been raised regarding to the procedure of the service users Disability Living Allowance (DLA) being used by the organisation to go towards the funding of the mini bus. Service users are now receiving their individual DLA into there own bank accounts. Service users have individual locked boxes in their rooms. Records and receipts are maintained of financial transactions involving service users monies. Records seen were clear and well recorded. Petty cash is checked each week at the head office. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The premises were found to be safe, comfortable, bright, homely and clean. There is a problem with one of the bedrooms with regard to odour, however the acting manager was able to evidence that this was being dealt with and was being monitored. The ground floor bathroom has been refurbished since the previous inspection with a walk in shower. There was sufficient lighting, heating and ventilation on the day of inspection. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 17 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. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. 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. The inspector is satisfied 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. All staff must receive adequate supervision. 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 has at least 3 members of staff on duty during the day. At nighttimes there is one waking night and one sleep-in. An on call rota is available for staff support. On the day of inspection there were five staff on duty to cover service user activities. Through observation and discussions with staff they demonstrated a good understanding of their roles and responsibilities and good knowledge around individual service users needs. Staff assist service users with domestic tasks in the home, dependant on their individual assessed need. Staff were observed throughout the inspection interacting with service users in a relaxed and Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 19 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 an action plan recorded clearly stating who was responsible for each action. The head office deals with all recruitment and this is where the main personal files are stored. Two of the files for the most recently recruited staff were examined. One of the files only contained one reference. Another did not show evidence of the staff had right to work in this country. As such it 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 or the Commission will consider further action. Additionally there were no CRB certificates available for inspection. The organisation now uses an umbrella agency and only receives written confirmation that the CRB has been received. The inspector was informed that if there were any convictions recorded they would be informed. It is required that copies of Criminal Records Bureau checks are available for inspection and can be destroyed once they have been seen by the inspector. The acting manager discussed the on going training programme all staff are undertaking the LADAF Induction and Foundation course. Since the previous inspection staff have received the following training: Medication. Fire training. Challenging behaviour. Moving and handling for all staff was scheduled for the 22/03/07. The acting manager stated that the registered manager has all supervision records; these were made available for inspection by the head office. The staff supervision records provided were examined. There was evidence that the staff have supervision sessions set up in advance however there is a concern that this is not on a regular basis. None examined had received supervision at least six times in a year. For example one staff member was supervised in June and November 2006, another October and November 2006. The registered manager must ensure that all staff have regular, recorded supervision sessions at least six times a year. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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. 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. The inspector believes that the current management provides stability for staff, which in turn is providing a positive atmosphere within the home for service users. EVIDENCE: The registered manager has over twenty-two years experience in social care field. Previous work experience includes nursing, care of the elderly and therapeutic work. The registered manager has obtained the level 4 NVQ in Management and Care. At the time of this inspection the registered manager was acting up into another post. There is an acting manager in place who was able to assist with inspection. The organisation will need to inform the commission of the management situation for the coming months in writing. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 21 The acting manager talked through with the inspector the new systems being set up, such as the shift handover process and the expectation that whoever is the team leader will allocate tasks on each shift to individual staff so that there is a clear line of accountability. They are also about to introduce a new system of a key worker system. There will be two teams responsible for half the service users in the care home. This is to ensure that all staff have a wider knowledge of service users needs. The monthly-unannounced monitoring visits are untaken; copies are forwarded promptly to the Commission. Service users and staff meetings are being held and copies of the minutes were examined during the inspection. The following health and safety checks have been evidenced: Emergency lighting checked 31/01/07 Gas certificate was seen dated 18/07/06 valid for one year. The electric certificate 24/1/05 valid for 3 years. Portable Appliance Test was completed 12/06/06 Fire alarm was last serviced 31/01/07 The certificate of registration was on display along with a valid certificate of insurance. Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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 Standard No Score 1 2 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 x 26 x 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 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 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 22 Requirement The registered manager must ensure that the complaints procedure in the service user guide be amended as stated in this report. (Timescale of 30/04/06 not met) YA34 2 19.1 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) 3. YA36 18.2 The registered manager must ensure that all staff have regular, recorded supervision sessions at least six times a year. 23/04/07 23/04/07 Timescale for action 23/04/07 Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations It is recommended that the Health Action Plans contain information of annual checks (undertaken or due) Queen Elizabeth Walk (57) DS0000010281.V333020.R01.S.doc Version 5.2 Page 25 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.V333020.R01.S.doc Version 5.2 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. 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