Inspection on 27/08/08 for Queen Elizabeth Walk (57)

This inspection was carried out on 27th August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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) 10/01/06

Queen Elizabeth Walk (57) 02/12/04

Queen Elizabeth Walk (57) 20/09/04

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Norbury Crescent (30)

Edenvale

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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 08/11/2008.

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (57) 57 Queen Elizabeth Walk Hackney London N16 5UQ Lead Inspector Robert Sobotka Unannounced Inspection 27th August 2008 09:55 Queen Elizabeth Walk (57) DS0000010281.V370279.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.V370279.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.V370279.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 Manager post vacant 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.V370279.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 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. 19th December 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 learning disabilities 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.V370279.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 this service experience adequate quality outcomes. This inspection took place over one day and was unannounced. During his visit, the inspector spoke with the home manager and several members of staff who worked 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 her Personal Assistant. She spoke to the people who use the service and undertook a tour of the premises. Following this inspection they produced a report, extracts from which are included within this report. Prior to this inspection the home was asked to complete an Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. During this visit, the inspector requested that a record of staff training should be forwarded to the Commission. This however was not received. 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: The home continues to meet the needs of the service users accommodated there. Service users who spoke with the expert by experience stated that they were happy living in the home and they liked staff supporting them. People who use the service access a wide range of activities. Staff working in the home have a good and clear understanding of the service users’ needs. The home appropriately meets cultural and religious needs of the people who use the service. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Following this inspection 6 statutory requirements and 3 good practice recommendations were made. Improvements are required to the home’s medication systems. This included safe storage as well as records in relation to administration of medication. Guidelines are also needed for staff regarding PRN (as required medication). More regular monitoring of service users’ weight must be implemented, where it has been identified as beneficial in order to monitor service users’ health. The registered person must ensure that all complaints are resolved without delays. In addition, it is recommended that the home’s complaints procedure Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 7 be produced in a format that is easily accessible to the current service users’ group. Record of training and staff development plans should also be introduced to demonstrate that staff have received all mandatory training and any other relevant training. The home should purchase a cordless phone, so that the service users are able to use it in the privacy of their rooms, should they wish. 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.V370279.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.V370279.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. 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 and interviews with members of staff working in the home and the home manager and review of the documentation kept in the home, as well as 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.V370279.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 good. This judgement has been made using available evidence including a visit to this service. Improvements have been noted to the home’s care planning process. Service users are 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, so that people who use the service can take responsible risks. EVIDENCE: As part of this visit, the inspector viewed care plans of four service users accommodated in the home. Care plans checked were chosen at random. The registered person has ensured that individual care plans are further developed, in order to demonstrate that all aspects of care included in pre-admission assessments and statutory reviews have been taken into consideration. The new home manager stated that she was in the process of introducing person centred planning. In the Annual Quality Assurance Assessment (AQAA), the previous home manager stated that service users are encouraged to participate in their individual care planning and activities. There was evidence that the service Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 11 users were consulted about their care planning process. Weekly service users’ meetings are also organised. Minutes from these were available for inspection. The home operates a key working system, when each key worker is responsible for co-ordinating care of her key client. At the previous inspection visit a requirement was made that all risk assessments must reviewed on a regular basis in order to minimise any risk to people who use the service. Risk assessments were now being reviewed on a regular basis, as previously required. Queen Elizabeth Walk (57) DS0000010281.V370279.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: “The home was bright and cheerful, but not very homely. Some staff were friendly and mainly encouraging of the residents and there seemed to be Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 13 plenty of activities going on. We spoke to two residents and one said “I like living here”. The residents have lunch out often, but if they eat at home, they are encouraged to make it themselves with support. Some residents go to local cafes and Sainsbury’s for kosher lunch and one resident told me “the local kosher bakery is very good!” Some residents go to the local Jewish day centre where they do art. All residents pray every day; one resident said: “my faith is good and very important”. All residents take part in Jewish festivals with the local Jewish community and are often invited to parties and weddings. The residents go to the Synagogue every Saturday. Residents have a large garden and are encouraged and supported to help in the garden and greenhouse. Residents’ meetings happen every Sunday evening and one Jewish member of staff is with them at this. They talk about the week ahead and what meals they will have.” Those who live in the home enjoyed food offered to them. All food purchased whether for the home, clubs, holidays or outings must be hescher (certificate of Kashrus) of Kedassia or one of equal standing. Milk and meat sections of the kitchen were clearly separated. Appropriate food supplies were kept in the home on the day of this unannounced inspection. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. At the time of this inspection, the home was generally meeting service users’ emotional and physical health, however improvements are required to ensure that service user’s weight is monitored when required and that medication systems are improved. EVIDENCE: All personal care required by the people who use the service is carried out by female staff. Guidelines as to how personal care should be provided were included in individual service users’ care plans. 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. During the case tracking exercise, the inspector noted that some of the service user’s care plans indicated that their weight should be monitored and recorded on a regular basis. There was no evidence to demonstrate that this was taking place, as frequently as indicated within individual care plans. The registered Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 15 manager must ensure that appropriate systems are in place to monitor and record weight of any service users, where it has been deemed as necessary and/or beneficial to their wellbeing. The home’s medication systems were checked during this inspection. The home uses Boots blister pack systems. Record of medication received by the home and disposed of was checked and was found to be correct. Improvements are required to records relating to administration of medication, as some of the medication administration records (MAR sheets) did not contain full instructions as to how each medication should be administered. The home uses Boots blister pack systems. Record of medication received by the home, administered to the service users and disposed of was checked and was found to be correct. During the check of medication stocks, the inspector noted that the name of one of the people who use the service on her medication administration record (MAR sheet) did not correspond with the name printed on her dispensed medication. This was due to the fact that medication administration record had this person’s Hebrew name and their dispensed medication was labelled with her English name. This could lead to some confusion and potential medication administration errors and must be addressed without delay. The inspector advised the home manager 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. In addition, the registered person should ensure that guidelines are drawn up to guide staff as to when they should administer PRN (as required) medication and what dose should be administered. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 16 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. Improvements are required to the home’s complaints system to ensure that all complaints are promptly resolved. Appropriate systems were in place to protect service users from abuse. EVIDENCE: As part of this visit, the inspector checked the home’s complaints folder. There have been four complaints made to the home since the last inspection visit. One complaint, which was made in early July 2008, appeared to be unresolved. This required improvement. The registered person must ensure that all complaints are resolved in accordance with the home’s complaints procedure and within set timescales. The following comments was made by the expert by experience: “When asked if she knew how to complain, one resident said, “I would talk to my mum”. There is a complaint book, but it is not in easy words and pictures”. It is recommended that the home’s complaints procedure be produced in a format that is easily accessible to the current service users’ group. 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. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 17 Following the previous inspection visit a requirement was made 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 the previous inspection visit they were found to be inadequate and therefore being open to potential abuse. The home’s financial systems were rechecked during this inspection visit and they were found to be sufficiently improved. There was a clear log of expenditure made on behalf of service users. The inspector checked finances and all corresponding financial records in relation to two service users and these were found to be correct and appropriately maintained. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been noted to the home’s environment, so that the people who use the service benefit from a safe and clean environment. EVIDENCE: The following observations were made by the Expert by experience: - The home was bright and cheerful, but not very homely. - Residents have a large garden and are encouraged and supported to help in the garden and greenhouse. - All residents have their own room with a sink in. - There was a lovely home made welcome with all the residents’ names on in the hall and pictures of a recent party, but no staff pictures. - The respite bedroom is bare and I was shown two different mattresses, one that staff on overnight duty use and one that respite service users use. I find this a bit odd. - Some areas seemed a bit cramped and some rooms have a “residential home” feeling about them. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 19 - Not all areas are accessible for a resident in a wheelchair. - The daily menu had Tuesday on, but it was Wednesday. As part of the visit, the inspector also undertook a tour of the premises. Since the last inspection carpets in communal areas have been replaced, as previously required. During the last visit, it was noted that some of the service user’s bedrooms did not have any lampshades. These have now been provided. 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. At the time of this inspection, the home manager was in the process of devising a planner for service users with pictures of staff, so that those who use the service would be able to check who was on duty and working in the home. 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. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were adequate to meet the assessed needs of the people who used the service. Improvements have been noted to the way staff are recruited and their supervision sessions. 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 nighttime 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. 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. Record of training offered to staff working in the home was Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 21 not available in the home at the time of this visit. Subsequently, the inspector requested that a record of staff training should be forwarded to the Commission. This however was not received. The registered person must ensure that record of training offered to staff is kept in the home and is available for inspection, in order to demonstrate that staff have received all mandatory training and any other relevant training. The following observations were made about members of staff during this inspection visit by the expert by experience: “On the whole, staff interaction wasn’t outstanding. I observed one staff member spending a great deal of time with a resident on a puzzle and speaking and acting very gently when supporting her. I also observed another member of staff member being bossy and showing little understanding of her needs. One resident told me: ‘I get on very well with staff and I can talk to them.’ A member of staff nearly went into a resident’s bedroom without asking and I said that we don’t go into people’s bedroom without asking.” 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. The inspector was satisfied that appropriate recruitment systems were now in place. The new home manager has able to demonstrate that she has recommenced staff supervision sessions. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate quality assurance systems were in place. Health and safety in the home was maintained. EVIDENCE: There has been a change of the home manager since the last inspection. The previous manager resigned as from the 1st August 2008 and a new manager has since been appointed. At the time of this inspection, she was still within her probationary period. The inspector was informed that she would be applying to the Commission to become the registered manager imminently, as at the time of this inspection the registered manager’s position was vacant. The inspector receive positive comments from staff in relation to the new home manager and staff were looking forward to working with her. It was noted by the inspector, that the new manager has already made some positive changes Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 23 within the home, however further work is required to ensure that all the requirements are met. Appropriate quality assurance systems were in place. The monthlyunannounced monitoring visits are undertaken and copies from those are forwarded promptly to the Commission. This visit was also carried out in the home on the day of this inspection. 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 and relevant records to demonstrate this were kept in the home. Since the last inspection, the registered person has ensured that the home’s electrical appliances were tested, as previously required. The home was appropriately insured for its purpose. Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 3 X X 3 X Queen Elizabeth Walk (57) DS0000010281.V370279.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA19 Regulation 12(1)(a) Requirement Timescale for action 15/10/08 2. YA20 12(3) 3. YA20 12(3) 4. YA20 12(3) The registered manager must ensure that appropriate systems are in place to monitor and record weight of any service users, where it has been deemed as necessary and/or beneficial to their wellbeing. In accordance with change in 19/11/08 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. The registered person must 15/10/08 ensure that there is a consistency in recording names of each service user on both medication administration records and dispensing labels, where both English and Hebrew names are being used, in order to avoid any potential medication misadministration. The registered person must 15/10/08 ensure that all medication administration records contain full directions as to how each medication should be administered, in order to avoid DS0000010281.V370279.R01.S.doc Version 5.2 Queen Elizabeth Walk (57) Page 26 5. YA22 22(3), 22(4) 6. YA35 18(1)(c) any errors in administering medication. The registered person must ensure that all complaints are resolved in accordance with the home’s complaints procedure and within set timescales. The registered person must ensure that record of training offered to staff is kept in the home and is available for inspection, in order to demonstrate that staff have received all mandatory training and any other relevant training. 01/11/08 01/11/08 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 YA20 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. The registered person should ensure that guidelines are drawn up to guide staff as to when they should administer PRN (as required) medication and what dose should be administered. It is recommended that the home’s complaints procedure be produced in a format that is easily accessible to the current service users’ group. 3. 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