Inspection on 01/08/07 for Queen Elizabeth Walk (64)

This inspection was carried out on 1st August 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Elizabeth Walk (64) 28/02/07

Queen Elizabeth Walk (64) 21/09/06

Queen Elizabeth Walk (64) 27/02/06

Queen Elizabeth Walk (64) 30/11/05

Queen Elizabeth Walk (64) 28/03/05

Queen Elizabeth Walk (64) 17/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (64) 64 Queen Elizabeth Walk Hackney London N16 5UX Lead Inspector Robert Sobotka Unannounced Inspection 1 - 10 August 2007 12:45 st th Queen Elizabeth Walk (64) DS0000010282.V347295.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 (64) DS0000010282.V347295.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 (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Walk (64) Address 64 Queen Elizabeth Walk Hackney London N16 5UX 020 8880 2674 0208 809 5420 yadvoezer@btconnect.com 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) Yad Voezer Mr Anthony Marcus Care Home 10 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One registered place may be used for the accomodation and care of a service user over the age of 65 in the category MD. One registered place may be used for the accommodation and care of a service user under the age of 65 in the catergory MD 28th February 2007 Date of last inspection Brief Description of the Service: 64 Queen Elizabeth Walk is a care home for orthodox Jewish males with learning disabilities including some with mental health issues. The home focuses on Jewish education and practice and is situated in the heart of Stoke Newington, which has a very large orthodox Jewish community. There is easy access to transport facilities and a number of local parks. The home focuses on ensuring that each service users participates in activities of their choice, and the required support is available. Strong family links are encouraged and maintained. Service users are encouraged to be independent and where possible are enabled to manage their own finances and medication and to make decisions regarding their preferred activities and daily routines. Information on the service at 64 Queen Elizabeth Walk is available in the Statement of Purpose, which is available on request. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection commenced on the 1st of August and was unannounced. As part of this visit, the inspector spoke to some of the people who used the service, staff working in the home and the registered manager. He also carried out a tour of the premises and checked various records. The inspector also spoke to the Community Nurse who was visiting one of the service users in the home during this inspection visit. Prior to this inspection visit, the registered manager was asked to complete an Annual Quality Assurance Assessment Tool, which was received by the Commission on the 10th of August. Comments from the AQAA have been included in this inspection report. The inspector would like to thank both service users and staff who contributed to this inspection. What the service does well: What has improved since the last inspection? All staff working in the home have commenced LDAF (Learning Disability Awards Framework) induction training and NVQ in Care training. A cook has been employed, whereas previously meals were delivered. The appointment of a religious/cultural advisor hasd led to service users being more invloved in a day-to-day community activities. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 6 Two of the service users have recently aquired cars via Motabilty Scheme. Improvements have been made to the home’s medication systems and the registered manager has ensure that medications are administered, recorded and disposed of appropriately. The home had a copy of the new procedure regarding the management of Disability Living Allowances, as previously required. Satisfactory evidence was in place to demonstrate that Criminal Record Bureau checks were being carried out in relation to staff working in the home. What they could do better: There were 2 requirements, which remain unmet since the last inspection. These included: - The registered manager must ensure that individual service users care plans are further developed. - The registered manager must ensure that all documents required by law are maintained in line with the Care Home’s Regulations. In addition the following requirements were made during this inspection: - The registered manager must ensure that all significant events listed in Regulation 37 of the Care Homes Regulations must be reported to the Commission without delay. - The registered manager must ensure that one of the bedrooms on the first floor is repainted. - The registered manager must ensure that communal carpets located on the first floor are cleaned or replaced. - The registered manager must ensure that an unpleasant odour in one of the bedrooms is eliminated. - The registered manager must ensure that the home’s laundry facilities are cleaned/tidied up. The following good practice recommendation has also been repeated: - It is recommended that the Criminal Records Bureau checks be undertaken every 3 years. Queen Elizabeth Walk (64) DS0000010282.V347295.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 (64) DS0000010282.V347295.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 (64) DS0000010282.V347295.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, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users had adequate information about the home and it’s facilities. Each person who used the service had a costed contract in place. EVIDENCE: The home had an up-to-date statement of purpose and a service user’s guide, which included information about the home. There have been no changes to both documents since the last inspection. There have been no new admissions to the home since the last inspection visit. Standard relating to the home’s admission systems was therefore not assessed on this occasion. The home had an admission policy in place, which covers initial enquiries, emergency admissions and assisting new residents to settle in addition to the assessments required prior to admission. The home provides accommodation for Jewish orthodox males and enables service users to continue their religious studies and religious/cultural observance. Each person who used the service had a written contract/statement of terms and conditions in place, which covered such aspects as conditions, trial periods, fees, visitors, health and complaints. Queen Elizabeth Walk (64) DS0000010282.V347295.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, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited progress has been made in relation to the service user’s care plans. Service users are enabled and encouraged to make decisions about their care and about how the home is run. Confidentiality was being maintained. EVIDENCE: As part of this inspection visit the inspector reviewed care plans of 4 service users, which were randomly chosen. Although some improvements have been noted since the last inspection, not all care plans were up-to-date at the time of this inspection visit. The requirement that the registered manager must ensure that individual service users’ care plans are further developed remains unmet and must be met without any further delay. Further non-compliance will result in the Commission considering an enforcement action against the provider. The inspector was satisfied that those living in the home were enabled and encouraged to make decisions about their care and about how the home is run. People who use the service were encouraged to attend regular house Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 11 meetings, minutes from which were available for inspection. The home operates a keyworking system and each service user had an allocated keyworker who was responsible for coordinating their care. There was evidence that service users were involved in the day-to-day running of the home, participation of daily living and inlovement in choice of daily activities. Following discussions during service users meetings it was decided that a cook should be employed in the home rather than having meals delivered by a catering company. Service users are encouraged and supported to their best ability to take part on daily routines, such as shopping, cleaning their rooms, making snacks and beverages. Service users are free to come and go from the home as they choose. The inspector was satisfied that risk were appropiately managed and there were risk assessments in place to evidence this. Risk assessments were being reviewed on a regular basis. Confidentiality was being maintained. All confidential documents were kept in the staff office on the ground floor and the manager’s office in the attic. Both rooms were kept locked when not in use. Information kept computers was password protected. Staff shared information with the inspector on a need to know basis. Queen Elizabeth Walk (64) DS0000010282.V347295.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. The home continues to provide a wide range of age and culturally appoproate activities. Service users are encouraged to be a part of the local community and to develop and maintained friendships and family links. Those who lived in the home enjoyed food in the home. EVIDENCE: The home provides care for Jewish orthodox males and all service users come from orthodox Jewish families. The home is culturally appropriate to the needs of those accommodated there. Service users attend the local synagogue and are supported by staff with undertaking daily prayers in accordance with the religious tradition. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 13 As previously mentioned, since the last inspection the home appointed a team leader, who is responsible for ensuring that the service users’ cultural needs are met. In addition, there is also a team leader responsible for activities. The home maintained an activity folder/diaries, where activities attended by the service users were recorded. Some of the activities on offer included: visit to a farm, swimming, horse riding, visits to cinema etc. Some service users attended local Jewish day centres. The registered manager stated that since the last inspection some day activities and been sourced and increased, which has benefited those living in the home. A living skills programme has been put in place for two residents. Some service users attended activities with the support of staff, whilst others accessed community independently. This is based on individual risk assessments. Holidays are arranged on a regular basis for those service users who wish to spend a week away from home. At the time of this inspection visit, one of the service users was on holiday in Israel supported by his relatives. Those people who used the service who spoke with the inspector felt that there was a good range of activities on offer. The inspector was informed that the majority of the service users maintain contact with their relatives. In the AQAA, the registered manager stated that one service user is supported to phone family daily. The home maintained the visitors’ book. Visitors are welcome in the home. Service users are offered three meals a day, as well as drinks and snacks between main meals. The preparation and serving of food respects service users’ cultural and religious requirements. All food offered to service users is kosher. As previously mentioned, since the last inspection the home has employed a cook., who prepares wholesome meals, which meet the religious standards of the people who used the service and organisation. Where required staff use food-monitoring charts to monitor and evaluate service users’ nutritional intake. The registered manager stated that although most residents choose to eat in the dining area, one person chooses to eat his evening meal in a separate room, and on ocassions residents choose to eat in their bedrooms. There were appropriate food supplies in the home during this unannounced inspection. All food products were appropriately stored and labelled once opened. Milk and meat sections of the kitchen were clearly separated, in accordance with the religious requirements. Queen Elizabeth Walk (64) DS0000010282.V347295.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 good. This judgement has been made using available evidence including a visit to this service. Service user’s healthcare needs were being appropriately managed. Satisfactory medication systems were in place. EVIDENCE: At the time of this inspection visit service users required different levels of assistance with personal care, from full assistance to verbal prompting. Residents who require personal care are supported by male staff. Service users wear clotes that meet their particular age and cultural background. Each person had a Health Action Plan in place, which provided a clear picture about each service user’s healthcare needs, as well as what appointments have been attended and any issues that needed to be followed up. All service users were registered with the local General Practitioner. There was evidence that the home appropriately utilised services of the local health professionals, such as chiropodists, psychiatrists etc. During this inspection visit, the inspector spoke with the Community Nurse, who felt that the home was appropiately meeting the needs of the service user who he was visiting. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 15 The home’s medication systems were checked during this inspection and they were found to be satisfactory. The home uses Boot’s blister pack systems. Record of medication received by the home, administred to the service users and disposed of were appropriately maintained. All medication was appropriately stored. At the time of this visit one of the service users was assesed as able to administer his own medication. Queen Elizabeth Walk (64) DS0000010282.V347295.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. Complaints were appropriately dealt with. Significant events in the home were not always reported to the Commission as required by the Regulations.. EVIDENCE: The home’s complaints records were checked during this visit. There have been two complaints since the last inspection, both of which were appropriately dealt with and resolved. The home had a compliants procedure/policy in place. Those who live in the home are encouraged to discuss any issues during service users’ meetings and to record any concerns in the complaints book. The home had an adult protection procedure in place. Staff spoken to during this inspection demonstrated their awareness of the adult protection issues. All staff working in the home, including agency staff have received adult protection training. The inspector checked a random sample of service users’ money. Money kept in individual tins tallied with the service users’ financial records. Receipt and bank statements were also available for inspection. Since the last inspection, the registered manager has ensured that a copy of the new procedure regarding the managerment of Disability Living Allowance was now available in the home. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 17 Accidents and incidents records were appropriately maintained, however it was noted that not all significant events have been reported to the Commission. The registered manager must ensure that all significant events listed in Regulation 37 of the Care Homes Regulations must be reported to the Commission without delay. Queen Elizabeth Walk (64) DS0000010282.V347295.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 adequate. This judgement has been made using available evidence including a visit to this service. The premises were generally well maintained, however improvements are required to some parts of the building. EVIDENCE: The home is situated in a residential area of Stoke Newington and is in keeping with the local community. It offers easy access to local amenities. The premises were suitable for its stated purpose. There is no lift in the home, which means that only the ground floor part of the building is wheelchair accessible. The service users’ bedrooms were of adequate size and personalised by each service user. Some parts of the premises required improvement. These were: - One of the bedrooms on the first floor required repainting. - Communal carpets located on the first floor required cleaning or replacing. One of the bedrooms had an unpleasant odour. This must be eliminated. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 19 The premises were sufficiently lit and heated. The main lounge/dining room is bright and the dining area is also used to religious study. There is a conservatory adjoining the lounge, which opens out onto the garden. The garden was well maintained. The home has ramps leading to the entrance of the home and at the rear of the building leading to the garden. Service users had specialist equipment needed to maximise their independence. The home employs a domestic member of staff. Laundry facilities required cleaning, as they were untidy at the time of this inspection visit. Queen Elizabeth Walk (64) DS0000010282.V347295.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, 33, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent and well trained team. Appropriate recruitment systems were in place, however the recommendation that criminal record checks are repeated every three years. EVIDENCE: Duty rosters were viewed during this inspection visit. There are usually five staff working in the morning and four or three staff working in the afternoon. There is a sleep-over cover, as well as a waking night. Duty rosters indicated to staff when Shabbos begins and ends. The inspector was satisfied that there were sufficient numbers of staff on duty throughout the day to meet the needs of those accommodated in the home. Staff who spoke to the inspector felt that the workload was manageable. Staff who spoke with the inspector during thi s inspection felt that there has been an improvement in the organisation’s training. The registered manager stated that staff receive LDAF (Learning Disability Awards Framework) induction training and following this they are put forward for NVQ in Care. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 21 At the time of this inspection 3 out of 13 members of staff have obtained NVQ Level 2 or above and 6 staff were in the process of obtaining the qualification. Some of the training recently attended by staff working in the home includes: Fire Safety, Protection of Vulnerable Adults, LDAF Induction training, Understanding Autism, Supervision training, and Health and Safety. Since the last inspecition, the deputy manager has left employment. Staff personnel files were checked during this inspection visit. Four files were viewed, all of which included all information required by law. Satisfactory evidence was in place to demonstrate that Criminal Record Bureau checks were being carried out in relation to staff working in the home. The recommendation that the Criminal Records Bureau checks be undertaken every 3 years remains unmet from the last inspection.. Queen Elizabeth Walk (64) DS0000010282.V347295.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, 41, 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good progress has been made to ensurethat the previous requirements and recommendations are met, however further work is required to ensure that the National Minimum Standards are achieved. EVIDENCE: The inspector was satisfied that troughout the inspection the registered manager demonstrated a good knowledge of the National Minimum Standards and Care Homes Regulations 2001. Appropriate quality assurance systems were now in place. Regular visits from the registered provider were taking place, reports from which are forwarded to the Commission on a monthly basis. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 23 The registered manager stated that internal service users reviews give people who use the service an opportunity to raise any issues. Kyworkers meet regularly with the residents. As previously mentioned, there has been an improvement in the record keeping within the home, however further work is required to ensure that all documents required by law are maintained in line with the Care Home’s Regulations. Appropriate health and safety checks were in place. The home was appropriately insured for its purpose. Queen Elizabeth Walk (64) DS0000010282.V347295.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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 x 3 X 3 X 2 3 x Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement The registered manager must ensure that individual service users care plans are further developed. (Previous timescale of 01/05/07 was not met). The registered manager must ensure that all documents required by law are maintained in line with the Care Home’s Regulations. (Previous timescale of 01/05/07 was not met.) The registered manager must ensure that all significant events listed in Regulation 37 of the Care Homes Regulations must be reported to the Commission without delay. The registered manager must ensure that one of the bedrooms on the first floor is repainted. The registered manager must ensure that communal carpets located on the first floor are cleaned or replaced. The registered manager must ensure that an unpleasant odour in one of the bedrooms is eliminated. The registered manager must ensure that the home’s laundry DS0000010282.V347295.R01.S.doc Timescale for action 01/10/07 2. YA41 17 01/10/07 3. YA23 37 15/09/07 4. 5. YA26 YA24 23(2)(d) 23(2)(d) 01/11/07 01/11/07 6. YA30 16(2)(k) 01/10/07 7. YA30 23(2)(d) 01/10/07 Queen Elizabeth Walk (64) Version 5.2 Page 26 facilities are cleaned/tidied up. 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 YA34 Good Practice Recommendations It is recommended that the Criminal Records Bureau checks be undertaken every 3 years. Queen Elizabeth Walk (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 27 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 (64) DS0000010282.V347295.R01.S.doc Version 5.2 Page 28 - 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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