Inspection on 21/09/06 for Queen Elizabeth Walk (64)

This inspection was carried out on 21st September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Elizabeth Walk (64) 01/08/07

Queen Elizabeth Walk (64) 28/02/07

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 Kristen Judd Key Unannounced Inspection 21st September 2006 10:15 Queen Elizabeth Walk (64) DS0000010282.V301874.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.V301874.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.V301874.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 Mr Moshe Robinson Care Home 10 Category(ies) of Learning disability (9), Mental Disorder, registration, with number excluding learning disability or dementia - over of places 65 years of age (1) Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One registered place may be used for the accommodation and care of a service user over the age of 65 in the category MD. 27th February 2006 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. 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. Fees are currently between £769.31-£1619.49 per week. Queen Elizabeth Walk (64) DS0000010282.V301874.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 commenced at 10.15 am and finished at 7.30 pm. This inspection report follows up requirements from the unannounced inspection held on 27th February 2006. The inspector spoke with service users, staff, the registered manager and acting service manager during the inspection. A tour of the environment was undertaken and samples of records were examined. There have been 20 requirements and 1 recommendation made following this inspection. An enforcement notice will be served regarding employment records. An unannounced inspection gives the Commission an opportunity to assess the home against the National Minimum Standards applicable to the service without the home having notice of the visit. A number of requirements were made at the last inspection 4 of which have not been met and have been restated in this report with a new timescale for compliance. Verbal feedback was given to the registered manager. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection. What the service does well: What has improved since the last inspection? What they could do better: There are serious concerns with regard to the recruitment records and as such an enforcement notice will be issued to seek compliance. No staff may work in the home without a clear Criminal Bureau check in place. Care plans require further reviewing to ensure that all of the service users assessed needs are recorded. Risk assessments must indicate actions/guidance to minimise risk. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 6 Financial records must be accurately maintained at all times. There remains concern with regard to staff abilities for example recording accurately. More work needs to be achieved to develop staff on an individual basis. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 7 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.V301874.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relevant documentation is in place to inform service user of the services provided. EVIDENCE: The home’s statement of purpose covers the aims and objectives of the home, and the additional aspects as listed in Schedule 1 of The Care Homes Regulations 2001. The service user guide has been developed; the format has been improved and is more suitable for service users with learning disabilities. There have been no new admissions since the previous inspection. There is an admission policy in place that covers initial enquires, emergency admissions and assisting new residents to settle in addition to the assessments required prior and following admission. Service user files examined contains information gathered prior to admission, which provides necessary information to produce an individual service user plan. The process involves the service user and/or their representative Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 9 The organisation has developed a written contract / statement of terms and conditions with the home. Contracts cover such aspects as conditions; trail periods, fees, conditions, visitors, health and complaints. The home caters for Jewish orthodox males and enables service users to continue their religious studies and religious/cultural observance. Queen Elizabeth Walk (64) DS0000010282.V301874.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved however further work must be achieved on improving care plans to ensure that staff are able to deliver appropriate care to service users in line with assessed health and social care needs. EVIDENCE: There has been some improvement noted with regards to the individual care plans, which have been updated and further developed. However there are some issues, which still need to be addressed. The inspector tracked three service users individual care plans. The previous inspection raised concerns regarding one of the service users nutritional intake. The care plan still indicated that the ‘service user eats normally’, however daily recordings and the risk assessment clearly indicate that this is not the case. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 11 The risk assessment indicates that staff should monitor the food and drink intake however there is no documented guidance for staff to follow if there are concerns and there is no evidence of the monitoring records being evaluated or any decision making being made if the service user goes for long periods with eating or drinking. At the last review dated July 2005 there was clear guidance recorded, this guidance was not transferred to the care plan or risk assessment and when cross referencing the daily recording and the monitoring sheets there was no evidence that the guidance was being followed. The monitoring records were examined recording indicated that from 3.00pm on 20/9 to 11.00am on the 21/9 the service user only had some water. There were gaps in excess of 24 hours where the service user did not have any recorded intake of food. Additionally generally the food is recorded as ‘bread’. The registered manager stated that this would have been some form of sandwich in which case he must address the importance of accurate recording with staff as a matter of urgency. Another service user care plan was seen to track the nutritional issues raised at the previous inspection. The care plan had been updated and clearly indicated that the service user should be weighed monthly and that an analysis should be made. However the inspector noted that the service user had not been weighed since the 16/7/06. Once again monitoring records were examined which were poor. The service user records indicated that his main diet was of bread and jam or cereals. The care plans require urgently updating to accurately reflect the service users care needs and clear guidance given to staff as to the level of monitoring required and records need to be evaluated. The previous inspection highlighted concerns with regard to three service users who may be inappropriately placed. The registered manager has commenced the re assessment process to ascertain the service users needs in relation to mental health and learning disability, this must be evaluated to determine whether the service users needs can be met in the current placement and if so to ensure that clear strategies are in place and guidance for staff. More time is required for the assessment to be completed and it therefore remains a requirement and the timescale will be extended to allow the social acre professional to complete the assessment of the service uses needs. This must be forwarded to the Commission. There was evidence to suggest that service users are involved in the day-today running of the home, participation in activities of daily living and involvement in choice of daily activities. Service users were observed during the inspection undertaking such tasks. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 12 Service users are encouraged and supported to take an active part in the daily routines, such as cleaning their rooms, making snacks and beverages. It was evident from observations made during the inspection that service users have choice and control over their daily lives. Service users are free to come and go from the house as they choose. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 offers service users the opportunity to participate in daily living tasks and are supported to make choices. 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. Records indicated that service users attend the synagogue and were observed during the inspection with support and direction to undertake daily prayers during the inspection. The inspector was informed that the registered manager has been working with an external consultant to work specifically with two of the service users to look as suitable activities, this includes swimming, use of art and crafts and photography. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 14 One service user spoken to during the inspection is attends college to undertake training in soft furnishings. The inspector was satisfied that service uses are given the opportunity to take part in educational and fulfilling activities in line with their abilities. Service users’ are involved in the day-to-day routines of the home dependant on their individual abilities. The inspector is satisfied that that daily routines and house rules do promote independence and individual choice for the service users. The inspector was informed that holidays are arranged for service users who wish to attend annually. The service users went to Canterbury this year in two groups, each group were on holiday for one week. The inspector was informed that the holiday went well .The inspector spoke with one of the service users who attended who stated that he really enjoyed the break. Staff provide the service users with the assistance with their finances if required. However further in this report will address concerns are records are not being maintained accurately. Details of family and friends were evidenced on the individual service user files. The inspector was informed that family and friends are always welcome in the care home. There are three meals offered daily, with additional drinks and snacks. The preparation and serving of food respects service user’s cultural and religious requirements. An outside cater is contracted to provide prepared meals for the home. The prepared meals are supplied for Mondays – Thursdays. 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. There was plenty of food available on the day of inspection. All food was stored correctly and labelled at the time of inspection. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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. Improvements have been noted however remain some concerns with regard to the accurate recording of medications. Additionally service users must have adequate input and regularly appointments with relevant health care professionals. EVIDENCE: The home has Health Action plans for each service user. 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. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 16 Service users files contained documented medical appointments to GPs, dentist, the local hospital and occupational therapist. However through the tracking of care the inspector was concerned to note that for one service user an optician’s appointment was missed on the 12/9/06 and records indicated that this was because there was no money for transport. The registered manager must investigate this and forward a report to the Commission. It is unacceptable that service users miss appointments under such circumstances. As stated in this report there are serious concerns with regard two service user nutritional intake. This has also been highlighted in the previous inspection report. The registered manager must liaise with relevant health care professionals to seek clear guidance with regard to the diet intake of the two service users concerned. Services users require different levels of assistance with personal care, from total assistance with all personal care to supervision and prompting. The medication policy and procedure covers receipt, storage, handling and disposal of medication. Medication is supplied the ‘Monitored Dosage System’. All service user files contained medical profiles, which outlined their individual medication and side effects. Medication Administration Records ( MAR ) sheets were seen, there were three entries of a code which indicates medication not given on 14/9 however no detail of why this was the case. This is not in line with procedure. The medication cabinet also contained a bottle that was not labelled. After discussion with staff it was established that this was almond oil and had been recommended by the GP for a service user however was not being used at the time of inspection. It was requested that this be disposed of at the time of inspection. The MAR sheets indicated that ‘Calcipotsial ointment 000.5 ’ be used twice daily for a service user, signatures were present for 11/9,12/9,19/9 and 21/9 ( once daily) this meant that from the 11/9 to the day of inspection 16 treatments were not signed for. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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. Staff have received Adult protection training and through discussions with staff they appeared to know how to respond correctly to allegations. However there are still concerns about how service individual Disability Living Allowance is managed. EVIDENCE: There is a complaints procedure/policy in place. The home has a complaints book and service users are encouraged to record any concerns. This was seen at the time of inspection. There have been no complaints recorded since the previous inspection. Policies and procedures for dealing with allegations of abuse are in place. It also includes the procedure of responding to allegations or suspicions of abuse. The inspector was informed that there have been no allegations in regards to abuse within the home since the previous inspection. Following previous concerns all staff have received internal training on Adult Abuse in May 06 and an additional external training session was conduct in July 06 by the London Borough of Hackneys Adult Protection officer. Staff spoken to during the inspection had a clearer understanding of what is expected and how to report any concerns that they may have. Concerns were raised at previous inspections regarding to the procedure of the service users Disability Living Allowance being used by the organisation to go towards the funding of the mini bus. An audit has been undertaken and monies have been credited to service user individual accounts. The inspector Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 18 was informed that new procedures have been produced although the registered manager did not have access to a copy on the day of inspection. However the inspector remains concerned as the organisation continues to ‘bill’ service users for one to one support from staff on occasions. This is deemed unacceptable. The service provides twenty-four hour care for service users and any increase in assessed need (such as one to one care) must be referred to the Local Authority. This must not be funded by their Disability living Allowance. The home holds monies on behalf of service users in individual locked boxes. Records and receipts are maintained of financial transactions involving service users monies. However there were concerns as some discrepancies were noted. For example one service user money had been audited on 14/9 and was found to be incorrect however there was no evidence on the outcome /investigation. The service users money was also incorrect on the day of inspection. There must a complete audit of service uses finances. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. 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 environment is suitable for purpose. The home is clean and free from any odours. EVIDENCE: The home is situated in a residential area and is in keeping with the local community. It offers easy access to local amenities. The inspector was satisfied that the premises are suitable for the stated purpose, and it is accessible to service users. The service users’ bedrooms are of adequate size. The home has undergone a re decoration programme which has greatly improved the environment. There is sufficient light, heat and ventilation. Furnishings and fittings are of adequate standard. The main lounge/dining room is bright and the dining area is used for religious study. There is a conservatory adjoining the lounge, which opens out onto the garden. The garden is well maintained. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 20 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 if required. The service user with specialist equipment is placed on the ground floor. There is a full time domestic support; the standard of cleanliness throughout the home was of a high standard on the day of inspection. The staff member will also complete minor repairs to service users clothes such a replacing lost buttons. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34,35 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is the inspectors’ view that there is limited evidence to show that there is a robust recruitment and selection process in place, which puts service users at risk. EVIDENCE: During the inspection a staff member who was on suspension and subsequently dismissed entered the home to collect belongings. The manner in which this was conducted was inappropriate. The registered manager was not present at the time and was unaware that staff had permitted the person in to the home. The inspector who was in the communal area at this time heard inappropriate language being used with service users present and was extremely concerned about the staff responses. The inspector had to ask a staff member to alert the registered manager to the situation. This incident once more questions the competency and abilities of staff. The inspector examined staff rotas, it was noted that generally there are five staff on duty in the mornings until 3.00pm and three until the evening. There is one waking night and one sleep in at night. The rota also indicates to staff when Shabbos begins and ends. However on Saturdays the inspector raised concern as for a two hour period during the day there was only one staff member on duty with one sleep in. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 22 This is deemed unsatisfactory. The registered manager addressed this at the time of inspection to ensue that there was a minimum of two staff on duty. Given the incident previously reported the inspector remains concerned about the abilities of the staff team in addition to concerns with regard to poor recording for example on monitoring forms and daily recoding sheets. There remains no deputy manager in place even though the Commission were informed by the responsible individual in writing that this would be addressed. At the time of inspection there was agency staff member on duty and a volunteer to assist with cooking. There was no evidence of CRB in place for either of these staff members. This is unacceptable practise. As such the inspector completed a complete audit on fourteen staff files. It was noted that: Three files did not contain any references. One file only contained one reference. Six contain no photographic identification. One file contained a CRB from the previous employee .The employee commenced work after the 17/7/05 when the guidance was changed and employers had to apply for a CRB in their own right. One file contained a CRB in a different name. The inspector was informed that the employee changed their name after the CRB was applied for. A new CRB must be sought. A requirement of the last inspection stated: The registered manager must ensure that records for all employees comply with Regulation 19 and the accompanying Schedule of The Care Homes Regulations 2001. The timescale for compliance was 30/04/06 and was a re-stated requirement from the previous report, which gave a timescale for compliance of 28/02/05. Since there have been repeated failures to ensure all staff have satisfactory employment checks in place the Commission will be taking enforcement action to secure compliance for the health and wellbeing of service users. A requirement of the last inspection stated: The registered manager must undertake a training needs analysis of all staff and use this to develop and individual training and development plan to equip staff with the skills and knowledge to meet service users needs appropriately. The timescale for compliance was 30/04/06. The inspector acknowledges that some work has been achieved to ensure that staff receive training, however there is still a need to ascertain individual training needs of staff. This will therefore be a repeat requirement. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 23 A random selection of three staff supervision records was examined. There was evidence that the registered manager has set supervision sessions however there remains some concern that this is not on a regular basis. None had received at least six times in a year. One staff member was supervised in August 2006 prior to this the last recorded supervision was February 2006. This is another issue that supports the need for a management structure in the home to support the large staff team. Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39,41,42& 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Much work has been achieved since the previous inspection however there remains much work to be done to ensure that the National Minimum Standards are achieved EVIDENCE: Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 25 The inspector is satisfied that the registered manager has a good knowledge of the National Minimum Standards and Care Home Regulations 2001. Given the service users complex needs and the size of the establishment an efficient and effective staff team is essential. As highlighted in the previous inspection the deputy manager’s post has not been filled for some time. There is some administration support being provided by the head office. This remains a concern; the responsible individual did indicate in writing to the Commission following the last inspection that this matter was to be addressed however this was not the case at the time of writing this report. The monthly-unannounced monthly monitoring visits were seen and evidence indicated that these were being complete in line with regulation. However given the evidence in this report there is clearly a need for continued selfmonitoring. There are concerns about the size of the home and the lack of management structure as the registered manager undertakes all the management responsibility. The inspector acknowledges that there has been some improvement in some recordings although there remain some issues with regard to the service users individual plans and risk assessments. Requirements have been made against individual standards. Staff meetings are being held and minutes were seen for July 2006 and September 2006. Additionally resident meetings were held and minutes were seen for July 2006 and August 2006. The inspector check the petty cash held and raised concerns as it was deemed in correct by a substantial amount of money. The registered manager was informed and requested to investigate. As previously stated service users monies were also check and discrepancies were noted. All financial issues must be accurately maintained at all times. As previously highlighted in this report a staff member had suspended and subsequently dismissed. The Commission for Social care inspection had not been notified of the incident Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 26 The manager has delegated a staff member to monitor the Health and Safety issues in the home. The following health and safety checks have been evidenced: The last recorded fire drill is recorded as 4/7/06 Emergency lighting checked 7/2/06 Gas certificates were seen dated 20/6/06 valid for one year. The electric certificate 24/1/05 valid for 3 years. Portable Appliance Test were completed 19/6/06 Fire extinguishers were last checked 14/11/05 Fire alarm was last serviced 17/7/06 Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 27 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 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x 2 3 2 Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15.1 Requirement The registered manager must ensure that all identified needs are reflected in individual plans and what staff support is needed and clear guidance identified as to the level of monitoring required. (Timescale of 30/04/06 not met) The registered manager must ensure that monitoring records are accurately maintained at all times. The registered manager must identify any service user who fall outside the registration category of the home. Service users must be re assessed and if required a variation of registration obtained. The registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. (Timescale 31/01/06 not met) Timescale for action 30/11/06 2 YA6 12.1 30/11/06 3 YA6 14.1 31/12/06 4 YA9 13.4 30/11/06 Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 29 5 YA19 13.1(b) 6 YA19 13.1 7 YA19 13.1 8 YA20 13.2 The registered manager must ensure that service users attend health care appointments when required. The registered manager must forward a report regarding missed appointment due to lack of funds to the Commission. The registered manager must liaise with relevant health care professionals when there is concern raised to service users health care. The registered manager must ensure that medications are administered, recorded and disposed of appropriately. (Timescale of 31/03/06 not met) The registered manager must forward a copy of the new procedure regarding the management of Disability Living Allowances. The registered manager must ensure that service user Disability Living Allowance is managed appropriately. The registered manager must ensure that a full audit is completed on all service ser monies, which is forwarded to the Commission. The registered manager must ensure that staff have the competencies and qualities required to meet service users needs. The responsible person must evidence that a clear staff structure will be put in place to ensure that the outstanding requirements can be met. The registered manager must ensure that that there is adequate staff on duty at all time to meet service users needs. DS0000010282.V301874.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 9 YA23 25.3(c ) 30/11/06 10 YA23 25.1 30/11/06 11 YA23 17.2 30/11/06 12 YA32 18.1 30/11/06 13 YA33 18.1 30/11/06 14 YA33 18.1 15/11/06 Queen Elizabeth Walk (64) Version 5.2 Page 30 15 YA35 18.1(c ) The registered manager must 31/12/06 undertake a training needs analysis of all staff and use this to develop and individual training and development plan to equip staff with the skills and knowledge to meet service users needs appropriately. 16 YA36 17 YA42 18 YA41 19 YA41 20 YA43 (Timescale of 30/04/06 not met) 18.2 The registered manager must ensure that staff have regular, recorded supervision sessions at least six times a year. 24.1(a)(b) The registered manager must establish and maintain a system to review at intervals and improve the quality of care provided in the home. 37 The registered manager must ensure that the Commission for Social Care inspection is informed of any notifications without delay. 37 The registered manager must notify and forward to the Commission all correspondence with regard to the staff suspension and dismissal as stated in this report. 25.1 The registered manager must ensue that all financial issues are accurately maintained at all times. 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 31 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 (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Elizabeth Walk (64) DS0000010282.V301874.R01.S.doc Version 5.2 Page 33 - 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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