Inspection on 27/02/06 for Queen Elizabeth Walk (64)

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 21 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) 21/09/06

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

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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 09/07/2008.

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (64) 64 Queen Elizabeth Walk Hackney London N16 5UX Lead Inspector Kristen Judd Unannounced Inspection 27 February 2006 9:50am th Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 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.V282519.R01.S.doc Version 5.1 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.V282519.R01.S.doc Version 5.1 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 - over of places 65 years of age (1) Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One registered place may be used for the accomodation and care of a service user over the age of 65 in the category MD. 30th November 2005 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. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Monday. This inspection followed up the requirements made at the unannounced visit held on 30th November 2005. There have been twenty-one requirements made following this inspection. 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 six of which have not been met and have been restated in this report with a new timescale for compliance. Unmet requirements impact on the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure 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: 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.V282519.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 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 were examined contain 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 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. Copies of the contract and service users guide are in service users rooms. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 8 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,& 9 It is the inspectors’ view that there has been limited progress on improving care plans; as such staff are unable to deliver appropriate care to service users in line with assessed health and social care needs. This potentially places service users at risk. EVIDENCE: Service user individual plans highlight the issues/needs, the goals and actions. Identified needs are highlighted covering daily living skills, personal care, activities, religion and health. The inspector tracked individual service users needs, and noted that there has been little improvement since the previous inspection. Concerns have been raised previously regarding one of the service users and the deterioration in his mental health. The service user spends much of the day in the up stairs bathroom, these individual behavioural issues must be addressed within the care plans with clear direction for staff about how to deal with the service users on a daily basis. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 9 The service user was being monitored with regard eating and drinking. The inspector was extremely concerned about the poor recording. Additionally on the day of inspection it was noted that staff were not checking on the service user and had not been offered a drink for four hours. Staff stated that a jug of juice was in the service users room however no one was aware whether this was being used. The care plan requires 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. Two further care plans were examined both required reviewing and were clearly out of date. It remains an outstanding requirement that the registered manager must ensure that individual service plans are reviewed in line with the organisational policy. Additionally through the tracking of care of another case the inspector continues not be satisfied that the all risks which were highlighted in the care plan, have been comprehensively assessed. This was in particular to the risk to others when a service user absconds. The service user has at times has displayed challenging behaviour to others in the community. Further documentation is required to evidence that the risk assessment is comprehensive. This must be reviewed continually following incidents. It therefore remains an outstanding requirement that the registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. Another service user has deteriorated and is spending much of the day in bed. Although there was evidence of liaison with health professionals this is limited. Through the tracking of care and observations made during the inspection concerns were raised with regard to the three service users who may be inappropriately placed. The registered manager must ensure that a comprehensive assessment of need is undertaken 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 to ensure that clear strategies are in place and guidance for staff. This must be forwarded to the commission. Any service user who requires additional or specialist support must be continually assessed to ensure that these needs can be met. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 10 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): 16 & 17 The home offers service users the opportunity to participate in daily living tasks . EVIDENCE: Service users’ are involved in the day-to-day routines of the home. Service users are offered a key to their own bedroom. Through observation and discussion with the registered manager, it evident that daily routines and house rules do promote independence and individual choice for the service users. One service ser who chooses to rise late morning was observed making his breakfast independently. Service users were seen to move around the home without any restrictions. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 11 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 at the time of inspection. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 12 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): 19 &20 It was the inspectors view was that medication was not being accurately administered; this must be addressed as a matter of urgency. EVIDENCE: The home has Health Action plans for service users. This document provides a very clear picture for the service users health needs, as to what appointments have been undertaken and issues that may need following up. However through the tracking of care it was noted that service users health needs had changed for example one service user had a catheter but this was not recorded and other as already stated there were concerns regarding food and fluid intakes. It was noted that the action plans had not been updated. 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 records were seen. Concern was raised as PRN medication (paracetomal) was not entered onto the Medication Administration Record (MAR). There were 150 tablets in the medication cabinet in total. Additionally another PRN medication was checked and was incorrect by one tablet. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 13 It was raised in the previous inspection that one service user had missed much of his medication as he often absconds. The registered manager stated that this had been discussed with the doctor and guidance had been given however no evidence of a risk assessment with regard to missing medication and possible affects has been implemented. It was noted that a second service user is also refusing medication on a regular basis; this to requires a risk assessment in place. In the medication cabinet the inspector found that there was a tablet in a medication cup. There was no indication as to what the medication was or which service it belonged to. The inspector was informed that it belonged to a service user who is refusing medication. The records were checked and it was noted that the service user in question had refused the medication on the previous evening. The inspector was shown a box of refused medication. The practise to keep the medication in a medication cup which staff are suppose to seal and label however it was clear that this practise was not being adhered to. There was a large amount of refused medication being stored. A system must be set up in line with the medication policy regarding the recording and disposal of refused medication. The additional supplies of medication were seen the inspector raised concern as due to repeat prescriptions there was much medication that needed to be returned. In one case there was seven months supply of medication. The MAR sheets for February were examined gaps were noted additionally one service users medication had run out and was not available for four days. The inspector was informed that one staff member is now responsible for checking medication sheets monthly and records any errors. Evidence was seen of the January audit. Given the amount of errors the registered manager must ensure that these checks are completed regularly as such errors potentially puts service users at risk. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 14 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 There are serious concerns, as adult protection procedures are not being followed. This potentially puts service users at risk. EVIDENCE: The home’s complaints procedure/policy is in place and indicates the timescales to be adhered to for the responses. The complaints procedure was on display. The home has a complaints book and service users are encouraged to record any concerns. Two complaints had been logged since the previous inspection. One entry had not been signed and relevant information such as contact details for the complainant was missing. The registered manager was unaware of the complaint being made. The inspector was concerned as there was a second entry in the complaints book, which made reference to one of the service users behaviour, but there was no information regarding the complaint. The registered manager must ensure that all complaints are accurately recorded and that the complaint procedure is followed in all cases. At the time of inspection an allegation was being investigated. Policies and procedures for dealing with allegations of abuse were not available at the time of inspection. The registered manager confirmed with the Commission following the inspection that they had been found in the home. Serious concern was raised regarding the delay of reporting the allegation to the Commission for Social Care Inspection. Additionally through the case Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 15 tracking it was noted that statements had been taken from staff and the service user concerned. This is not in line with the Adult Protection Procedures and such practise could damage any investigation to be undertaken. The inspector is also very concerned that staff in the home had been aware of a particular situation for some time and had not discussed the issue with the registered manager. The registered manager must ensure that all staff are fully aware of the Adult Protection Procedure including whistle blowing. The inspector was also very concerned as to the process followed once staff alerted the concern to the manager. The inspector acknowledges that the registered manager completed a ‘spot check’ however it took some time following this to conduct a supervision session regarding the staff members’ current practise. Any issues regarding care practise that may adversely affect a service users must be addressed promptly. This is a requirement under supervision of staff. 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. The inspector saw the records being maintained however there was concern as to the accuracy. The registered manager must forward the end of year account of the benefits and evidence how the funds are spent on accessing the community. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 &30 The home is suitable for purpose however minor repairs must be addressed. 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 premises are comfortable, bright, and airy. 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.V282519.R01.S.doc Version 5.1 Page 17 However the inspector noted the following requirements: First floor bathroom needs urgent re decoration. There was an odour present in room 3. Areas of the home had cracks or small holes in the plasterwork. The broken furniture in room three must be repaired/replaced 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 now a full time domestic support, which has clearly impacted on the standard of cleanliness throughout the home. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 & 35 It is of considerable concern that examples of ability and quality of staffing were found to be lacking. This not only compromises the overall provision of individulised care, but also presents risk to service users. EVIDENCE: Concerns were raised in the previous inspection with regard to the abilities of the current staff team. Following this inspection this remains a matter of concern. For example there are still concerns regarding the errors found with regard to medication. Recording remains out of date in particular care plans and financial matters. There are concerns regarding the recording and following up of complaints. Staff must communicate with the registered manager regarding such issues. The most serious concern is regarding the lack of knowledge with regard to Adult Protection. As previously stated the inspector is also very concerned that staff were aware of poor care practise however left it some time before reporting concerns to the registered manager. The inspector highlighted in the previous inspection that there is no deputy manager in place. Given the concerns raised in this report the organisation must forward a full report as to how adequate support and supervision is to be provided for all staff to ensure that correct procedures are followed and that all the records required by regulation are maintained accurately. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 19 Two of the most recently recruited staff files were inspected. It was noted one file contained two personal references, the second contained two references that had been received by e-mail, this is concerning as there was no verification of references evidenced. One file did not contain proof of identification. Both application forms were part completed and one showed no evidence any previous employment history. The inspector noted that on the second file a reference was received from a previous employer however there was no reference to this employment on the application form. It therefore remains an outstanding requirement that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. Through discussions with the registered manager it was clear that there is minimal support as there is no deputy in place and the administers post is also vacant. This places additional workload onto the registered manager. Additionally as stated in this report some of the service users have complex needs and as required these needs must be reassessed to ensure that service users are appropriately placed. The organisation needs to look at the needs of the service users, the size of the establishment, the supervision and support needs of staff and determine whether the staff structure in place is suitable to meet statutory requirements. The responsible must evaluate the staffing structure and forward a full report and action plan to the Commission. The previous inspection highlighted that staff had received relevant training. Additionally staff have received training Abuse of Adults and Challenging behaviour since the previous inspection. However the concerns in this report highlights the need to evaluate staff competencies following training. The registered manager has endeavoured to implement systems since the previous inspection to allocate particular tasks within the home to address previous outstanding requirement. For example one staff member has been given the direct responsibility for Health and Safety and another for medication. However as highlighted in this report the systems do not appear to be robust enough to cease errors. As previously stated the inspector was a very concerned as to the process followed once staff alerted a concern regarding care practise of one of the staff team to the manager. The registered manager completed a ‘spot check’ however it took some time following this to conduct a supervision session regarding the staff members’ current practise. Any issues regarding care practise that may adversely affect a service users must be addressed promptly. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 41 The content of this report, which includes unmet requirements from the last inspection, reflects poorly on the conduct and management within the home. EVIDENCE: The inspector is satisfied that the registered manager has a good knowledge of the National Minimum Standards and Regulations. Given the service users complex needs and the size of the establishment an efficient and effective staff team is essential. As previously stated in this report the deputy managers post has not been filled for some time and the part time administrator post is also now vacant. This in turn has increased the registered managers workload, which is of concern. The registered manager and the responsible individual must address the content of this report as a matter of urgency. The monthly-unannounced monthly monitoring visits were seen however there were no reports for January 2006. The registered individual must ensure that visits under regulation 26 be completed and recorded monthly. The reports must be available for inspection. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 21 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 at the time of inspection the registered manager informed the inspector that service users monies and petty cash were not up to date and therefore could not be deemed correct. The inspector is concerned as this was the situation at the previous inspection. Records were seen during the inspection in relation to Schedules 2, 3 and 4 of the Care Homes Regulations. This standard scored ‘2’ because, as identified in relevant standards, not all records required were not up to date or accurate. Requirements have been made against some individual standards. Further improvements are required in the following areas to keep records up to date and valid: Risk assessments. Care plans Medication records Financial records Complaints It therefore remains an outstanding requirement that the registered manager must that all records detailed in The Care Homes Regulations 2001 and accompanying Schedules are kept as required. This matter must be addressed as a matter of urgency. Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 1 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 2 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 1 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 x x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 1 x 3 x 1 x 2 x x Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 14.1 Regulation Requirement 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 individual service plans are reviewed in line with the organisational policy.(Timescale 31/01/06 not met) 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 for action 30/04/06 YA6 2 15.2 30/04/06 3 YA6 15.1 30/04/06 YA9 4 13.4 The registered manager must 30/04/06 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) Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 24 5 YA19 13.1 YA20 6 YA22 7 13.2 22 8 YA23 37.1 9 YA23 13.6 10 YA23 13.6 YA23 . 11 YA24 12 25.3(c ) 23.2 13 YA27 23.2 YA30 14 23.2 The registered manager must ensure that service users health needs are accurately monitored and input from relevant health professional sought when necessary and clearly recorded. The registered manager must ensure that medications are administered ,recorded and disposed of appropriately. The registered manager must ensure that all complaints are recorded accurately and investigated in line with the complaints procedure. All allegations of abuse must be reported to the Commission for Social Care inspection without delay. The registered manager must ensure that the Ault Protection procedure are available and are followed if there are any allegations of abuse. The registered manager must ensure that all staff receive training on the Adult Protection Procedure including the whistle blowing policy. The registered manager must forward the end of year account of the benefits and evidence how the funds are spent on accessing the community. The registered manager must ensure that the repairs to areas in the home and furniture as stated in this report are addressed The registered manager must ensure that the issues highlighted in this report relating to the bathroom be addressed. The registered manager must ensure that all areas of the home are kept free from odour. 30/04/06 31/03/06 30/04/06 31/03/06 31/03/06 30/04/06 20/05/06 15/05/06 31/05/06 31/03/06 Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 25 15 YA33 18.1(a) 16 YA33 18.1 17 YA34 17 18 YA35 18.1(c ) 19 YA36 18.2 20 YA39 26 21 YA41 17 The registered manager must ensure that that all staff in the care home are suitably competent and experienced. (Timescale 31/01/06 not met) The responsible must evaluate the staffing structure and forward a full report and action plan to the Commission. The registered manager must ensure that records for all employees comply with Regulation 17 and the accompanying Schedule of The Care Homes Regulations 2001. (Timescale of 28.2.05 not met) The registered manager must undertake a training needs anayalis 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 appropratly. The registered manager must ensure that any issues regarding care practise that may adversely affect a service users must be addressed with staff without delay. The responsible individual must ensure that the monthly visits under regulation 26 be conducted and a report is made available for inspection. (Timescale 31/01/06 not met) The registered manager must that all records detailed in The Care Homes Regulations 2001 and accompanying Schedules are kept as required. (Timescale of 28.2.05 not met) 30/04/06 30/04/06 30/04/06 30/04/06 31/03/06 30/04/06 30/04/06 Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Elizabeth Walk (64) DS0000010282.V282519.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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. 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