Inspection on 30/11/05 for Queen Elizabeth Walk (64)

This inspection was carried out on 30th November 2005.

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 12 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) 27/02/06

Queen Elizabeth Walk (64) 28/03/05

Queen Elizabeth Walk (64) 17/11/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Queen Elizabeth Walk (64) 64 Queen Elizabeth Walk Hackney London N16 5UX Lead Inspector Kristen Judd Unannounced Inspection 30th November 2005 1.00pm Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 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.V269149.R01.S.doc Version 5.0 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.V269149.R01.S.doc Version 5.0 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 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.V269149.R01.S.doc Version 5.0 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. 28th March 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.V269149.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which started at 1.00pm. This inspection followed up the requirements made at the unannounced visit held on 28th March 2005. The inspector spoke with several service users, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There have been twelve requirements made following this inspection. Verbal feedback was given to the registered manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 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.V269149.R01.S.doc Version 5.0 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&3 The inspector believes that staff are clear about the service provision and what assistance is expected to be provided to service users. However documentation such as the service user guide must accurately reflect the service to enable service users to be accurately informed. 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 residents’ service user guide has been developed; the format has been improved and is more suitable for service users with learning disabilities. However requires further amendment as it does not indicate that complaints can made to outside agencies such as social services or the commission directly. Additionally the guide has not been individually developed to accurately reflect the individual home. The words and pictures should provide the service users with an accurate description of the individual service being provided. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 8 Through discussion, the inspector was satisfied that staff were able to demonstrate that the home has the capacity to meet the service users’ needs. 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.V269149.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 &10 The inspector believes that staff are aware of service users needs. However all of the service users needs must be reflected in the individual service users plans and be supported by comprehensive risk assessments to demonstrate how those needs are to be met effectively. 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, some of which were not highlighted with the individual plans. One service is being monitored with regard eating and drinking. Evidence was seen of relevant health professionals being consulted. However the care plan required updating to accurately reflect the service users care needs. Another service users spends much of the day in the up stairs bathroom, these individual behavioural issues must be addressed with 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.V269149.R01.S.doc Version 5.0 Page 10 The registered manager was aware of these issues and informed the inspector that the individual service user plans required reviewing and were clearly out of date. The registered manager must ensure that individual service plans are reviewed in line with the organisational policy. Through the tracking of care the inspector was not satisfied that the all risks which were highlighted in the care plan, had 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 .The registered manager must liaise closely with outside professionals to reassess service user accordingly to ensure their needs can be met by the home and to ensure that clear strategies are in place and guidance to staff when incidents occur. 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. 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. Service users are encouraged and supported to take an active part in the daily routines, such as cleaning their rooms, making snacks and beverages, preparing the house for the Sabbath. 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. The confidentiality policy has been amended as previously required. The inspector was informed that the all records in regards to the service user are kept secure and confidential in a locked office. Through interviewing the staff the inspector is satisfied that service users information is handled in a confidential manner and that staff have a clear understanding of confidentiality. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15&17 The inspector observed and was satisfied that staff provide service users with support to make choices and provide them the opportunity to lead independent lives. EVIDENCE: This care home is an orthodox Jewish home and all service users are from orthodox Jewish families. The home is culturally appropriate to the needs of the service users. The inspector was satisfied through observations made during the inspection that staff encourage service users to be involved with many activities and organisations outside the home. This is one of the homes strengths. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 12 One service user spoken to during the inspection is currently undergoing a National Vocational Qualification in soft furnishings. The service user is paid a nominal wage for attending the courses. He clearly enjoys the work and it gives structure to his week. The inspector was satisfied that service uses are given the opportunity to take part in educational and fulfilling activities. The staff were observed taking service users out during the inspection. They actively use the mini bus and offer to take service users out even if it’s just for the ride, shopping or for a structured outing. At one stage of the inspection there were just two service users in the home as everyone one was out at some form of activity. The inspector was satisfied that they are encouraged by staff and management to participate in the local community. Service users attend the synagogue and have observed support and direction to undertake daily prayers. The inspector was informed that holidays are arranged for service users who wish to attend annually. 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 regularly. Details of family and friends were evidenced on the individual service user files. Family and friends are always welcome in the care home. Evidence was seen on service users files of family involvement. 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.V269149.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 The inspector believes that the home is meeting service users personal care needs, however there are concerns with regard to the safe administration, storage and recording of medications. EVIDENCE: The home has implemented Health Action plans for service users. This document provides a very clear picture for the service users health needs, what appointments have been undertaken and any issues that may need following up. The inspector is satisfied that referrals are made to relevant health professional such occupational therapist. One service user requires total assistance with personal care; the remaining service users require prompting, supervision and encouragement to complete personal care. The inspector was satisfied through indirect observation that the staff are flexible with regards to meal times, bedtimes and activities. Staff were observed during the inspection encouraging the service user to make decisions and complete tasks when appropriate. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 14 One service user suffers from epilepsy; staff have had relevant training. Evidence was seen of staff recording episodes of fits and indicating the length and type of incident due to this service users condition there are often admissions to hospital the inspector was satisfied that health issues were responded to effectively. 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 .The inspector was informed that two members of staff administer medication. However concern was raised as staff were not following procedures. For example one service users medication had been signed for however the medication was still present in the blister pack. Staff spoken to at the time of inspection could not explained how the error occurred although did appear to be aware of the correct procedure. One service user had missed much of his medication as he often absconds. The registered manager must implement a relevant risk assessment with regard to missing medication and possible affects. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 All complaints or concerns must be appropriately investigated to provide the reassurance to service users, staff and others that they will be listened to, taken seriously and action taken. EVIDENCE: The home’s complaints procedure/policy is in place and indicates the timescales to be adhered to for the responses. Complaints and concerns are also raised in the service users meetings, if appropriate. The complaints procedure was on display. The home has a complaints book and service users are encouraged to record any concerns. This was seen at the time of inspection. The inspector was however concerned as one of the complaints indicated that a visitor to the home had slept in a service users bedroom on the floor. This is unacceptable practise. The registered manager had investigated the complaint however the inspector is not satisfied that the outcome and actions are appropriate. This issue raises concern about staff and decisions that are taken when the registered manager is not present. The registered manager must forward to the commission further information regarding this complaint. 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 procedure covers immediate respond and action, how to alert management, who to notify, protection, and formal investigation. The guidance covers the importance of accurate recording. Clear time scales are indicated. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 16 The registered manager informed the inspector that there have been no allegations in regards to abuse within the home. 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 was informed that the accounts were not up to date and therefore not inspected. The registered manager must clearly account for the sum of the benefit and be able to evidence how the funds are spent on accessing the community. This information must be made available for inspection. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 17 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): 24,25,27,29&30 It is the inspector’s view that the home is suitable for its purposes however there are some minor issues regarding the standard of the environment that needs to 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. Each bedroom has been personalised by the service users. 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. The kitchen has been recently refurbished. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 18 However the inspector noted the following requirements: First floor bathroom needs re decoration. The shower clip is broken in the additional first floor bathroom Suitable window covering in M’s room. Additionally is was noted that M’s room was extremely cold on the day of inspection; the inspector was informed that this was because M leaves the windows open. The registered manager discussed with the inspector the plans for the room. This will be monitored at the next inspection. 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. During the inspection the home was free from odour. The home was of adequate cleanliness and hygiene. There is support from domestic staff on a daily basis. In addition staff are expected to share the cleaning within the care home whilst on duty. Service users are supported by staff to maintain their own rooms. There is a separate laundry facility. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 19 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&36 It is the inspectors view that there has a focus on training staff however any staff member working in the home must be deemed competent by the registered manager so as not to potentially put service users at risk. EVIDENCE: Staff spoken to during the inspection, had knowledge of the service users needs and were observed communicating appropriately with service users throughout the inspection. There are at least three staff members on duty during the day and one waking night. There are currently eight full time posts and two part time. The inspector was informed that three of the staff team have completed the National Vocational Qualification Level 2 and five are currently on the course. Two of the staff team are undertaking level three. It is acknowledged that much training has been undertaken since March 2005. In addition to monitory training this has included Mental Health Awareness in Learning disabilities, Autism and Knowledge of Epilepsy. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 20 However during the inspection some concerns were raised regarding the abilities of the staff team, for example although staff were clearly aware of the medication procedures errors were found. Much of the recording is out of date in particular care plans and financial matters. Additionally all staff need to have an awareness of the standards so decisions can be made accordingly. The complaint discussed in this report was unacceptable and no visitor should ever be allowed to go to bed in the home in a service users room. There is no deputy manager in place and the organisation need to look at the homes structure to ensure that there is adequate support for all staff with suitable competencies to ensure that all the records required by regulation are maintained accurately. Three files were inspected all contained criminal bureau checks, job descriptions and application forms, however it was noted one file contained only one reference and no proof of identification. 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. Staff meetings are held; matters such as health and safety, activities meals and training were covered. The inspector was informed that the registered manager currently supervises all staff and has a six-week schedule in place. Records were seen that indicated that supervision will be completed in line with the National Minimum Standards of at least six times yearly. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 21 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): 39,41 &42 The home appears well managed however recordings’ being inconsistent reflects poorly on management. EVIDENCE: The registered manager has a good knowledge and understanding of the cultural needs of the service users and ensures that Kashrut laws are maintained within the home. The inspector was satisfied through discussions with the registered manager and the inspection process that the manager was competent and experienced to run the care home in line with its stated purpose. However as previously stated that are concerns as much of the paperwork is out of date. 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. This issue will be looked at closely at the next inspection. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 22 The monthly-unannounced monthly monitoring visits were seen however there were no reports for October 2005 or July 2005. The registered individual must ensure that visits under regulation 26 be completed and recorded monthly. The reports must be available for inspection. The home holds monies on behalf of service users in a 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 registered manager must ensure that all financial issues in the acre home are maintained accurately and efficiently at all times. 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 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 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. Relevant documentation was in place regarding the health and safety requirements; certificates were available for inspection. Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X 2 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 2 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queen Elizabeth Walk (64) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 1 3 x DS0000010282.V269149.R01.S.doc Version 5.0 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5.1 Requirement The registered manager must ensure that the service users guide reflects the service provision accurately. Additionally the complaints procedure must indicate that complaints can be made directly to the Commission. The registered manager must ensure that individual service plans are reviewed in line with the organisational policy. The registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. The registered manager must ensure that staff are aware of the organisations policy and that procedures are followed at all times. (Timescale of 31.12.04 not met) The registered manager must forward a full report regarding the complaint mentioned din this report. DS0000010282.V269149.R01.S.doc Timescale for action 31/03/06 2 YA6 15.2 31/01/06 3 YA9 13 31/01/06 4 YA20 13.2 31/01/06 5 YA22 22 15/01/06 Queen Elizabeth Walk (64) Version 5.0 Page 25 6 YA23 20 7 YA25 16.2 The registered manager must clearly account for the Disability Living Allowance being used and be able to evidence how the funds are spent on accessing the community. This information must be made available for inspection. The registered manager must ensure that there are suitable window covering in M room that meet the service users needs. The registered manager must ensure that the issues highlighted in this report relating to the bathrooms be addressed. The registered manager must ensure that that all staff in the care home are suitably competent and experienced. 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) 31/01/06 31/01/06 8 YA27 23.2 28/02/06 9 YA33 18.1 31/01/06 10 YA34 17 31/01/06 11 YA39 26 12 YA41 17 The responsible individual must 31/01/06 ensure that the monthly visits under regulation 26 be conducted and a report is made available for inspection. The registered manager must 31/01/06 that all records detailed in The Care Homes Regulations 2001 and accompanying Schedules are kept as required. (Timescale of 28.2.05 not met) Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 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.V269149.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Queen Elizabeth Walk (64) DS0000010282.V269149.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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