Care Home: Queen Elizabeth Walk (57)

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What the care home does well The home continues to meet the needs of the service users accommodated there, with the exception of one person. The home manager was however able to evidence those alternative arrangements were being sought for one of the people who used the service. Service users who spoke with the Expert by Experience stated told her that they were happy living in the home and they liked staff supporting them. People who use the service access a wide range of activities. Staff working in the home appear to have a good and clear understanding of the service users’ needs. The home appropriately meets cultural and religious needs of those accommodated at 57 Queen Elizabeth Walk.Queen Elizabeth Walk (57)DS0000010281.V377633.R01.S.docVersion 5.3 What has improved since the last inspection? Since the last inspection, the manager has ensured that appropriate systems have been put in place to monitor and record weight of any service user, where it has been deemed as necessary and/or beneficial to their wellbeing. A cabinet has been installed for the storage of Controlled Drugs in order to meet the requirement of the Misuse of Drugs Regulations 1973. The manager has ensured that all medication administration records contain full directions as to how each medication should be administered, in order to avoid any errors in administering medication. The recommendation that the home purchase a cordless phone, so that the service users are able to use it in the privacy of their rooms if they wish, has now been met. The home has also produced its complaints procedure in a format that is easily accessible to the current service user group, as previously recommended. What the care home could do better: Improvements are required to the way the home deals with complaints. In addition the registered person must ensure that all care plans and risk assessment are up-to-date and kept under review. Some improvements are also required to the home’s medication systems. During this visit we noted that not all significant events were being reported to appropriate authorities and this must be improved, in order to protect service users from potential abuse. Additionally, a policy on management of service user’s money and financial affairs must be drawn up, so that staff working in the home are clear who pays for their expenses when supporting service users on activities and holidays. Although the home premises were generally well maintained, bathrooms in the home need to be redecorated and the rear garden should be tidied up, to ensure pleasant and homely atmosphere for those accommodated in the home. It is also required that staff receive all mandatory training and any other training appropriate to the work they are to perform.Queen Elizabeth Walk (57)DS0000010281.V377633.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Queen Elizabeth Walk (57) 57 Queen Elizabeth Walk Hackney London N16 5UQ Lead Inspector Robert Sobotka Key Unannounced Inspection 10th August 2009 10:00 Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Walk (57) Address 57 Queen Elizabeth Walk Hackney London N16 5UQ 020 8809 3817 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) yadvoezer@btconnect.com Yad Voezer Manager post vacant Care Home 8 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. Agreed room may be used for respite care. Agreed residents may have relatives/friends to stay overnight in respite room and not in their own bedr Agreed room may be used for respite care. Agreed residents may have relatives/friends to stay overnight in respite room and not in their own bedrooms One Service user with Mental Health needs may be accommodated for a period of six months from the date of this certificate and thereafter reviewed by CSCI on a three monthly basis. 27th August 2008 2. Date of last inspection Brief Description of the Service: 57 Queen Elizabeth Walk is a Jewish Orthodox care home for seven females with learning disabilities and one respite bed. The care provider is Yad Voezer (A Helping Hand), an orthodox Jewish charitable organisation, managed in accordance with strict Torah guidelines. All areas of daily life, including food (Kashrus requirements), Shabbos (Sabbath) traditions, festivals, religious rituals etc. are culturally observed. Yad Voezer aims to ensure that despite a learning disability, people are given the maximum opportunity to enjoy their lives to the full. A range of activities is offered within and outside of the home. These include opportunities for employment, day care, Hebrew lessons, religious instruction, art therapy, music therapy, keep fit and computer training. Service users’ independent living skills, spiritual needs and personal development are actively promoted. There are additionally strong links with the local orthodox Jewish community. The home is a large family type property situated in a quiet residential area in Stoke Newington. The home offers access to local amenities, transport and relevant support services, to suit the lifestyle needs of service users and the purpose of the home. Restricted permit parking is in operation. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced. During our visit, we spoke with the home manager and several members of staff who worked in the home. We also looked around the premises and viewed various records. This inspection was undertaken with help from an Expert by Experience, who visited the home with her Personal Assistant. She spoke to the people who use the service and undertook a tour of the premises. Following this inspection they produced a report, extracts from which are included within this report. Prior to this inspection the home was asked to complete an Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. During this visit, the inspector requested that a record of staff training should be forwarded to the Commission. This was received in due course. The aim of this unannounced inspection was to check the home’s compliance with the National Minimum Standards and the Care Homes Regulations. We would like to thank people who use the service and staff working in the home for contributing to this inspection. What the service does well: The home continues to meet the needs of the service users accommodated there, with the exception of one person. The home manager was however able to evidence those alternative arrangements were being sought for one of the people who used the service. Service users who spoke with the Expert by Experience stated told her that they were happy living in the home and they liked staff supporting them. People who use the service access a wide range of activities. Staff working in the home appear to have a good and clear understanding of the service users’ needs. The home appropriately meets cultural and religious needs of those accommodated at 57 Queen Elizabeth Walk. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 6 What has improved since the last inspection? What they could do better: Improvements are required to the way the home deals with complaints. In addition the registered person must ensure that all care plans and risk assessment are up-to-date and kept under review. Some improvements are also required to the home’s medication systems. During this visit we noted that not all significant events were being reported to appropriate authorities and this must be improved, in order to protect service users from potential abuse. Additionally, a policy on management of service user’s money and financial affairs must be drawn up, so that staff working in the home are clear who pays for their expenses when supporting service users on activities and holidays. Although the home premises were generally well maintained, bathrooms in the home need to be redecorated and the rear garden should be tidied up, to ensure pleasant and homely atmosphere for those accommodated in the home. It is also required that staff receive all mandatory training and any other training appropriate to the work they are to perform. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and any prospective service users have appropriate information about the home in order to make decision whether it would be suitable to them. EVIDENCE: The home had an up-to-date statement of purpose and the service user’s guide in place, which cover its aims and objectives and additional aspects listed in relevant sections of the Care Homes Regulations 2001. Both documents contained relevant information to allow service users to make an informed choice whether to live in the home. There have been no new admissions to the home since the last inspection. The standard relating to the assessment process could not therefore be fully assessed. Files of existing service users contained appropriate pre-admission assessments. Following discussion and interviews with members of staff working in the home and the home manager and review of the documentation kept in the home, as Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 10 well as feedback from the expert by experience, we were satisfied that the needs of those accommodated in the home were being met, with the exception of one service user, where alternative living arrangements were being made. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are required to the home’s care planning and risk management systems. EVIDENCE: As part of this inspection we reviewed care plans of four service users, including one care plan of a person who was using the service on a respite basis. Care plans of the service users who were living in the home permanently appeared to be up-to-date, however the care plan of the service user who was in 57 Queen Elizabeth Walk on respite, was last updated in August 2006. The registered person must ensure that each person has an up-to-date care plan, which outlines how the home will meet their assessed needs. This includes care plans for any person using the service as a respite. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 12 Service users, whenever possible, are encouraged to participate in their individual care planning and activities. There was evidence that the service users were consulted about their care planning process. Regular service users’ meetings are also organised. Minutes from these were available for inspection. The home operates a key working system, when each key worker is responsible for co-ordinating care of her key client. Our Expert by experience made the following observation: ‘Residents have a choice of when to go to bed and when to get up depending on the activities they have for the day.’ ‘Residents are involved in planning for their holidays and said they love going of holiday and loved the holiday they had been recently to in Oxford.’ ‘Staff give residents choices of what to do from day to day. ‘ Some improvements are required to the home’s risk management systems. Following an incident in April 2009 where a service user ran into the street, a recommendation was to draw up a risk assessment to minimise identified risk and hazards. This however was not in place at the time of this inspection. The registered person must ensure that appropriate risk assessments are in place, where necessary, in order to minimise identified risks and hazards. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16, 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are encouraged and supported to become part of the local community, develop friendships and maintain family links. They enjoyed the food offered in the home. EVIDENCE: Following discussions with staff working in the home, direct and indirect observation, feedback from the Expert by experience, and review of documentation in the home, such as care plans, we were satisfied that people who use the service were supported and encouraged to take part in appropriate leisure activities. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 14 The home offers a wide range of culturally appropriate activities for inside and outside of the care home. Some of the observations by the Expert by experience were: ‘The community around the home is predominantly Jewish and the residents form part of this community.’ ‘Residents said the staff are good and they treat them well. Staff give residents choices of what to do from day to day. While at the home we witnessed one member of staff discussing with a resident as to what she wanted to do and gave choices of watching a DVD, puzzles or relaxing in her chair.’ ‘The home has a large lounge with a large table where residents undertake activities like sewing, drawing and do puzzles.’ ‘Some residents attend a day centre. During the visit the day centre was closed and staff offered other activities like shopping and going for meetings at the synagogue.’ ‘Residents have a choice of meals. They plan the menu when they have their weekly meetings.’ Those who live in the home enjoyed food offered to them. All food purchased whether for the home, clubs, holidays or outings must be hescher (certificate of Kashrus) of Kedassia or one of equal standing. Milk and meat sections of the kitchen were clearly separated. Appropriate food supplies were kept in the home on the day of this unannounced inspection. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was generally appropriately meets service users’ emotional and physical health; however improvements are required to its medication systems. EVIDENCE: All personal care required by the people who use the service is carried out by female staff in line with cultural requirements. Guidelines as to how personal care should be provided were included in individual service users’ care plans. The examined files evidenced the home’s commitment to facilitate the service users’ access to community health resources. Each person was registered with a local General Practitioner. They also had “Health Action Plans” in place, which were incorporated into their care plan. At the last inspection we made a requirement that service users’ weight should be monitored and that record must be kept, where the service user’s care Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 16 plans indicated that their weight should be monitored and recorded on a regular basis. This was now being done. We checked the home’s medication systems during this inspection visit. The home uses Boots blister pack systems. Record of medication received by the home and disposed of was checked and was found to be correct. At the last inspection visit we noted that improvements were required to records relating to administration of medication, as some of the medication administration records (MAR sheets) did not contain full instructions as to how each medication should be administered. This has now been addressed by the home. During the check of medication stocks at the previous inspection visit, we noted that the name of one of the people who use the service on her medication administration record (MAR sheet) did not correspond with the name printed on her dispensed medication. This was due to the fact that medication administration record had this person’s Hebrew name and their dispensed medication was labelled with her English name. This could lead to some confusion and potential medication administration errors. At the time of this inspection visit this practice appeared to be still in place. We gave the home advice to include the person’s both names on the medication administration sheet to alert members of staff administering medication to the fact this the service user was using both Hebrew and English versions of her name. Additionally, staff administering medication must use appropriate codes on individual medication administration sheets to indicate any reason for not administering medication to service users. During the last inspection we advised the home manager that in accordance with change in legislation, a cupboard is required to be installed for the storage of Controlled Drugs. The cupboard must meet the requirements of the Misuse of Drugs Regulations 1973. A suitable controlled drugs cabinet has now been installed in the home. The requirement issued at the last inspection that guidelines must drawn up to guide staff as to when they should administer PRN (as required) medication and what dose should be administered has now been met. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are required to the home’s complaints system to ensure that all complaints are promptly resolved. Not all significant events were being reported to the Commission and other relevant authorities, as required by law, which may put people who use the service at risk. EVIDENCE: As part of this visit, the inspector checked the home’s complaints folder. There were two complaints, which were made in August and December 2008, that appeared to be unresolved. This required improvement. The registered person must ensure that all complaints are resolved in accordance with the home’s complaints procedure and within set timescales. This is a repeated requirement and must be resolved without any further delay. Further failure to comply may resolve in the Commission issuing an enforcement notice. The following comment was made by the expert by experience: ‘Residents I talked to said they were happy at the home and would not want to change anything about the home. Staff I talked to said there is a complaint procedure in the home and is in picture format/easy read in case the residents wanted to make a complaint.’ Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 18 During the previous inspection visit we recommended that the home’s complaints procedure be produced in a format that is easily accessible to the current service users’ group. This has now been done. The home’s accidents and incident records were inspected and were found to be appropriately maintained. It appeared however that not incidents were being reported to the Commission in line with Regulation 37 of the Care Homes Regulations 2001. This included one incident where one service user’s money was snatched from a cash point machine and another one where one of the service user’s Disabled Blue Badge went missing. There have also been a couple of incidents were one service user hit another, which should have been reported to the local Safeguarding Adults team. The registered person must ensure that each the Commission is informed of any significant events in line with Regulation 37 of the Care Home’s Regulations 2001. In addition, the registered person must ensure that any potential adult safeguarding issues are reported to all the relevant authorities, in order to protect those who use the service from abuse. The home’s financial systems were checked during this inspection visit and appeared to be in order. There was a clear log of expenditure made on behalf of service users. We checked finances and all corresponding financial records in relation to two service users and these were found to be correct and appropriately maintained. Whilst the finances were found to be in order, daily records did not reflect some of the activities/outings during which money was spent. Additionally there appeared to be some confusion amongst staff as to which budget should be used for paying for staff travel. We asked to see a policy in relation to service user’s expenses, which was not in place. The registered person must ensure that there is a policy in place on management of service user’s money and financial affairs, in order to protect those who use the service from financial abuse. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from generally well maintained and clean premises. EVIDENCE: The home is located in a quiet residential road in Stoke Newington. It is a large terraced town house and blends unobtrusively into the neighbourhood. The home offers access to local amenities, transport and relevant support services to suit the personal and lifestyle needs of service users. 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. The home does not however have a passenger lift. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 20 The service is fully wheelchair accessible at both back and front of premises A cleaner is employed to maintain the high standard of cleaniness with the home. A house keeper is employed to ensure all laundry is completed appropiately and to a high standard, to oversee the cleaner, monitor health and safety checks, including hygienne checks and monitoring the stock control regarding cleaning materials. There are four bathrooms within the home. On the ground floor the bathroom has been converted into a walk in shower room to meet the needs of the one wheelchair user. Our Expert by experience made the following comments: ‘I was shown around by one of the residents. I looked into three of the bedrooms and all of them were furnished with residents personal items. The resident said she was involved in choosing her furniture and décor for her bedroom.’ ‘One resident, who uses a wheelchair, has her room adapted with an overhead hoist for ease of support and has a bathroom on the ground floor.’ She noted two areas of improvement: ‘The bathrooms need decorating.’ and ‘the garden is at the rear of the home is unkempt.’ Appropriate laundry facilities were in place. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels were adequate to meet the assessed needs of the people who used the service. EVIDENCE: As part of this visit, we checked staff duty rosters, which evidence that there were sufficient staffing levels in place to meet the assessed needs of the service users accommodated in the home. There are at least 3 members of staff on duty during the day. At night time there is one person doing waking night and one person working sleep-in. Those members of staff who spoke with us were able to demonstrate good knowledge of the service user’s needs. The home employs a number of Jewish staff to meet the religious needs of the people who use the service and to supervise and host Shabbos and Holy Holidays arrangements. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 22 The following comment was made by our Expert by experience: ‘The staff are able to effectively communicate with the residents who have high communication needs through expressions and body language. A member of staff I talked to said, ‘most of the staff have worked here for a long time and are able to tell what a residents wants’. Those who spoke with us told us that they were satisfied with training offered to them. Record of training offered to staff working in the home was not available in the home at the time of this visit. Subsequently, the inspector requested that a record of staff training should be forwarded to the Commission. This was forwarded in due course. Record of staff training received by us showed that there were some gaps in staff training. It is therefore required that staff receive all mandatory training and any other training appropriate to the work they are to perform. As no new staff have been employed in the home since the last inspection, staff personnel files were not checked on this occasion. There were found to be in order at the time of the last visit. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by a competent and knowledgeable manager, however further work is required to ensure that all requirements are met to achieve better outcomes for the service users. Appropriate quality assurance systems were in place. Health and safety in the home was maintained. EVIDENCE: The home is managed by a competent and knowledgeable manager. She has worked in the home for over a year and there was evidence that she has worked hard to improve the quality of care offered in the home. At the time of this inspection, the manager told us that she was in the process of applying to be formally registered with the CQC as the manager of the home. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 24 The following comment was made by our Expert by experience: ‘The staff in the home said they were happy working there and the management supports them well, offering training to be able to attend to the residents’ changing needs and according to Jewish culture.’ Appropriate quality assurance systems were in place. The monthlyunannounced monitoring visits are undertaken and copies from those are forwarded promptly to the Commission. Service users and staff meetings are being held and copies of the minutes were examined during this inspection. Health and safety checks were undertaken on a regular basis and relevant records to demonstrate this were kept in the home. The home was appropriately insured for its purpose. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Version 5.3 Page 26 Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 12(3) Requirement Timescale for action 15/10/09 2. YA22 22(3), 22(4) 3. YA6 15 4. YA9 13(4) The registered person must ensure that there is a consistency in recording names of each service user on both medication administration records and dispensing labels, where both English and Hebrew names are being used, in order to avoid any potential medication misadministration. (This is a repeated requirement.) The registered person must 15/10/09 ensure that all complaints are resolved in accordance with the home’s complaints procedure and within set timescales. (This is a repeated requirement.) The registered person must 15/10/09 ensure that each person has an up-to-date care plan, which outlines how the home will meet their assessed needs. This includes care plans for any person using the service as a respite. Each care plan should be kept under review. The registered person must 15/10/09 ensure that appropriate risk assessments are in place, where necessary, in order to minimise DS0000010281.V377633.R01.S.doc Version 5.3 Queen Elizabeth Walk (57) Page 27 identified risks and hazards. 5. YA20 12(3) Staff administering medication must use appropriate codes on individual medication administration sheets to indicate any reason for not administering medication to service users The registered person must ensure that each the Commission is informed of any significant events in line with Regulation 37 of the Care Home’s Regulations 2001. The registered person must ensure that any potential adult safeguarding issues are reported to all the relevant authorities, in order to protect those who use the service from abuse. The registered person must ensure that there is a policy in place on management of service user’s money and financial affairs, in order to protect those who use the service from financial abuse. The registered person must ensure that bathrooms are redecorated, in order to provide a pleasant and homely environment. The registered person must ensure that the rear garden is tidied up and appropriately maintained. It is required that staff receive all mandatory training and any other training appropriate to the work they are to perform. 01/10/09 6. YA23 37 01/10/09 7. YA23 13(6) 01/10/09 8. YA23 13(6) 01/11/09 9. YA30 23(2)(d) 01/12/09 10. YA30 23(2)(o) 15/11/09 11. YA33 18(1)(c) 01/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 28 No. Refer to Standard Good Practice Recommendations Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Queen Elizabeth Walk (57) DS0000010281.V377633.R01.S.doc Version 5.3 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!