Care Home: Queen Elizabeth Walk (64)

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What the care home does well The home is an orthodox Jewish home and it appropriately meets cultural and religious needs of the service users accommodated there. Service users are encouraged and supported to carry out daily living tasks and are supported to make choices. Culturally appropriate activities were also on offer. The home is situated in the heart of the orthodox community. Staffing in the home is diverse, which meets the needs of the service users. Staff treat service users with respect and ensure that their welfare is paramount to the service. Appropriate complaints system was in place. Those who use the service are protected from abuse. What has improved since the last inspection? There has been a change of the registered manager in the home. Mr Anthony Marcus has left the organisation and the current registered manager (Mr Nathaniel Gass) has been transferred from another project run by Yad Voezer.Since the last inspection visit the registered manager has ensured that individual service users` care plans have been improved/further developed, as previously required. He has ensured that the Commission is informed about any significant events in the home, in line with Regulation 37 of the Care Homes Regulations. One of the bedrooms on the first floor has been repainted and communal carpets on the first floor have been cleaned. Unpleasant odour in one of the bedrooms has also been eliminated. The home`s laundry facilities have been cleaned, as previously required. The recommendation that Criminal Record Bureau checks are undertaken every 3 years has also now been met. What the care home could do better: The home must ensure that storage of confidential records in improved. More stringent checks are required in relation to staff references and the organisation should wherever possible to obtain a reference from the applicant`s most recent employer. Some improvements are also required to the way records relating to service users` medication are managed, in order to avoid any potential mistakes in administering medication. This includes consistent use of each service user`s name and recording any known allergies on each person`s medication administration record sheet. CARE HOME ADULTS 18-65 Queen Elizabeth Walk (64) 64 Queen Elizabeth Walk Hackney London N16 5UX Lead Inspector Robert Sobotka Unannounced Inspection 7th August 2008 09:45 Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Walk (64) Address 64 Queen Elizabeth Walk Hackney London N16 5UX 020 8880 2674 020 8809 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 Nathaniel David Gass Care Home 10 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One registered place may be used for the accommodation and care of a service user over the age of 65 in the category MD. 1st August 2007 Date of last inspection Brief Description of the Service: 64 Queen Elizabeth Walk is a care home for orthodox Jewish males with learning disabilities including some with mental health issues. The home focuses on Jewish education and practice and is situated in the heart of Stoke Newington, which has a very large orthodox Jewish community. There is easy access to transport facilities and a number of local parks. The home focuses on ensuring that each service users participates in activities of their choice, and the required support is available. Strong family links are encouraged and maintained. Service users are encouraged to be independent and where possible are enabled to manage their own finances and medication and to make decisions regarding their preferred activities and daily routines. Information on the service at 64 Queen Elizabeth Walk is available in the Statement of Purpose, which is available on request. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place over one day and was unannounced. As part of this visit, the inspector spoke to some of the people who used the service, staff working in the home and the registered manager. He also carried out a tour of the premises and checked various records. In addition, he visited the organisation’s head office to check staff personnel files. Prior to this inspection visit, the registered manager was asked to complete an Annual Quality Assurance Assessment. Comments from this document have been included in this inspection report. The inspector would like to thank both service users and staff who contributed to this inspection. What the service does well: What has improved since the last inspection? There has been a change of the registered manager in the home. Mr Anthony Marcus has left the organisation and the current registered manager (Mr Nathaniel Gass) has been transferred from another project run by Yad Voezer. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 6 Since the last inspection visit the registered manager has ensured that individual service users’ care plans have been improved/further developed, as previously required. He has ensured that the Commission is informed about any significant events in the home, in line with Regulation 37 of the Care Homes Regulations. One of the bedrooms on the first floor has been repainted and communal carpets on the first floor have been cleaned. Unpleasant odour in one of the bedrooms has also been eliminated. The home’s laundry facilities have been cleaned, as previously required. The recommendation that Criminal Record Bureau checks are undertaken every 3 years has also now been met. 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. The summary of this inspection report can be made available in other formats on request. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice whether to live in the home, however the home’s statement of purpose required minor amendments. Prospective service users can be confident that appropriate assessment systems ate in place to ensure that the home can meet each person’s needs and aspirations. EVIDENCE: The home’s statement of purpose provided useful information about the home. It however required minor amendment to reflect that the home has recently started using one of the bedrooms to provide respite services. In addition it needs to include details of the new manager. There was also a service user’s guide in place. There has been one new admission to the home since the last inspection. This person was admitted to the home for a respite just a few days prior to inspection. The registered manager was able to evidence that he had carried out an assessment in consultation with the service user and his family and that he has also obtained relevant information from this person’s doctor, in order to Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 9 ensure that his health needs are going to be met. Following an initial assessment, the registered manager has produced a care plan outlining this person’s assessed needs and has drawn up a relevant risk assessment to minimise any potential risks. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been noted to the home’s care planning systems, however staff did not always record daily events to demonstrate how individual care plans were being followed. Service users are enabled, supported and encouraged to make decisions about their care and about how the home is run and to take controlled risks. Confidentiality was not always being maintained. EVIDENCE: As part of this inspection visit the inspector checked care plans of four service users. These documents were chosen at random. The inspector was satisfied that sufficient improvements have been made to ensure that all care plans reflect the current needs of each person accommodated in the home. The registered manager stated that the home involves service users wherever possible and according to their ability in their individual care planning. This is Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 11 acknowledged on individual care plans and individuals are asked to sign their care plans to evidence that they took part in planning their care. The registered manager stated that the home was in the process of changing its care planning systems and that all records would be computerised and managed electronically via palm devices and staff imputing information via computers. There are also plans to compile Person Centred Plans. As part of the case tracking process the inspector checked daily logs of some of the service users. It was noted that staff did not always complete these following each shift and there were some gaps in recording and as a result there was no evidence that care plans were being followed up. In addition, on some occasions information contained in daily notes did not fully explain the actual event. For example some of the notes were: “X was in a good mood, but hallucinated a bit” or “X was aggressive in the evening, but later calmed down”. This needed improvement. The inspector was satisfied that those living in the home were enabled and encouraged to make decisions about their care and about how the home is run. People who use the service were encouraged to attend regular house meetings, minutes from which were available for inspection. The home operates a keyworking system and each service user had an allocated keyworker who was responsible for coordinating their care. There was evidence that service users were involved in the day-to-day running of the home, participation of daily living and involvement in choice of daily activities. Service users are encouraged and supported to their best ability to take part on daily routines, such as shopping, cleaning their rooms, making snacks and beverages. Service users are free to come and go from the home as they choose, subject to risk assessments and restrictions based on individual risks. The inspector was satisfied that risks were appropriately managed and there were risk assessments in place to evidence this. There was evidence that individual risk assessments were being reviewed on a regular basis. Confidentiality was generally being maintained. Information kept computers was password protected. Staff shared information with the inspector on a need to know basis. The majority of documents were being kept in the manager’s office under lock and key. Some of the care plans and incident records were being kept on a shelf in the conservatory (Sukah) and could potentially be read by any visitor to the home. This was brought to the attention of the registered manager on the day of this inspection. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to provide a wide range of age and culturally appropriate activities. Service users are encouraged to be a part of the local community and to develop and maintained friendships and family links. Those who lived in the home enjoyed food in the home. EVIDENCE: The home provides care for Jewish orthodox males and all service users come from orthodox Jewish families. The home is culturally appropriate to the needs of those accommodated there. Service users attend the local synagogue and are supported by staff with undertaking daily prayers in accordance with the religious tradition. The home has got an appointed team leader, who is responsible for ensuring that the service users’ cultural needs are met. In addition, there is also a team leader responsible for activities. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 13 The home maintained an activity folder/diaries, where activities attended by the service users were recorded. Some of the activities on offer included: visit to a farm, swimming, horse riding, visits to cinema etc. Some service users attended local Jewish day centres. Some service users attended activities with the support of staff, whilst others accessed community independently. This is based on individual risk assessments. Holidays are arranged on a regular basis for those service users who wish to spend a week away from home. Since the last inspection visit two service users have been a holiday in Bournemouth, another person has been to Switzerland. Two residents are also booked to go for a holiday to Sevenoaks and another trip was being organised for some of the service users to go to Paris. Those who spoke with the inspector felt that there was a good range of activities on offer. The inspector was informed that the majority of the service users maintain contact with their relatives. In the AQAA, the registered manager stated that one service user is supported to phone his family daily and visits them on a weekly basis. The home maintained the visitors’ book. Visitors are welcome in the home. Service users are offered three meals a day, as well as drinks and snacks between main meals. The preparation and serving of food respects service users’ cultural and religious requirements. All food offered to service users is kosher. Some of the meals are prepared by staff (dinners each Tuesday) and some are provided by a local catering company. Where required staff use foodmonitoring charts to monitor and evaluate service users’ nutritional intake. There were appropriate food supplies in the home during this unannounced inspection. All food products were appropriately stored and labelled once opened. Milk and meat sections of the kitchen were clearly separated, in accordance with the religious requirements. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s healthcare needs were being appropriately managed. Minor improvements were required to the home’s medication systems. EVIDENCE: At the time of this inspection visit service users required different levels of assistance with personal care, from full assistance to verbal prompting. Residents who require personal care are supported by male staff. Service users wear clotes that meet their particular age and cultural background. Each person had a Health Action Plan in place, which provided a clear picture about each service user’s healthcare needs, as well as what appointments have been attended and any issues that needed to be followed up. All service users were registered with the local General Practitioner. There was evidence that the home appropriately utilised services of the local health professionals, such as chiropodists, psychiatrists etc. Staff who spoke with the inspector during this visit felt that the new registered manager has made a lot of positive changes to ensure that any healthcare needs of the people who use the service were being met without any delay. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 15 The home’s medication systems were checked during this inspection and they were found to be generally satisfactory. The home uses Boots blister pack systems. Record of medication received by the home, administered to the service users and disposed of was checked and was found to be correct. All medication was appropriately stored. During the check of medication stocks, the inspector noted that the name of one of the people who use the service on his medication administration record (MAR sheet) did not correspond with the name printed on his 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 his English name. This could lead to some confusion and potential medication administration errors and must be addressed without delay. In addition, an allergy section within each medication administration sheet must be completed, in order to identify any allergies that each person may have. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their complaints will be listened to and dealt with appropriately and that they will be protected from any form of abuse. EVIDENCE: The home’s complaints records were checked during this visit. There have been three complaints since the last inspection, all of which were appropriately dealt with and resolved. The home had a complaints procedure/policy in place. Those who live in the home are encouraged to discuss any issues during service users’ meetings and to record any concerns in the complaints book. The home had an adult protection procedure in place. Staff spoken to during this inspection demonstrated their awareness of the adult protection issues. All staff working in the home, including agency staff have received adult protection training. There has been one adult protection case since the last inspection, which remains unresolved. It was noted however that the home had followed an adult protection procedure and acted appropriately to protect those using the service. Service users’ finances were not checked during this inspection, however they were found to be correct at the last visit. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 17 Accidents and incidents records were appropriately maintained. At the last inspection it was noted that not all significant events were being reported to the Commission. Since the last inspection, the registered manager has ensured that all significant events listed in Regulation 37 of the Care Homes Regulations are now being to the Commission without delay. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from a generally well-maintained environment. EVIDENCE: The home is situated in a residential area of Stoke Newington and is in keeping with the local community. It offers an easy access to local amenities. The premises are suitable for its stated purpose. There is no lift in the home, which means that only the ground floor part of the building is wheelchair accessible. The service users’ bedrooms are of adequate size and personalised by each service user. One of the bedrooms on the first floor has been repainted and communal carpets on the first floor have been cleaned. Unpleasant odour in one of the bedrooms has also been eliminated. The home’s laundry facilities have been cleaned, as previously required. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 19 The premises were sufficiently lit and heated. The main lounge/dining room is bright and the dining area is also used for religious studies. There is a conservatory adjoining the lounge, which opens out onto the garden. The garden was well maintained. The home has ramps leading to the entrance of the home and at the rear of the building leading to the garden. Service users had specialist equipment needed to maximise their independence. The home employs a domestic member of staff. Appropriate laundry facilities were in place. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate staffing levels were in place to meet the needs of the people accommodated in the home and those who lived in the home were supported by well-trained care staff. Improvements are required to the way staff references are verified, in order to demonstrate that sound recruitment and selection practices are in place. EVIDENCE: Duty rosters were viewed during this inspection visit. There are usually five staff working in the morning and four or three staff working in the afternoon. There is a sleep-over cover, as well as a waking night. Duty rosters indicated to staff when Shabbos begins and ends. The inspector was satisfied that there were sufficient numbers of staff on duty throughout the day to meet the needs of those accommodated in the home. Staff who spoke to the inspector felt that the workload was manageable and confirmed that in their opinion satisfactory staffing levels were in place. The home employs a religious/cultural advisor as well as a number of Jewish staff who can support residents with religious practice and attending synagogue. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 21 Staff who spoke with the inspector during this inspection felt the organisation offered good level of training. The registered manager stated that staff receive LDAF (Learning Disability Awards Framework) induction training and following this they are put forward for NVQ in Care. At the time of this inspection 11 out of 16 members of staff have obtained NVQ Level 2 or above and 3 staff were in the process of obtaining the qualification. Some of the training recently attended by staff working in the home includes: Fire Safety, Protection of Vulnerable Adults, LDAF Induction training, Understanding Autism, Supervision training, and Health and Safety. On the day of this inspection, one of the team leaders received news that he was successful in applying to the Deputy Manager’s post. Staff personnel files were checked during this inspection visit. Two files were viewed. They contained all relevant documentation, it was noted however that one of the staff’s reference was not from his most recent employer. The registered persons must ensure that wherever possible a reference is obtained from the most recent employer and that each reference is verified for authenticity, in order to demonstrate that sound recruitment practices are in place. Satisfactory evidence was in place to demonstrate that Criminal Record Bureau checks were being carried out in relation to staff working in the home. The recommendation that the Criminal Records Bureau checks be undertaken every 3 years has now been met. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current registered manager transferred from another residential care home run by Yad Voezer. He has been approved by the Commission as fit to manage a care home for people with learning disabilities. He has obtained the relevant qualifications, as required by law. The inspector was satisfied that throughout the inspection the registered manager demonstrated a good knowledge of the National Minimum Standards and Care Homes Regulations 2001. During the course of this visit, the inspector received positive comments about the registered manager, his abilities and managerial style. Staff also commented that he has made a lot of improvements in the home. Appropriate quality assurance systems were now in place. Regular visits from the registered provider were taking place, reports from which are forwarded to the Commission on a monthly basis. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 23 The registered manager stated that internal service users reviews give people who use the service an opportunity to raise any issues and keyworkers meet regularly with all residents. Appropriate health and safety checks were in place. Gas safety, fire fighting equipment, portable appliances and electrical wiring testing were found to be up-to-date. The home was appropriately insured for its purpose. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 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 3 X 3 X X 3 X Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA10 Regulation 17(1)(b) Requirement Timescale for action 15/09/08 2. YA34 19(1)(C) 3. YA20 13(2) The registered person must ensure that all confidential records are stored securely, in order to maintain confidentiality. The registered person must 01/10/08 ensure that wherever possible a reference is obtained from the most recent employer and that each reference is verified for authenticity, in order to demonstrate that sound recruitment practices are in place. The registered person must 15/09/08 ensure that appropriate arrangements are in place for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This includes ensuring 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. The “allergy” section must also be completed on each medication administration record, in order to DS0000010282.V367293.R01.S.doc Version 5.2 Queen Elizabeth Walk (64) Page 26 identify whether a service user has any allergies. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Daily records in relation of each user should be clear and concise and they should include information, which is detailed enough to evidence whether care offered is consistent with each person’s plan of care. Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Elizabeth Walk (64) DS0000010282.V367293.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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