Inspection on 11/01/08 for Rachel House

This inspection was carried out on 11th January 2008.

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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rachel House 06/08/08

Rachel House 31/07/07

Rachel House 06/04/06

Rachel House 21/10/05

Rachel House 06/05/05

Rachel House 02/12/04

Rachel House 09/06/04

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

CARE HOME ADULTS 18-65 Rachel House Rachel House 103 Sixth Avenue Manor Park London E12 5PS Lead Inspector Lea Alexander Unannounced Inspection 11th January 2008 1:00 Rachel House DS0000022872.V357701.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 Rachel House DS0000022872.V357701.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. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rachel House Address Rachel House 103 Sixth Avenue Manor Park London E12 5PS 020 8514 2556 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) rachellhouse@hotmail.com Ms Estelle Moyo Ms Estelle Moyo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2007 Brief Description of the Service: Rachel House is a three-bedded care home for people with mental health support needs. A private individual Estelle Moyo owns the home and is also the Registered Manager. Newham Registration and Inspection Unit initially registered Rachel House in August 2000. The home offers 24-hour care and accepts emergency placements. The premises are a terraced property in a residential area of Manor Park, with easy access to Ilford shopping area. A range of culturally diverse services and amenities are located in the Romford Road, which is within walking distance. The home is well served by several bus routes, which includes the 25 and 86. Ilford, Manor Park and Woodgrange Park British Rail stations are approximately a mile away. Unrestricted car parking is available. All service users have their own room. Each service user is provided with his or her own room key. Service users are able to personalise their rooms to reflect their individuality. There are no placement vacancies. Currently two African Caribbean females and one White British male reside at the home Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was carried out by one Inspector who visited the home on two occasions during the course of the inspection. The focus of the inspection was upon key standards and the progress made with requirements from an earlier inspection in July 2007. During the course of the inspection the Inspector met with the Manager and the care worker on duty and also met privately with one person who uses the service. A range of documents relating to the running of the home were seen. What the service does well: What has improved since the last inspection? People who use the service have a risk assessment that relates to their individual plan, and are supported to participate in the local community. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 One Page 6 resident has been supported to access advocacy services, and the home has also contacted Social Services regarding rehabilitative work for this resident. Repairs and maintenance works identified at the previous inspection completed. A thermometer has been installed in the medicine cupboard. The complaints and whistle blowing policies have been updated to include the current contact details for CSCI, and a fire risk assessment has been developed. All staffs have CRB’s prior to starting work, and 50 of staffs are NVQ level qualified. The homes quality assurance exercise been expanded to include the views of families, professionals and other interested parties. What they could do better: Thirteen requirements are made as a result of this inspection, six of which are restated. The home must evidence that people competent to do so properly assess potential service users, and care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. The home must ensure that there is equality of opportunity for all people who use the service to engage in fulfilling activities, education and training or work. The arrangements for contact with family and any support required with facilitating this must be detailed in the individual plan. The home must evidence that a variety of meals that meet the dietary and cultural needs of people who use the service are provided. The homes complaints procedure must include the timescales within which it aims to investigate and respond to complainants. The homes adult protection policy and procedure requires minor revision to ensure it complies with local safeguarding protocols. Maintenance and repairs must be carried out in the upstairs WC. The home must ensure that it complies with all appropriate employment legislation. All care workers must receive a minimum of five days training each year. The outcome of the quality assurance exercise should be collated, published and made available for interested parties including the Commission for Social Care Inspection. All started processed foods must be date labelled. The home must maintain records that indicate which smoke alarms have been tested. Records of fire evacuation drills must include timings. The home must Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 7 liaise with the London Fire and Emergency Planning Authority (LFEPA) to arrange for them to inspect the home. 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. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 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 Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home cannot clearly evidence that prospective residents are assessed prior to their moving in. EVIDENCE: The Inspector looked at the current and archived personal information for two people who use the service. The Inspector was unable to find evidence of an assessment completed by the home prior to the residents moving in. The Manager advised the Inspector that these assessments would have taken place as a matter of course, and suggested that the papers had been misplaced due as it had been several years since they were admitted. Rachel House DS0000022872.V357701.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, 8 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individual plans are basic and not person centred. They are reviewed regularly and risk assessments have also been developed. EVIDENCE: The Manager told the Inspector that since the last inspection they had been developing a template for individual residents plans that was more person centred, and a draft format was shown to the Inspector. The Manager advised that the new format would now be completed with each resident. The Inspector viewed the individual plans developed with two residents. These evidenced that a range of support needs such as physical and mental health, community activities, financial support and safety in the home had been addressed. However, for one person who uses the service there was no information on their strengths or needs with regard to personal care. This Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 11 person was also identified as being an insulin dependant diabetic. Whilst this was mentioned in their plan, there was no detailed information on the role of the Diabetic Nurse who was recorded as visiting. For a second person that uses the service in the section of their individual plan addressing social contact “needs to have more” was recorded in this section, with no information about current or potential contacts or activities. Sampling of the individual plans for both residents evidenced that people who use the service sign their plans to evidence their participation in their development. Copies of plans available evidenced that these are reviewed at least every six months. Sampling of the homes daily logs for two people who use the service evidenced that staff engage with residents and encourage them to engage in activities. However, there is no key working system and it was not evidenced that staff work with people who use the service in a systematic way to proactively address identified needs. For example one person who uses the service has been identified as having very limited community activities in their individual plan. The daily log records activities they have completed, but there is no evidence of ongoing dialogue with the service user about new activities they might be interested in pursuing, or discussion around barriers to engagement with activities they might be interested in. The Manager told the Inspector that these discussions do take place, and that in future they would ensure that they are recorded. The Inspector also spoke with the person who uses the service, they said that they would like to go out more, however during further discussion they were unable to say why they had not participated in some activities they had previously expressed an interest in. Sampling of the personal file for one service user evidenced that they had been supported to access specialist services to advice regarding their finances, and to make representations to the DSS. All of the service users within the home receive assistance in withdrawing their benefits from the local post office. One person who uses the service then manages their finances independently. The other two service users receive support in budgeting their weekly allowance and have agreed that the home will retain some monies on their behalf that are then issued on a daily basis. Details of this support with finances was reflected in the individual plans seen by the Inspector. The home maintains a record of all financial transactions relating to money held on behalf of residents, and the Inspector viewed these records for one person who uses the service. This evidenced that for each deposit or withdrawal an entry giving the date, amount and nature of transaction is completed and that this is signed by the staff member and resident. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 12 The Manager advised the Inspector that monthly meetings were held with people who use the service to involve them in the day-to-day decision making processes in the home. Minutes of these meetings are made, and the Inspector saw these. They evidenced that at meetings held since July 2007 there have been discussions about the sleeping arrangements for staff, activities for people who use the service and staffing levels. Each of the resident’s case tracked by the Inspector was found to have a risk assessment that related to their individual plan. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must ensure that all residents are given the opportunity to take part in a variety of activities within the home and the community. A varied menu must be offered. People who use the service are supported to maintain contact with their families. EVIDENCE: Sampling of the personal file for one service user evidenced that since the last inspection the home had written to the Community Team seeking clarification as to whether they would be providing rehabilitative services to the resident. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 14 The Manager told the Inspector that two people who use the service are able to access the community independently, but that a third is escorted on all trips outside of the home because of a visual impairment. The Manager told the Inspector that since the last inspection the home have started enquiries with regards to talking books for this person. The Manager said that they had also encouraged this resident to attend a local “ music in the park” event they had expressed an interest in, but the resident declined. The person is supported to attend church in accordance with their wishes, and they are also supported to go for walks in the local community. The Manager told the Inspector that other potential activities that had been identified with the resident, such as a drop in service, had not been progressed because of the residents anxiety around spending even small amounts of money, however the Inspector noted that this was not reflected in the individual plan or recorded in the daily logs. The Inspector viewed the homes daily logs for this person from October 2007 to date. This evidenced that during a three-month period the home had recorded the resident attending church on five occasions, and going for a walk locally or shopping on a total of four occasions. Most frequently there were entries stating that this resident was listening to the TV or talking with staff. During discussions with this resident, they told the Inspector that they would “like to get out more”. The Inspector also examined the daily logs for another resident who uses the service, who is able to access the community independently. This evidenced that since October 2007 they had visited their partner on eight occasions, been shopping on ten occasions and been for a walk in the locality on nineteen occasions. There were also entries evidencing that family members had visited this resident within the home, that they had visited church on one occasion and also engaged in conversations with staff or other residents within the home. The Manager told the Inspector that everyone who uses the service is in contact with family members. The Inspector was advised that one resident regularly visits their parents and siblings, and another regularly visits their husband and adult children. A third resident is supported to maintain contact with their siblings and has phone contact with their mother who lives in a residential home in the North of England. This service user told the Inspector how staff had supported them to telephone their mother on Christmas day. The Inspector also viewed the daily logs for these residents, which detailed contacts with family members. The Inspector sampled the individual plans for two service users and noted that they did not contain information about who residents were in contact with, the frequency of this contact and any staff support needed to facilitate contact. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 15 During the course of the inspection staff were observed talking to and interacting with people who use the service. Residents were observed choosing when to be alone or in company. The Manager told the Inspector that each resident is asked what meals they would like to appear on the menu, and then a weekly plan accommodating these is developed. One person who uses the service told the Inspector that they did not always get to choose their meals. The Inspector also looked at the log the home maintains for each meal provided, and found that the menus were repetitive. For example, for the period 21st December to 29th December 2007 chips were served on five occasions, with roast chicken, pasta or sausages also been served on numerous occasions. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 16 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. The home provides flexible personal support and people who use the service are supported to access healthcare services. The home has sound medication practises. EVIDENCE: The Manager told the Inspector that all residents are independent in their personal care, and staff only prompt and encourage them. The Inspector met with one person who uses the service. They were well groomed and told the Inspector that they chose their own clothes and that their appearance reflected their personality. The Inspector viewed the available medical records for two people who use the service. These evidenced that both are registered with local GP’s and have been supported to access a range of healthcare services including the dentist, podiatrist and psychologist. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 17 Since the last inspection the home have installed a thermometer in the medicine cupboard as required. The Manager told the Inspector that none of the service users are selfmedicating, and no one is currently prescribed any controlled drugs. The Inspector viewed the Medication Administration Records (MAR) for two people who use the service and compared these with the actual medication available. In both cases the available medication and the MAR sheet were found to correspond. The MAR sheets were found to be in good order with all medication signed to evidence administration at the correct dose at the correct time. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, but it is not evidenced that complaints are always logged. The homes safeguarding policy requires revision and staff have not received adult protection training. EVIDENCE: The Inspector viewed the homes complaints policy, and found that this had been updated since the last inspection to include contact details for the Commission for Social Care Inspection. However, it did not include the timescales within which the home aims to investigate and respond to complainants. The Inspector asked to view the homes complaints log and was shown an empty book with no recording format or entries. The service user who the Inspector spoke with advised that they had “no complaints” and felt comfortable talking with the Manager if there was anything they were unhappy about. The Manager told the Inspector that they had suspicions that one resident may be under pressure to give financial support to an extended family member. The matter had been reported to their care manager for initial investigation, sampling of the residents personal file also evidenced that a risk assessment addressing this concern had also been developed. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 19 The home has developed an adult protection policy and procedure, and the Inspector viewed this. It requires minor revision to ensure that the responsibilities identified for the Manager comply with local safeguarding adults protocols. The Inspector noted that staffs were not evidenced as having received adult protection training. The Inspector viewed the homes whistle blowing policy and procedure and noted that this had been revised as required since the last inspection to include contact details for the Commission for Social Care Inspection. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 20 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, 28 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable and the environment meets the needs of people who use the service. Some maintenance to the WC is required, and the Manager must ensure that appropriate facilities are provided for night staff. EVIDENCE: The home operates in a three bed roomed terraced house located in a quiet residential area. The home has a large entrance hallway and a lounge with comfortable seating, a TV and stereo is situated off this. One resident’s bedroom is located on this level, and to the rear of the property there is a kitchen diner. This has a range of fitted units and a dining table and chairs. A large bathroom is situated in a corridor running from the kitchen. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 21 Access to the first floor is via a staircase, and two residents’ bedrooms and a WC are located on this level. The Inspector observed that former staff sleep in room on this level is being converted into a potential fourth bedroom for an additional resident. The Manager advised that one member of staff is employed for a sleeping night, and they are currently sleeping on the sofa in the residents lounge. The Inspector and Manager had a discussion about the provision of a sofa bed, and measures to ensure the privacy of the staff member during the night. The home has a small rear garden that is accessed from the kitchen. A number of maintenance and repair issues were identified at a previous inspection, and the Inspector noted that these had all been addressed. Some minor repairs were identified in the upstairs WC and these are detailed in the requirements section of this report. The home was found to be clean, hygienic and free from odours. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 22 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 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs are supported to undertake NVQ qualifications, however there is a lack of core and refresher training. The home is recruiting additional staff and agency cover is currently being used. The homes recruitment procedure safeguards people who use the service. EVIDENCE: At the time of this inspection the home employed two care staff in addition to the Manager. Agency staff is used to cover shifts these staff are not able to work. The Manager advised the Inspector that they are in the process of recruiting new staff. The Inspector viewed the homes current staffing rota. At the present time a singleton care worker on duty staffs the home at any time. In addition the Manager is rostered to be on site between 10 am and 4 pm two to three days per week and on call for two to three days per week. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 23 One of the staff is currently studying for their NVQ level 2 and the other has successfully completed their NVQ level 3 studies. The Inspector noted that in the minutes of a staff and service users meeting held in September 2007 care staff highlighted to the Manager the difficulties only having two staff caused, particularly the difficulties in providing support to residents to access the community. The Inspector viewed the homes staffing rota and noted that this accurately reflected the staffing situation found in the home. The Inspector sampled the personnel files for both of the homes care workers. The available records evidenced that the home had carried out the necessary pre-employment checks including obtaining two satisfactory references, proofs of identity and a Criminal Records Bureau (CRB) check. However, one staff member was found to have a stamp in their passport indicating that the Secretary of State must approve their employment, and the Manager was unable to produce documentation to evidence that this had occurred. Copies of the employment terms and conditions were found on each care workers personnel file. The Manager told the Inspector that whilst staff had undertaken no training since the last inspection, they were in talks with a local provider to arrange refresher and update training in first aid, food hygiene and fire training. Sampling of the training records on personnel files evidenced that one staff had received medication training in March 2007, but that no other training had been provided since. Sampling of available supervision records evidenced that both staff members had received a minimum of six supervisions within the last twelve months. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is suitably qualified and has the necessary experience. The home must develop its practise to ensure that all health and safety legislation is complied with and that the outcomes of the quality assurance exercise and collated and published. EVIDENCE: The Manager is a qualified RMN with experience of running a care home. They advised the Inspector that they had completed their NVQ level 4 studies and are awaiting the outcome. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 25 The Manager told the Inspector that since the last inspection they had developed an additional survey for relatives and professionals. The Manager also stated that they would be sending out these surveys along with questionnaires for people who use the service in the next few weeks. The Manager also told the Inspector that they intend to collate and publish the outcomes from this quality assurance exercise when it is completed. The Inspector asked to see the home accident book. This was produced, and no accidents were recorded as having happened. The Inspector viewed the contents of the homes fridge and freezer. Some started processed ham and decanted baked beans had not been date labelled. Sampling of the homes fire records evidenced that a fire evacuation drill was carried out in January 2008, however no timings were recorded for the drill. The Manager advised the Inspector that the home has smoke alarms, and records evidenced that these are t every fortnight, however there is no record of which of the homes smoke detectors have been tested. The Manager showed the Inspector a letter from the London Fire and Emergency Planning Authority dated 2001, in which they stated they would be visiting. However the Manager was not able to evidence that they had visited. The home has developed a fire risk assessment since the last inspection. The home maintains a daily record of water temperatures, and these were found to be within acceptable limits. The Inspector also viewed the homes log of fridge and freezer temperatures and found that these are recorded daily and maintained within acceptable limits. The home displays a current insurance certificate with appropriate cover. The home has not developed a business plan, however copies of the accounts for the year ending 31st March 2007 were made available to the Inspector. Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 26 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 X 2 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 X 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 3 Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14 Requirement The home must evidence that people competent to do so properly assess potential service users. Care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. These are restated requirements. The previous timescales of the 01/01/06 and 30/12/07 were not met. Staffs must support people who use the service to engage in fulfilling activities, education and training or work. Timescale for action 30/05/08 2. YA6 14 & 15 30/05/08 3. YA12 16 30/05/08 4. YA15 23 This is a restated requirement. The previous target of the 30/12/07 was not met. The arrangements for contact 30/05/08 with family and any support required with facilitating this must be detailed in the individual plan. DS0000022872.V357701.R01.S.doc Version 5.2 Page 28 Rachel House 5. YA17 13 & 16 This is a restated requirement. The previous target of the 30/12/07 was not met. The home must evidence that a variety of meals that meet the dietary and cultural needs of people who use the service are provided. This is a restated requirement. The previous target of the 30/12/07 was not met. The homes complaints procedure must include the timescales within which it aims to investigate and respond to complainants. The homes adult protection policy and procedure requires minor revision to ensure it complies with local safeguarding protocols. The following maintenance and repairs must be carried out in the upstairs WC: The uneven floor covering must be made good or replaced. (ii) The damp peeling patches on the walls must be made good. (iii) The walls and WC must be kept clean. (iv) Mouldy grout must be replaced. The home must also ensure appropriate facilities are provided to staffs that are required to sleep in the home. The home must ensure that it complies with all appropriate employment legislation. All care workers must receive a minimum of five days training DS0000022872.V357701.R01.S.doc 30/05/08 6. YA22 22 30/05/08 7. YA23 13 30/05/08 8. YA24 23 30/05/08 (i) 9. YA28 23 30/05/08 10. 11. YA34 YA35 19 18 30/05/08 30/05/08 Rachel House Version 5.2 Page 29 each year. This is a restated requirement. The previous target of the 30/12/07 was not met. The outcome of the quality assurance exercise should be collated, published and made available for interested parties including the Commission for Social Care Inspection. This is a restated requirement. The previous target of the 30/12/07 was not met. All started processed foods must be date labelled. The home must maintain records that indicate which smoke alarms have been tested. Records of fire evacuation drills must include timings. The home must liaise with the London Fire and Emergency Planning Authority (LFEPA) to arrange for them to inspect the home. 12. YA39 24 30/05/08 13. YA42 12 & 37 30/05/08 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 Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Rachel House DS0000022872.V357701.R01.S.doc Version 5.2 Page 31 - 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!