CARE HOME ADULTS 18-65
Rachel House Rachel House 103 Sixth Avenue Manor Park London E12 5PS Lead Inspector
Sharon Lewis Unannounced Inspection 21st October 2005 1:45 Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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) 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.V259396.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th May 2005 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 is a terraced property in a residential area of Manor Park, with easy access to Ilford shopping area. A range of services and amenities are located in the Romford Road, which is within walking distance. The home is well served by several bus routes ,including 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. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken on a Friday afternoon and lasted approximately three and a half hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. In addition to checking the home’s compliance with the legal requirements made at the last Inspection. The Inspector spoke individually to the three service users currently living at the home. An individual discussion was also held with the Support Worker on duty. Service users files, medication and medication administration records, all health and safety records, policies and other relevant documentation were also examined. A tour of the premises was also undertaken. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well:
Service users were consistent in their praise for the home and had no complaints about staff. Rachel House has developed the necessary policies and procedures to meet the needs of prospective service users. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 6 Service users are supported to take risks as part of an independent lifestyle. A risk assessment and management policy is in place and all service users had current risk assessments. Service users have opportunities to fulfil their spiritual needs and are part of the local community. Service users engaged in a range of activities in the community, which included attending social clubs, visiting family in the locality, regular walks, attending church and going out shopping. Service users are supported to keep pets. One service user has their own pet cat. A cat flap has been provided in their room along with a cat food and pet litter area. There have been no complaints or accidents during the last 12 months. The home has a Registered Manager and sufficient staffing. It was observed that staffing is additionally increased to meet service users needs. Staff discussions and observations demonstrated that staff had caring attitudes and wished to improve practice. The management of the home was seen to be open and promoted a homely atmosphere. What has improved since the last inspection?
The home has continued to advocate for external assistance to address the independent living skills and personal development of a service user. It was encouraging to see that after two years of campaigning this service user has had a specialist assessment. The home has installed Sky Television, which promotes greater service user choice. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 7 As required from the last Inspection service users confirmed that greater amounts of fruit and vegetables are now provided. A visiting optician had visited the home. users to access healthcare support. This has made it easier for service What they could do better:
This Inspection identified thirteen legal requirements and five recommendations. It was disappointing that five requirements made at the last Inspection have not been effectively addressed. Four of these requirements are therefore repeated. The home is intending to transfer to supportive living. It was noted however that greater improvements in promoting independence was needed. Staff practices have not changed. Staff are still doing things ‘for’ service users, instead of supporting service users to do things for themselves. Independent living skills must be actively promoted. Service users must be actively assisted to address their individual needs. In the last Inspection it was requested that an application to cancel registration is sent to the Commission for Social Care Inspection. An application has not been received. On the basis of this Inspection the home is not in a position to provide supportive living accommodation. This is due to the continued culture of providing ‘care’ and not actively promoting service user independence. Medication administration records must be accurately maintained. All medication must be accounted for. Medication no longer in use must be disposed of. Additional dressings must be purchased to restock the first aid box. This requirement is repeated from the last Inspection. Service users must be protected by the home’s medication and first aid procedures. All service users must benefit from regular dental appointments. This requirement is repeated from the last Inspection. The home must ensure all service users health needs are met. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 8 Criminal record bureau checks (CRB) are not portable. A new CRB check must be applied for on appointment. Staff members must not work unsupervised without a new criminal record bureau (CRB) check or Pova (Protection of Vulnerable Adults) First check. Service users must be protected by the home’s recruitment practices. Fire records must consistently include the evacuation time and any comments. A fire risk assessment must also be developed. This requirement is repeated from the last Inspection. Fire records must also detail the names of service users. Service users must be protected by the home’s fire safety procedures. The home must ensure refrigerated foods are labelled on the date opened. Fridge and freezer temperatures must be recorded daily. This requirement is repeated from the last Inspection. Service users must be protected by the home’s food hygiene practices. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. A financial plan had been received however this was out of date. Service users must be protected and assured by the home’s financial viability. The home must obtain a copy of Newham’s Adult Protection policy and procedure. The home’s adult protection procedure must then be updated. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. Only current policies and procedures must be available, all others must be archived or disposed of. Service users must be protected by the home’s policies and procedures. Service users care plans must be more comprehensive. Care plans must fully identify service users individual needs. Service users should also sign their care plans to ensure accountability. Service users needs must be promoted by the home’s care planning arrangements. The lounge speaker and a small table in the lounge, were in a state of disrepair. These items must be repaired or replaced. The missing and broken tiles in the bathroom must be replaced. Service users must live in a wellmaintained accommodation. Service users must be encouraged, motivated and supported to pursue further interests and hobbies. A programme of activities must be arranged. Service users must be engaged in appropriate leisure activities. Service users must be encouraged and supported to maintain their personal appearance. Service users must receive the required personal support. It is recommended that an air humidifier be purchased to address any air pollution caused by smoking. Service users and staff should benefit from a well-ventilated atmosphere.
Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 9 Staff should ensure correction fluid is not used on records. Service users should be protected by the home’s recording practices. Resident’s meetings should be held more regularly. Service users should have a regular opportunity to address their concerns and views. 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. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 10 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.V259396.R01.S.doc Version 5.0 Page 11 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Rachel House has developed the necessary policies and procedures to meet the needs of prospective service users. EVIDENCE: All service users have lived at the home for many years. Service users’ files evidenced that service users were admitted to the home only after a full assessment had been undertaken. The assessment process involves the service user, their relatives and appropriate health and social care professionals. The home has eligibility criteria and service users are only admitted into the home, if their needs can be met. The home accepts emergency placements. Prospective service users have the opportunity to visit the home and stay on a trial basis. Service users’ files and discussions with service users evidenced that the home was endeavouring to meet the assessed needs of the individual service users. The home has continued to advocate for external assistance to address the independent living skills and personal development of a service user. It was encouraging to see that after two years of campaigning, this service user has had a specialist assessment. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-9 Rachel House must ensure service users are actively assisted to meet their goals. Service users must benefit from more comprehensive care planning. EVIDENCE: The integrated Care Programme Approach (CPA) for people with mental health needs forms the basis of the single care plan. Service users care plans must be more comprehensive. Care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. Service users must be assured that their needs and changing goals are consistently monitored. Service users should also sign their care plans to ensure accountability. Service users needs must be promoted by the home’s care planning arrangements. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 13 Each care plan is subject to regular review during the CPA (Care Programme Approach) meetings with the consultant psychiatrist and other professionals. Service users files evidenced monthly care plan evaluations. Service users’ individual choices were noted in their daily record. The home demonstrated that residents meetings were held. Service users were updated on developments within the home, staffing, activities, fire safety and were encouraged to clean their rooms. The last residents meeting was held in August. Resident’s meetings should be held more regularly. Service users should have a regularly consistent opportunity to address their concerns and views. Service users are supported to take risks as part of an independent lifestyle. A risk assessment and management policy is in place and all service users had current risk assessments. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 17 Rachel House encourages service users to maintain their individual lifestyles. Further improvements are needed in promoting independence and leisure activities. EVIDENCE: The home is intending to transfer to supportive living. It was noted however that greater improvements in promoting independence was needed. Staff practices have not changed. Staff are still doing things ‘for’ service users, instead of supporting service users to do things for themselves. Independent living skills must be actively promoted. Service users must be actively assisted to address their individual needs. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 15 Service users have opportunities to fulfil their spiritual needs and are part of the local community. There was evidence that service users engaged in a range of activities in the community, which included attending social clubs, visiting family in the locality, regular walks, attending church and going out shopping. Service users use Dial-A-Ride, the taxi card scheme and their free bus pass as means of transport. The home demonstrated that service users are encouraged to attend relevant day centre facilities and social groups. The home must ensure service users are encouraged, motivated and supported to pursue further interests and hobbies. A programme of activities must be arranged. Service users must be engaged in appropriate leisure activities. Service users maintain family and personal relationships. This included visits to their respective families and visits by family and friends to the home. In addition to regular telephone contact. Service users are able to have three meals per day and the menu appeared varied, balanced, nutritional and culturally reflective. As required from the last Inspection service users confirmed that greater amounts of fruit and vegetables are provided. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 21 Service users personal and health needs must be better promoted. Greater care must be taken when maintaining medication, personal appearance and dental care. EVIDENCE: Service users choose their own clothes and their appearance reflects their age and personality. On the day of the Inspection all service users looked dishevelled. One service user required shaving, another service user’s hair required combing and another was wearing clothing with stains on. Service users must be encouraged and supported to maintain their personal appearance. Service users must receive the required personal support. Times for getting up/going to bed, baths, meals and other activities are flexible and dependent on service users needs and preferences. Service users were observed exercising their individual choices throughout the Inspection. This included having their snacks at different times, staying in their rooms or watching television in the lounge. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 17 Service users are supported to access NHS healthcare facilities in the locality. During the Inspection a service user was escorted to the diabetic clinic. Service users files evidenced regular chiropody appointments, hospital appointments, community psychiatric nurse, district nurse and consultant psychiatrist involvement. A visiting optician had additionally visited the home. The need for regular dental appointments remains outstanding. This requirement is repeated from the last Inspection. All service users must benefit from regular dental appointments. The home must ensure all service users health needs are met. Medication is securely stored in a locked medication cabinet in staff office. Whilst examining medication it was found that eleven tablets were missing and could not be accounted for. Five gaps in medication administration records were noted. Medication was also stored which was no longer used. Medication administration records must be accurately maintained. All medication must be accounted for. Medication no longer in use must be disposed of. The first aid box was examined, and was not adequately stocked. Additional dressings must be purchased to restock the first aid box. This requirement is repeated from the last Inspection. Service users must be protected by the home’s medication and first aid procedures. A policy has been developed which addresses the ageing, illness and death of a service user. The home should further expand on the details in this policy. This recommendation is repeated from the last Inspection. Service users must be confident that in the event of ageing or death, matters will be managed in a respectful and sensitive manner. Service users respective wishes are noted in the event of death. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 - 23 Adult protection must be better promoted to minimise risk and safeguard service users from abuse or harm. EVIDENCE: The home has a complaints policy and procedure, there have been no complaints during the last 12 months. Adult Protection, Whistle Blowing and Restraint policies and procedures have been produced. The Commission for Social Care Inspection have not received any allegations in relation to adult abuse. Discussion with staff however evidenced that they were not fully aware of the Adult Protection procedure. The Registered Manager must ensure all staff are aware of the Adult Protection procedure, in order to better protect service users from abuse, neglect or selfharm. The home must obtain a copy of Newham’s Adult Protection policy and procedure. The home’s adult protection procedure must then be updated. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Rachel House provides service users with a homely environment. General maintenance must be further addressed. EVIDENCE: Rachel House is a terraced property, in a residential road in the Manor Park area of Newham. The property blends easily into the neighbourhood and presents as a large family home. The home is well decorated, comfortable, clean and free from offensive odours. The home has sufficient and suitable lighting and heating. The location is within easy access to Ilford shopping area. A range of services and amenities are located in the Romford Road, which is within walking distance. The home is well served by several bus routes including the 25 and 86. Ilford, Manor Park and Woodgrange Park British Rail stations are approximately a mile away. Unrestricted car parking is available. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 20 Service users’ rooms were personalised to reflect their individuality. One service user has their own pet cat. A cat flap has been provided in their room along with a cat food and pet litter area. This area was found to be clean and no health and safety issues were noted. Shared spaces complement and supplement service users’ individual rooms. A lounge, kitchen with dining area and garden are available for service users. The communal lounge is homely, comfortable and well decorated. Facilities include a television, dvd player, video and computer. During the last Inspection a service user requested the provision of Sky television. The home has since installed Sky Television, which promotes greater service user choice. Service users have a bathroom downstairs and an additional toilet with a hand basin upstairs. The missing and broken tiles in the bathroom must be replaced. Separate laundry facilities are not provided. The washing machine is located in the kitchen. The laundry facilities are not suitable for service users with continence needs. It is recommended that an air humidifier be purchased to address any air pollution caused by smoking. Service users and staff should benefit from a well-ventilated atmosphere. The lounge speaker and a small table in the lounge were in a state of disrepair. These items must be repaired or replaced. Service users must live in a wellmaintained accommodation. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 34 Generally staffing arrangements meet the needs of service users, however recruitment practices must be more stringent. EVIDENCE: The home has a Registered Manager and sufficient, competent support staff. Staffing rotas evidenced that one member of staff is on duty at all times. It was observed that staffing is additionally increased dependent on service users needs. During the Inspection it was noted additional staffing was provided to accompany a service user to a health appointment. Staff demonstrated an awareness of their roles, responsibilities and service users’ individual needs. Staff discussions and observations demonstrated that staff had caring attitudes and wished to improve practice. Service users were consistent in their praise for the home and had no complaints about staff. The recruitment policy must ensure the careful selection and vetting of care staff. The personnel file for a newly appointed staff member was examined and it demonstrated that a previous Criminal record bureau check (CRB) was accepted. CRB checks are not portable. A new CRB check must be applied for on appointment. Staff members must not work unsupervised without a new CRB check or Pova (Protection of vulnerable Adults) First check. Service users must be protected by the home’s recruitment practices.
Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42 & 43 Rachel House is adequately managed however service users welfare, health and safety must be better promoted. EVIDENCE: The Registered Manager is also the proprietor of the home. The Registered Provider/Manager is a qualified Registered Mental Health Nurse and is currently undertaking the NVQ Level 4 in Management and Care. Monthly staff meetings are held which updated staff on developments within the home, care planning, key working and other care practices. The management of the home was seen to be open and promoted a homely atmosphere. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 23 The home has produced policies and procedures in accordance with Appendix 3, National Minimum Standards for Younger Adults. Only current policies and procedures must be available, all others must be archived or disposed of. Service users must be protected by the home’s policies and procedures. Records evidenced recording practices were satisfactory. Staff should ensure correction fluid is not used on records. Service users should be protected by the home’s recording practices. The home has current health and safety certificates and incidents were recorded. There have been no accidents since the last Inspection. Fire records must consistently include the evacuation time and any comments. A fire risk assessment must also be developed. This requirement is repeated from the last Inspection. Fire records must also detail the names of service users. Service users must be protected by the home’s fire safety procedures. The home must ensure refrigerated foods are labelled on the date opened. Fridge and freezer temperatures must be recorded daily. This requirement is repeated from the last Inspection. Service users must be protected by the home’s food hygiene practices. The Inspector was not able to view the current business and financial plan. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. A financial plan had been received however this was out of date. Service users must be protected and assured by the home’s financial viability. As previously mentioned the home wish to cancel registration and provide supportive living accommodation. In the last Inspection it was requested that an application to cancel registration is sent to the Commission for Social Care Inspection. An application has not been received. On the basis of this Inspection, the home is not in a position to provide supportive living accommodation. This is due to the continued culture of providing ‘care’ and not actively promoting service user independence. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X 3 3 3 X 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 3 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Rachel House Score 2 2 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 2 2 DS0000022872.V259396.R01.S.doc Version 5.0 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) Care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. 2 YA11 12 (1) (a) Independent living skills must be actively promoted. 3 YA14 16 (2) (n) Service users must be encouraged, motivated and supported to pursue further interests and hobbies. A programme of activities must be arranged. 4 YA18 12 (1) (a) Service users must be encouraged and supported to maintain their personal appearance. 5 YA19 12 (1) All service users must benefit
Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 26 Requirement Timescale for action 01/01/06 01/12/05 01/01/06 01/12/05 01/12/05 from regular dental appointments. Repeat requirement timescale of 01.04.05 and 01.09.05 not met. 6 YA20 13 (2) Medication administration records must be accurately maintained. All medication must be accounted for. Medication no longer in use must be disposed of. 7 YA20 12 (1) (a) Additional dressings must be purchased to restock the first aid box. Repeat requirement timescale of 01.06.05 not met. 8 YA23 13 (6) The Registered Manager must ensure all staff are aware of the Adult Protection procedure. The home must obtain a copy of Newham’s Adult Protection policy and procedure. The home’s adult protection procedure must then be updated. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. 7 YA24 23 (2) (b) The missing and broken tiles in the bathroom must be replaced. 8 YA24 23 (2) (c) The lounge speaker and the small lounge table must be repaired or replaced.
Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 27 01/12/05 01/12/05 01/01/06 01/02/06 01/02/06 9 YA34 19 (4) (b) A new CRB check must be applied for on appointment. Staff members must not work unsupervised without a new CRB check or Pova (Protection of vulnerable Adults) First check. 01/12/05 10 YA40 12 (1) & 13 (4) (c) 01/02/06 Only current policies and procedures must be available. Old policies and procedures must be archived or disposed of. 11 YA42 23 (4) Fire records must consistently include the evacuation time and any comments. A fire risk assessment must also be developed. Repeat requirement timescale of 01.09.05 not met. Fire records must also detail the names of service users. 01/12/05 12 YA42 13 (4) Refrigerated foods must be labelled on the date opened. Fridge and freezer temperatures must be recorded daily. Repeat requirement timescale of 01.06.05 not met. 01/12/05 13 YA43 25 A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. 01/02/06 Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 28 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 2 3 Refer to Standard YA6 YA8 Resident’s meetings should be held more regularly. YA21 The ageing, illness and death of a service user policy should be further developed. Repeat recommendation. 4 YA24 It is recommended that an air humidifier be purchased to address any air pollution caused by smoking. 5 YA41 Staff should ensure correction fluid is not used on records. Good Practice Recommendations Service users should sign their care plans. Rachel House DS0000022872.V259396.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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