Inspection on 06/04/06 for Rachel House

This inspection was carried out on 6th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rachel House 06/08/08

Rachel House 11/01/08

Rachel House 31/07/07

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Rachel House Rachel House 103 Sixth Avenue Manor Park London E12 5PS Lead Inspector Sharon Lewis Unannounced Inspection 6th April 2006 2:10 Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 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.V288431.R01.S.doc Version 5.1 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 Older People and 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.V288431.R01.S.doc Version 5.1 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.V288431.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 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 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.V288431.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken on a Thursday afternoon and lasted approximately three 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. 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 two Support Workers 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: All service users are long term residents and were generally satisfied with the care received at the home. Comments included “All okay”, “Am fine, everything is alright” and “Am coping alright, staff are all alright and the food is not too bad”. 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, day services, visiting family in the locality, regular walks, attending church and going out shopping. Fresh fruit is available and service users benefit from varied, balanced, nutritional and culturally reflective meals. Service users benefit from a small consistent permanent staff team, with low staff turnover. It was noted that staffing is additionally increased to meet service users needs. Staff discussions evidenced that staff genuinely cared for Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 6 service users and were aware of their individual needs and wished to improve practice. What has improved since the last inspection? What they could do better: During this Inspection two concerns were highlighted which required immediate attention. Records evidenced that weekly fire alarm tests had not been undertaken since the last Inspection. In addition medication administration records evidenced a service user had not been given one item of prescribed medication for three weeks. Service users must be given their prescribed medication. Service users must be protected by the home’s fire safety and medication administration practices. An immediate requirement letter was issued to urgently address these concerns. An additional ten requirements and three recommendations were issued. It was disappointing that seven requirements made at the last Inspection, have not been effectively addressed. These requirements are therefore repeated. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 7 Repeated requirements relate to the development of a fire risk assessment, care planning, personal care, maintenance, provision of financial/business plan, a programme of activities, obtaining a copy of Newham’s Adult Protection policy and procedure and updating the Whistle Blowing procedure. . Service users health, safety and welfare must be promoted through the home’s care practices. The identified service user must be assisted and empowered to develop a more independent lifestyle. The home must actively pursue the necessary rehabilitation work with Social Services. Service users must also benefit from the home’s risk management systems. The home must ensure risk assessments are reviewed and updated In the upstairs toilet, the toilet seat and the toilet cistern must be secured. The light must also be able to be switched on and off. Service users must live in a well-maintained accommodation. 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.V288431.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-3 Rachel House has the necessary documentation, policies and procedures, which assist prospective service users in deciding if the home can meet their needs. EVIDENCE: The home has produced a Statement of Purpose and Service User guide, which provides prospective service users with the information they need, to make an informed choice about where they wish to live. Service user’s files evidenced that their respective religious and cultural needs are catered for, are recognised and met. The home currently meets the needs Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 10 of service users from African Caribbean and White British backgrounds. The home has all necessary policies and eligibility criteria, which relate to the choice of home. The current service users have resided at the home for a significant period of time. There have been no recent admissions. Policies and procedures ensure prospective service users individual aspirations and needs are assessed. Written referrals are only accepted from Social Services or Health Service professionals. Service users’ files evidenced that service users are admitted to the home only after a full assessment has been undertaken. The assessment process is multi-disciplinary and includes health and social care professionals and previous care providers. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 identify and achieve their goals. Risk management and care planning systems must also be improved. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 12 EVIDENCE: The integrated Care Programme Approach (CPA) for people with mental health needs, forms the basis of the single care plan. The care plans developed by the home must be more comprehensive. Care plans must fully identify service users individual needs. Care plans should detail the items addressed in National Minimum Standard 2.3. Service users are allocated key workers who are expected to provide guidance, support and monitor their progress. Records must evidence proactive working with service users to address their individual needs and goals. Service users must be motivated and assisted to continually improve their quality of life, no matter how small. Service users must be assured that their needs and changing goals are consistently monitored. Each care plan is subject to regular review during the CPA (Care Programme Approach) meetings with the consultant psychiatrist and other professionals. The home should also ensure service users care plans are evaluated on a monthly basis. Staff demonstrated that assistance and support was given to service users to make decisions about their own lives. Observation, examination of daily logs and discussion with service users evidenced that they exercised choice in their daily lives. It is recommended that advocacy services be provided for service users with limited family contact. Resident’s meetings are now held more regularly, which enables service users to routinely address their concerns and views. Records evidenced that service users planned their Christmas, were informed of dental screening, staffing and further developments in the home. Service users are supported to take risks as part of an independent lifestyle. A risk assessment and management policy is in place. Two of the three risk assessments examined had not been reviewed. The home must ensure risk assessments are subject to review and are updated. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) 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 - 17 Rachel House encourages service users to maintain their individual lifestyles. Further improvements are needed in promoting independence and leisure activities. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 14 EVIDENCE: Service users have opportunities for personal development within the home. Independent living skills are more actively promoted. Service users stated and staff confirmed they were more involved in daily living tasks. These included washing up, cleaning, cooking light meals and doing their own shopping. The rehabilitation for the service users with sensory needs remain outstanding. This is due to lack of action by the placing authority. The identified service user must be assisted and empowered to develop a more independent lifestyle. The home must actively pursue the necessary rehabilitation work with Social Services. 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 church, having regular walks, going to the hairdresser, post office and shopping. 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. The home should have a range of entertainments available for service users, apart from the television. Service users maintain family and personal relationships. This included visits to their respective families and visits by family to the home. In addition to regular telephone contact. The home demonstrated that service users’ rights are respected and responsibilities recognised in their daily lives. Service users were observed during the Inspection exercising their individual choice and participating in their own daily routines. Documentation and observation evidenced that service users choose when to get up, get dressed, be alone or in company, and when not to join an activity. Menus were examined and were found to be culturally reflective, nutritious, varied and balanced. All service users commented that the food was “alright”. Fruit is readily available and greater attention is now taken to promote good food hygiene. Refrigerated foods are now labelled on the date opened. Fridge and freezer temperatures are monitored and recorded daily. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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 - 20 Rachel House must ensure service users personal care and medication administration needs are better promoted. EVIDENCE: Service users choose their own clothes and their appearance reflects their age and personality. On the day of the Inspection one service user looked very dishevelled. This service user was unshaven, had greasy hair which needed cutting, overgrown eyebrows and nasal hair, and wore clothes that were ill fitting and scruffy. It is disheartening that this situation was also found at the last Inspection. The home must seriously balance their promotion of service user choice and their ‘duty to care’. Service users must be encouraged and supported to maintain their personal appearance. This requirement is repeated from the last Inspection. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 16 Service users are supported to access NHS healthcare facilities in the locality. Service users files evidenced regular chiropody appointments, hospital appointments, community psychiatric nurse, district nurse, diabetic nurse and consultant psychiatrist involvement. In the past a mobile optician had visited the home. Service users now benefit from regular dental appointments. A mobile dentist has also visited the home. This has made it easier for service users to access relevant healthcare support. The first aid box was examined, and was found to be adequately stocked. Medication is securely stored in a locked medication cabinet in staff office. Service users have benefited from recent medication reviews. Whilst examining medication records, it was evidenced a service user had not been given one item of prescribed medication for three weeks. Several other gaps were additionally found in medication administration records. Medication administration records must be accurately maintained. Service users must be given their prescribed medication. Service users must be protected by the home’s medication administration practices. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 Rachel House has appropriate arrangements to address complaints. Service users would benefit from more robust adult protection and whistle blowing procedures. EVIDENCE: The home has a complaints policy and procedure; there have been no complaints during the last 12 months. Service users related that they raised any concerns with staff or management. The home has produced an Adult Protection and Whistle Blowing procedure. The Commission for Social Care Inspection have not received any allegations in relation to adult abuse. The home must obtain a copy of Newham’s Adult Protection policy and procedure. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. These requirements are repeated from the last Inspection. Adult protection must be better promoted to minimise risk and safeguard service users from abuse or harm. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 comfortable and homely environment. Further improvements can be made by addressing the maintenance issues. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 19 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 heating. The location is within 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 including the 25 and 86. Ilford, Manor Park and Woodgrange Park British Rail stations are approximately a mile away. Unrestricted car parking is available. Service users’ rooms reflected their individuality. Service users can bring their own furniture and can decorate and personalise their rooms subject to fire and safety requirements. 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. The lounge has undergone some refurbishment. Items in disrepair have been disposed of. Service users benefit from the provision of a new three-piece suite and television. The purchasing of several pictures also contributes to the homely atmosphere. Facilities include Sky television, a dvd player, video and a computer. 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. This requirement is repeated from the last Inspection. In the upstairs toilet the toilet seat and the toilet cistern must be secured. The light must also be able to be switched on and off. Service users must live in a wellmaintained accommodation. 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. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 The staffing arrangements at Rachel House, adequately meets service users needs. EVIDENCE: Staff discussions and observations demonstrated that staff respect service users and have attitudes and characteristics that are important to them. Staff were found to be committed and caring. Service users benefit from a small consistent permanent staff team, with low staff turnover. It was noted that staffing is additionally increased to meet service users needs. Staff discussions evidenced that staff genuinely cared for service users and wished to improve practice. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 21 The home has a Registered Manager and sufficient support staff. Staffing rotas evidenced that one member of staff is on duty at all times. All staff have social care experience. Staff demonstrated an awareness of their roles, responsibilities and service users’ individual needs. Staffing rotas were examined. Staffing was found to meet the individual and collective needs of service users. The home has a recruitment policy and procedure. There have been no new staff appointments since the last Inspection. Staff confirmed that they had regular one-to-one supervision and welcomed the opportunity for regular training to expose them to new techniques. A staff training programme is in place and an action plan to address NVQ qualifications is in progress. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 39, 41, 42 & 43 Rachel House requires more stringent monitoring to ensure service users welfare, health and safety is better promoted. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 23 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. It was disappointing that seven requirements made at the last Inspection have not been effectively addressed. Management of the home must be more robust. Greater efforts must be made to comply with regulations and meet minimum standards. A quality assessment framework has been developed and evidence was seen of service feedback questionnaires. The home is no longer considering a transfer to providing supportive living accommodation. All service users files were examined and were found to be generally well maintained. Daily reports are completed and recording promoted service users’ individuality. The home has current health and safety certificates and incidents were recorded. There have been no accidents since the last Inspection. Records evidenced that weekly fire alarm tests had not been undertaken since the last Inspection. An immediate requirement letter was issued to urgently address this concern. A fire risk assessment must also be developed. This requirement is repeated from the last Inspection. Service users must be protected by the home’s fire safety procedures. The Inspector was not able to view the current business and financial plan. This requirement remains outstanding from previous Inspections. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. Service users must be protected and assured by the home’s financial viability. The home’s insurance policy was examined and found to provide adequate insurance cover. Lines of accountability within the home are clearly understood by staff and service users. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 3 42 2 43 2 2 3 3 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rachel House Score 2 3 1 X DS0000022872.V288431.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 15 (1) Requirement Care plans must fully identify service users individual needs. Records must evidence proactive working with service users to address their individual needs and goals. Timescale of 01/01/06 not met. The home must ensure risk assessments are regularly reviewed and updated. The home must actively pursue the necessary rehabilitation work with Social Services for the identified service user. A programme of activities must be arranged. Timescale of 01/01/06 not met. Service users must be encouraged and supported to maintain their personal appearance. Timescale of 01/12/05 not met. Medication administration DS0000022872.V288431.R01.S.doc Timescale for action 01/06/06 2. 3. YA9 YA11 13 (4) (c) 12 (1) (a) 01/06/06 01/08/06 4. YA14 16 (2) (n) 01/08/06 5. YA18 12 (1) (a) 01/05/06 6. YA20 13 (2) 01/05/06 Page 26 Rachel House Version 5.1 records must be accurately maintained. Timescale of 01/12/05 not met. Service users must also be given their prescribed medication. The home must obtain a copy of Newham’s Adult Protection policy and procedure. The Whistle Blowing procedure must also be updated to include the Commission for Social Care Inspection details. Timescale of 01/01/06 not met. The missing and broken tiles in the bathroom must be replaced. Timescale of 01/02/06 not met. In the upstairs toilet the light must be repaired to enable it to be switched on and off. In the upstairs toilet, the toilet seat and the toilet cistern must be secured. A fire risk assessment must be developed. Repeat requirement timescale of 01/09/05 and 01/12/05 not met. A record must be kept of the weekly fire alarm tests. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. Timescale of 01/02/06 not met. 7. YA23 13 (6) 01/06/06 8. YA24 23 (2) (b) 01/08/06 9. 10. 11. YA24 YA27 YA42 23 (2) (p) 23 (1) & (2) (j) 23 (4) 01/06/06 01/06/06 01/05/06 12. YA43 25 01/07/06 Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 27 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 YA7 YA24 Good Practice Recommendations Service users care plans should be reviewed on a monthly basis. It is recommended that advocacy services be provided for service users with limited family contact. It is recommended that an air humidifier be purchased to address any air pollution caused by smoking. Repeat recommendation. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Rachel House DS0000022872.V288431.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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