Inspection on 24/03/06 for Rainbow

This inspection was carried out on 24th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rainbow 04/09/07

Rainbow 26/10/06

Rainbow 06/10/05

Rainbow 17/03/05

Rainbow 07/09/04

Rainbow 26/02/04

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Thorndene

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Southfields

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

CARE HOME ADULTS 18-65 Rainbow 5 Victoria Road Canterbury Kent CT1 3SG Lead Inspector Mark Hemmings Announced Inspection 24th March 2006 11:30 Rainbow DS0000023531.V258545.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 Rainbow DS0000023531.V258545.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 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. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rainbow Address 5 Victoria Road Canterbury Kent CT1 3SG 01227 455745 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) L`Arche (Registered Office) Miss Dorota Wozniak Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Rainbow is a care home providing personal care and accommodation for up to five adults who have a learning disability. They are referred to by the Registered Provider, as being “core members” (service users). The premises are a large semi-detected property in which accommodation is arranged over three floors. The top floor is used to provide live-in quarters for members of staff. The Registered Provider refers to them as being “assistants” (support workers). There is provision for each of the core members to have their own bedroom. There is a normal complement of lounge areas and bathrooms/toilets. Most of the assistants live in the Home, this being a part of a deliberate philosophy which aims to foster the development of an inclusive Christian community within the Home. The Registered Provider is L’Arche, Kent. This is a part of L’Arche which is an international charitable body that operates a number of residential care homes both in this country and further afield. Rainbow is situated in a quiet residential street that is quite close to Canterbury’s city centre. The day to day operation of the Home is overseen by the Coordinator and by the Assistant Coordinator. They are based in Rainbow. At the moment, the post of Registered Manager is vacant. Consequently, formal responsibility for the administration of the Home has transferred to the Area Manager for L’Arche, Kent. He is based at another of the Charity’s residential communities. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was announced and it took about five hours to complete. During this time, the Inspector spoke with the Area Manager, with the Coordinator and with the assistant Coordinator. Also, he discussed the operation of the Home with three of the assistants. The Inspector had the opportunity to meet with each of the service users. Additionally, he examined selected areas of the accommodation and he reviewed various records and documents. The Home continues to provide the core members in residence with the support and assistance they need. Core members say or indicate that they remain satisfied with the provision made for them in Rainbow. There are two required developments at the end of this Report. What the service does well: What has improved since the last inspection? What they could do better: The Registered Provider should address omissions found to be present in the individual plans of care for two of the core members. This is important, because the plans of care constitute a point of reference for both core members and for assistants. In the case of the former, the plans define the agreement between the person concerned and the Registered Provider about what support the core member is going to receive and how this is to be accomplished. In relation to the latter, the plans are one of the means by Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 6 which the Registered Provider can ensure that assistants deliver support in a manner which the core members are likely to experience as being reliable and consistent. The Registered Provider should progress the introduction of a suitable quality assurance system in the Home. This is important because it will provide an additional system by means of which core members can contribute their expertise to the running of the Home. The Registered Provider should introduce a system which is designed to ensure that all assistants are aware of how best to avoid the occurrence a fire safety emergency and are aware of how to respond effectively to one should the need arise. This is important given the principle that prevention is the best form of fire safety. Also it is important because if a situation does occur, the level of protection provided by the Home’s fire safety equipment is largely determined by the appropriateness of how it is used by members of staff. 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. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4. There is provision for prospective core members to be given the information they need in order to make an informed decision about living in the Home. There are systems in place to enable core members’ needs and aspirations to be assessed before they move into the Home. Service users are confident that the Home will enable their needs for assistance and support to be met. As appropriate, prospective service users have the opportunity to visit the Home before deciding about moving in. EVIDENCE: There is a Service Users’ Guide. This is a brochure which prospective core members and their representatives are given and which outlines both in pictures and in text the facilities and services provided in Rainbow. The Inspector noted there to be a minor omission in the document which the Area Manager said would be corrected by 1 July 2006. In addition to being able to access information in the Guide, the Area Manager and the Coordinator said that one of them will speak with prospective core members and with members of their families in order to answer any remaining questions they may have. The Area Manager said that the Registered Provider’s local Placement Organiser and the Coordinator will meet with each prospective core member in order to assess their needs for assistance. This will be done to ensure that these needs can be met reliably in the Home, should the admission proceed. The Inspector was not able to review the details of this system in operation. This was because there had been no new admissions to the Home since the Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 9 last inspection visit. He has scored the Standard accordingly, both at the beginning of this section and at the end of this Report. The core members did not comment directly to the Inspector about their experience of having moved into the Home. However, one person indicated by her relaxed manner that the process had been handled in a manner which assisted her to settle subsequently in her new home. The Inspector understands that prospective core members are encouraged to visit the Home at least once before moving in, if this is considered to be helpful for them. Again, the Inspector could not validate effectively this matter on the present occasion given the absence of any new admissions. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Core members are confident that their present and future needs for personal care will be met in a reliable and consistent manner. They are suitably consulted about the assistance they receive and about the day to day running of the Home. Core members are supported in taking prudent risks EVIDENCE: There is an individual plan of care for core member. These documents are intended to describe the assistance the core member in question has agreed to receive. The Inspector sample checked several sections of three of these plans. He found them generally to be suitably detailed, given the context of their use within the Home. However, there was a category of omissions in relation to different aspects of the assistance provided for Core Member A and Core Member B. The Area Manager said that these oversights will be corrected by 1 May 2006. Core members are consulted about the contents of their plans and they are invited to contribute to any reviews which are convened. Core members say or indicate that they consider themselves to receive all the assistance they need. The assistants assist core members in a manner which is consistent with that described in the individual plans of care. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 11 Core members are assisted to take those reasonable risks which are part of everyday living. The Area Manager and the Coordinator are aware of the need to keep this matter under continuous review. This is so that core members are assisted to avoid situations in which their own welfare or that of others may become jeopardised. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 and 17. Core members have access to a suitably varied range of social and vocational activities. Some of these involve engagement with the local community. Core members are enabled to exercise their citizenship rights and to respect those of other people. Core members are provided with a normally balanced diet and they enjoy their meals. EVIDENCE: Core members undertake a range of social and vocational activities. Core members say or indicate that they consider themselves to be consulted adequately about what they want to do and that staff assist them to follow their individual interests. The Inspector noted that all of the core members had been out during the first part of the inspection visit attending various vocational commitments. Core members say or indicate that they consider their time to be occupied appropriately. The pace of daily life in the Home is relaxed and unhurried. There are no unnecessary rules or routines to disrupt core members’ experience of a normal domestic setting. Having said this, assistants do bring a definite measure of order to the pattern of each day. The Inspector considers this to be an Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 13 essential example of good practice. This is because it responds appropriately to the core members’ needs for guidance and direction. In so doing, it enables them to get around to doing more things than might otherwise be the case. Core members say that they are provided with good quality meals and that they always have enough to eat. The assistants confirmed this account and they said that the Registered Provider supplies sufficient funds to enable a good variety of dishes to be prepared. The Inspector noted that the record of the food served in the Home is not adequately detailed, in that it does not always identify the main dishes prepared for the core members. The Coordinator said that this omission would be corrected from the day of the inspection visit. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Core members receive assistance and support in a respectful and appropriate manner. Core members’ physical and emotional health care needs are met. There are suitable arrangements in place to enable staff to retain and dispense medication on behalf of core members. EVIDENCE: Core members say or indicate that assistants are attentive to their needs without being intrusive. The Inspector witnessed a number of occasions on which assistants helped core members. He noted these events to be characterised by a quiet and confident informality which is consistent with good care practice. Core members who have problems with aspects of their physical health, are assisted to seek and to follow the advice of their doctor. The assistants said that they keep a tactful eye open so that medical conditions are noted at an early point. The Commission has not since the last inspection visit, received any expressions of concern in relation to the Home, from members of the local primary health care team. None of the core members currently in residence, have elected to handle their own medication. However, the Coordinator said that this facility will be made available should it be appropriate for a core member to act in this capacity in Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 15 the future. The Inspector examined selected aspects of the arrangements used by staff to administer core members’ medication on their behalf. He found that suitable practices were in place to store medicines and to ensure that core members take them in the manner intended by their doctor. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Core members consider that their views are listened to and that as necessary they are acted upon. Core members are protected from abuse, neglect and self harm. EVIDENCE: There is a complaints procedure which explains how core members and other stakeholders can make a complaint about any aspect of the facilities and services provided in the Home. The core members did not comment directly about this matter to the Inspector. However, they did indicate by their relaxed and open manner that they are confident that any matter they raise will receive serious attention. The Inspector noted there to be a minor omission in the procedure. The Area Manager said that this oversight will be corrected by 1 July 2006. The Inspector understands that since the date of the last inspection visit, the Registered Provider, has not received any complaints about the facilities and services provided in the Home. Similarly, the Commission has not received any such expressions of concern. The assistants have a sound understanding of what constitutes good care practice. As part of this, they are aware of the need to be alert to instances which might jeopardise the well-being of a core member. Also, they are aware of how to bring such a matter to the attention of the Registered Provider and/or to external regulatory bodies. Core members say or indicate that they feel safe living in Rainbow. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 17 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, 27, 28, 29 and 30. The Home provides comfortable accommodation. There is a sufficient number of toilets and bathrooms. There are sufficient shared spaces. Core members are supported to maximise their independence. The Home is presented to a normal domestic standard of cleanliness. EVIDENCE: Core members say or indicate that their accommodation is homely and that it is comfortable. The Inspector noted the accommodation to be presented to a normal domestic standard. The core members say or indicate that they like their bedrooms and that they have all they need in order to use them as bed sitting areas. However on this occasion, the Inspector did not have the opportunity to see any of the bedrooms. Consequently, he has scored the Standards in question accordingly. There is an adequate number of toilets and bathrooms, given the needs of the core members presently in residence. Also, there is sufficient provision of lounge and dining space to enable the core members to relax in comfort when not occupying their bedrooms. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 18 Suitable arrangements are in place to assist one of the core members who experiences a measure of reduced mobility. The Coordinator is aware of the need to keep this matter under review. This is so that appropriate provision can be made should these needs change in the future. The accommodation is cleaned to a normal domestic standard. The Inspector examined the kitchen. He noted it to be presented to a suitable standard of hygiene. He understands that it continues to be operated in a suitable manner. Also, he understands that the local Department of Environmental Health has not recommended the completion of any improvements which remain outstanding. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 19 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, 32, 33, 34, 35 and 36. Assistants have a good understanding on their duties and they work together well as a team. Assistants have the competencies they need. There is an adequate number of staff on duty. A number of steps are taken to ensure that only suitable people work in the Home. The duties completed by the assistants are supervised adequately. EVIDENCE: The Inspector understands that the assistants are provided with a written account of their duties. The staff team is relatively stable. This means that people have got used to working together and that core members know who is going to be around and what they are going to be doing. There are handover meetings at the beginning and end of each shift. Also, assistants keep diary records of how things are going for each core member. There are regular staff meetings and assistants say that they are consulted actively by the Coordinator about how the Home is administered. The Registered Provider is responsible for ensuring that all of the assistants have the competencies they need to enable them to respond effectively and reliably to the core members’ current and likely future needs for support. The Coordinator said that all new assistants receive a period of introductory training before they work with core members without direct supervision. The assistants confirmed this account. They consider that the introductory training they received gave them the competencies they need in order to respond Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 20 effectively to the core members’ individual needs. The Inspector reviewed the written protocol which is used to organise the provision of this tuition. He noted some of the detail to be a little general in nature. Consequently, he has recommended that L’Arche Kent review its provisions against a new model which has been adopted by the Standards. In addition to the introductory training, the assistants undertake ongoing training in a variety of subjects directly related to their work in the Home. Assistants say that these training inputs have provided a useful platform from which to review and to develop further their care practice. Two of the five assistants have acquired a relevant National Vocational Qualification (NVQ) in health and social care. This qualification is designed to validate that individual assistants have the skills they need to respond effectively to service users’ needs for assistance. The Area Manager said that plans will be made to ensure that more assistants acquire the Award in the manner envisaged by the Standards. From the evidence reviewed during the course of the inspection visit, the Inspector considers that the assistants have the skills required in the areas of competency reviewed. There are at least two assistants on duty when most of the core members are at home. The Inspector considers there be sufficient staff on duty to enable the current core members’ needs for assistance to be met in a prompt and a sustainable manner. The Registered Provider undertakes a number of security checks in relation to each employee. These are completed in order to ensure that only suitable people have unsupervised access to core members who may be vulnerable. The Inspector sample checked aspects of the system in operation. He found them to be working in a suitable manner. The Coordinator routinely works alongside the assistants when they are providing assistance to the core members. This enables her to monitor and to give advice to assistants about aspects of their care practice. The assistants say that they consider both the Coordinator and the Assistant Coordinator to be knowledgeable about residential care and to be supportive in their manner. This informal dialogue is complemented by more organised meetings. These meetings entail each assistant meeting on a one to one basis with the Coordinator. This is done in order to review their work and to resolve any problems, should there be any. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 21 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, 39, 41 and 42. The Registered Provider runs the Home so as to reliably provide core members with appropriate assistance. The Registered Provider does not operate a suitably developed quality assurance system. Core members’ rights and best interests are protected the operation of the Registered Provider’s recording systems. The health and safety of service users and staff generally is adequately protected. EVIDENCE: As noted previously in this Report, the Registered Provider has not yet proposed to the Commission someone to be considered for the post of Registered Manager in relation to the Home. In the interim, the Coordinator is acting up in this role. The Inspector understands that the Registered Provider is soon to submit an application to the Commission to register the Coordinator. Given the determination which the Commission will have to make in relation to this matter, the Inspector is not in a position to ascribe a score to this Standard. However, it can be noted that the Commission is satisfied that Area Manager with the assistance of the Coordinator, operates a suitable system to monitor and to run the Home on a day-to-day basis. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 22 Earlier in this Report, the Inspector has noted on several occasions the steps taken by the assistants to consult with and to involve core members in the running of the Home. The Standards envisage these arrangements being developed further in that the Registered Provider should operate a formal quality assurance system. This will mean that each year the core members will be asked their views about the adequacy of the facilities and services provided in the Home, with the results of the consultation exercise being summarised in a written Quality Report. This Report, which will summarise what steps the Registered Provider intends to take to action any suggested improvements, will then form a platform for further consultations with the core members. The Area Manager said that the first round of this exercise will be completed within the timescale established in the relevant Required Development listed at the end of this Report. The Registered Provider maintains various recording systems to assist in the management of the Home. The Inspector examined several of these and in particular the records relating to the occurrence of accidents. He did not note anything which indicated the need for him to make any further enquiries. The Area Manager said that Registered Provider organises the completion a regular review of the premises. This is done to ensure that there are no significant hazards which might compromise the health and safety of anyone living and working in the Home. The Coordinator said that this exercise has not identified any significant hazards which remain to be addressed. The Inspector did not notice any such hazards when he examined selected aspects of the premises. The Inspector understands that the Kent Fire Service has not recommended any improvements which remain outstanding. The Coordinator has continued to complete the periodic checks which have to be made to ensure the continued adequacy of the Home’s fire safety regime. The Registered Provider does not operate a system which is designed to validate that all of the assistants are aware of how to help avoid the occurrence of a fire safety emergency and that they know what steps to take to respond effectively to one should the need arise. The Area Manager said that this matter will now be addressed within the timescale established in the relevant Required Development listed at the end of this Report. In the interim, the Inspector notes that the assistants do seem to have an adequate understanding of the selection of fire safety issues he raised with them during the course of the visit. The Area Manager confirmed that the Registered Provider has arranged for all appliances such as gas boilers to be serviced in accordance with the manufacturers’ instructions. Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X 3 2 X 3 2 X Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 24 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 38 Regulation 12 Requirement The Registered Provider should introduce a suitably specified system if quality assurance. This should comprise an annual consultation exercise the results of which should be summarised in a written Quality Report in the manner listed above. The Registered Provider should ensure that all assistants are included within a suitably specified programme which is designed to validate their competency to operate reliably the Home’s fire safety regime. Timescale for action 01/01/07 2. 42 23 01/06/06 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 Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Rainbow DS0000023531.V258545.R01.S.doc Version 5.1 Page 26 - 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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