Inspection on 08/01/07 for Rainbow Homes (London) Limited

This inspection was carried out on 8th January 2007.

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 found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rainbow Homes (London) Limited 18/11/08

Rainbow Homes (London) Limited 28/08/07

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

CARE HOME ADULTS 18-65 Rainbow Homes (London) Limited 23 Hoop Lane Golders Green London NW11 8JN Lead Inspector Tom McKervey Key Announced Inspection 8th January 2007 09:30 Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rainbow Homes (London) Limited Address 23 Hoop Lane Golders Green London NW11 8JN 0208 458 8288 0208 458 8288 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) Rainbow Homes (London) Limited Florence Nneamaka Abimbola Saweh Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection First Inspection Brief Description of the Service: This home is owned by Rainbow Homes London Ltd., which is a private company. The home opened in July 2006, following a major refurbishment of the property, which was previously owned by the local authority and accommodated homeless people. This is the company’s only care home, but the proprietors intend to open other care homes in the future. The home is located in the Golders Green area of North London, near to a large shopping area, and is well serviced by public transport. The home is registered to provide care and personal support for six people between 18 and 65 years of age who have mental health problems that may be associated with drugs and/or alcohol. The service aims to promote and develop service users’ independence through community living. The semi-detached building has three storeys, with one bedroom on the ground floor, three on the first floor and two located on the third floor. There is no lift in the building, which restricts the ability to accommodate people with mobility problems in upstairs bedrooms. All the bedrooms have en-suite facilities, and at the time of this inspection, the bedrooms also contained kitchenettes, which had been for the use of the previous occupants. However, it is intended to remove these during 2007, and in the meantime, the cookers have been disconnected from the mains. There is only one communal area for the residents, located on the ground floor, which contains the kitchen and a dining table, and also the lounge. A washer/drier is integrated with the kitchen units. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 5 There is a staff office and an area for storing medication on the ground floor. There is a small area for parking at the front of the building and a large garden and patio at the rear of the property. The fees for the service are £960 per week, which may be higher, depending on the dependency level of the service users. Following “Inspecting for Better Lives”, the provider must make information available about the service, including inspection reports. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, and the first of this new care home. The inspection was carried out as part of the Commission’s inspection programme to check compliance with the key standards. The inspection took place over a period of six-and-a-half hours, and the registered manager and one other member of staff were present, both of whom offered every assistance with the process. The inspection consisted of a tour of the home, discussions with the manager and staff, and the two people currently living in the home. The process also entailed examining residents’ and staffs’ records, policies and procedures, and other documents pertaining to the management of the home. There were no visitors to the home during the inspection. What the service does well: What has improved since the last inspection? This is a new service and has not been inspected before. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service do not have sufficient information to assess its suitability to meet their needs. The residents’ needs were comprehensively assessed before being admitted to the home and potential service users are offered visits to the home before deciding to move in. The local authority has service level agreements with the home that include the terms and conditions and the level of fees. The residents say they are satisfied that the service is meeting their needs. EVIDENCE: The home’s Statement of Purpose did not contain all the information as required in Schedule 1 of the regulations. The Service User Guide was satisfactory but had inappropriate references to staffs’ terms and conditions. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 10 Requirements are made to address these issues. The residents’ case files contained evidence of full assessments of their needs by the referring mental health teams and the manager of the home. Both residents were spoken to, and both said that they were glad they were living there and the home was meeting their needs and expectations. They were very satisfied with their bedrooms and were able to have their own personal possessions with them. One resident said they enjoyed the location of the home being near plenty of shops and easily accessible to public transport. Another resident was happy to be close to their relative. One resident said they had visited the home prior to moving in; the other had not been able to but said they were satisfied that their social worker had found the home on their behalf. Both residents’ care was funded by the local authority, which had written service agreements detailing the fees charged. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plan for one of the residents is appropriate, but for another, does not reflect their needs in the current situation. There are appropriate risk assessments in place, but although reasonable restrictions are imposed in the best interests of the residents, their written consent has not been obtained. Residents are able to discuss aspects of living in the home at regular meetings with their key worker and residents can be confident that information about them and their records, are secure. EVIDENCE: Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 12 A care plan had been made for both residents and they were allocated a key worker who reviewed the care plans each month. In the case of one resident, their care plan was based on their current needs and provided appropriate guidance on meeting those needs, which included provision of a specialist therapist in the prevention of alcohol and drug abuse. However, another resident had a care plan that may have been relevant in their previous home but in many instances did not relate to their present situation. For example, the care plan indicated that they were self-medicating, which was not the case now. In addition, the manager stated that this person’s smoking was a health and safety problem and this was being controlled by the staff on the resident’s behalf by giving out one cigarette at a time. Sanctions are imposed on the other resident when they breach their conditions of residence; for example, by taking illicit substances. This usually results in restricting their “social leave” in the community. In discussion with this resident, they accepted that these sanctions were reasonable and that they needed to be set boundaries to help them in their rehabilitation. The restrictions applying to both residents appeared to be appropriate and were recorded in their risk assessments. However, written consent to sanctions and restrictions had not been obtained from them or their representatives, and requirements are made about these issues. The residents said they were happy and felt safe living in the home and staff were supportive. They stated that they could choose their own meals and their bedtimes. The residents have one-to-one sessions once a month with their key workers when they can discuss their care plan and activities. They are responsible for cleaning their rooms and doing their personal laundry. Residents’ records are kept securely in the staff office in lockable cabinets and there is a policy on confidentiality of information and access to records, which meet the National Minimum Standards. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are fully engaged in activities of daily living within the home and are able to be part of the local community by going out from the home and visiting friends and relatives. However, they should be supported to gain access to local drop-in centres and advocacy groups where they can further develop their skills. There is frequent contact with relatives, and the residents say they are treated with respect by the staff, including recognition of their religion and culture. The food provided is wholesome and varied and the residents are able to choose their meals. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 14 EVIDENCE: Both residents were spoken to. They are responsible for cleaning their rooms and doing their laundry with staff support. Both residents were observed preparing lunch along with the staff. One resident is British and Jewish, the other, African and Christian. The inspector was informed that neither resident practiced their religion or had special dietary needs. One resident said that they had a bus pass and regularly visits their family and friends from their ethnic group. The other resident has regular visits from a relative and goes out with them to shops and local cafes. This is a new service and at the time of the inspection, neither service user was in employment nor attending drop-in centres or local advocacy organisations. One resident expressed a wish to eventually get a job, but recognised that they needed support to achieve this. This person had enrolled in a local college, but had failed to attend courses. A recommendation is made for appropriate local services, for example Mind, to be contacted as a resource to help the residents in further developing their skills. Both residents have their own televisions and music centres in their rooms and there was a large television and some board games in the lounge area. There is a large garden and patio available for barbecues etc in good weather. The home has a policy about sexuality and there was a book to record all visitors to the home. Residents said that generally, staff respected their right to privacy; for example, calling them by their preferred names, knocking on their doors before being invited in, and receiving their mail unopened. The residents are also offered a key to their rooms. The menus showed a good variety of meals and the residents said they enjoyed the food and were able to choose what to eat. Neither resident had any special dietary needs. There was an ample supply of food available, including fresh fruit. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 15 Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate facilities are available for residents’ personal care and the residents say that their mental and physical health needs are being met by a caring group of staff. Although a specific resident is exercising their choice of GP, they may experience difficulties in receiving prompt treatment by not being registered with a local GP. Residents’ welfare is safeguarded by good practices in the administration of medicines. However, a specific medication issue needs to be addressed by the GP. EVIDENCE: Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 17 All bedrooms have en-suite facilities and both residents are able to provide for their own personal care. The residents told the inspector that the staff were always available to talk to about worries and concerns and they were very caring. One resident is registered with a local GP. However, at the time of the inspection, the other resident was still registered with a GP where they used to live which is some distance away. The manager said that the resident was reluctant to change their GP. However, this could result in difficulties in this person receiving prompt treatment and a recommendation is made to address this issue. The residents’ records contained information about appointments with healthcare professionals. This is mainly the Community Mental Health Team, particularly the consultant psychiatrist and the community nurse who visits one resident each week to administer medication by injection. One resident has weekly sessions with a drug and alcohol therapist at the home. Both residents have regular Care Programme Approach meetings with the Community Mental Health Team, who review their medication. At the time of the inspection, neither resident was self-medicating. There is an appropriate procedure in place for the administration of medicines. The medication records were examined. In relation to one resident, their records showed that a specific 9am medication was frequently not given. The manager explained that it was often difficult to rouse this person at that time of the morning. A requirement is made to discuss this with the GP and for appropriate action to be taken. The medicines were stored securely and there were records to show that staff had been trained in the safe administration of medicines. There is an appropriate procedure for recording accidents, but the manager stated that up to the time of the inspection, no accidents had occurred. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Both standards were examined. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents say they are satisfied with the service they receive. Although one complaint was dealt with satisfactorily, it is important to log all complaints in the complaints book as evidence that they are properly addressed. There are good procedures, including staff training to safeguard the residents’ welfare and best interests. EVIDENCE: There is an appropriate procedure and complaints log in place, including the contact details of social services and the Commission for Social Care Inspection. The residents said they were satisfied with the service and had no major concerns. However, a resident had made a complaint at one time, which was recorded and dealt with at a staff meeting, but it was not logged in the complaints book. A requirement is made to ensure that all complaints are properly logged. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 19 The home has a copy of the local authority’s adult protection procedures and a policy about “whistle-blowing”. The staff member who was spoken to, was able to demonstrate a sound knowledge of the procedures to follow if they suspected abuse of any kind. Staff records showed that they had training in this subject and that they had been properly screened when they were recruited. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is very clean and well maintained. The bedrooms are spacious and comfortable and the residents are able to have their own personal belongings with them. The residents are happy with their environment, but their comfort and wellbeing is compromised by not having enough communal space for relaxation and socialising with fellow residents. There is a good standard of cleanliness throughout the home. EVIDENCE: Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 21 A full tour of the building took place, including visiting the two residents in their rooms. The three-storey building is in a residential street with good transport links and shopping facilities nearby. The inspector was concerned about the lack of communal space inside the home, especially when it is fully occupied with six service users. The only communal space available is a room that accommodates the kitchen, dining area and lounge. The kitchen also contains a built-in washer/drier machine. This could lead to an over busy and noisy environment, especially at mealtimes. When the home was registered, a large ground floor room was designated as a therapy room, which the proprietor was considering converting to a lounge. However, at the time of the inspection, a resident with mobility problems was using this room as their bedroom. Following representations from the inspector, the proprietor has agreed to extend the property to provide a lounge for the residents that meets the National Minimum Standards. In the meantime, a requirement is made for this project to be pursued. There are no communal bathrooms or toilets as each resident has en-suite facilities. There are toilets for visitors and staff. The bedrooms are spacious, bright and well decorated with comfortable furniture. At the time of this inspection, the bedrooms also contained kitchenettes, which had been used by previous occupants. However, it is intended to remove these during 2007. Both current residents had several items of personal possessions in their rooms and they were very happy with the overall accommodation. One resident has moderate mobility problems and has a wheelchair for when they go on outings, otherwise, they have no difficulty accessing all downstairs areas of the home, including the garden. The property appeared well maintained internally and externally, and at the time of the inspection, the home was clean and tidy and free of offensive odours. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet the current residents’ needs. The staff are fully aware of their roles and responsibilities and they are appropriately supervised. Residents’ best interests could be at risk because some staff do no have current CRB checks. Not all staff have been trained in mandatory subjects, which could have a negative effect on the residents’ health and safety. EVIDENCE: There are clear job descriptions in place for the staff, who in addition to their roles as carers, are responsible for cleaning and cooking. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 23 The member of staff who was spoken to, confirmed that the job description reflected their role. The staff member had previous experience of caring for people with mental health problems and said they enjoyed their job. There is a mix of male and female staff, and from observation and discussions with residents and staff, there appeared to be a good relationship between them. There is an establishment five staff, and the staff rotas showed that there were two staff, including the manager on duty during weekdays, and one at weekends, to care for two residents. There is one person on waking duty at night. The manager said that staffing levels will increase as more residents are admitted. A “training needs analysis” was carried out, which the manager stated will be used to identify all the training requirements of the staff group. Staff records showed that they all had undergone a written induction and some had attended training in the administration of medicines, health and safety, first aid and food hygiene. However not all staff had yet been trained in all the foundation programme subjects or mental health and a requirement is made to address this issue. Two staff had attained National Vocational Qualifications, (NVQ) at Level 2. There was evidence in minutes that the manager held regular staff meetings. The home has an appropriate recruitment procedure, including application forms, interviews and health screening. The recruitment records showed that references had been obtained for employees, but in the case of two staff, their Criminal Records Bureau certificates related to their previous employment and a requirement is made for new checks to be made. In the meantime, the manager agreed to ensure that these staff always work under supervision. There were records of one-to-one supervision sessions between the manager and staff, and a staff member informed the inspector that they valued this. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 24 Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the experience and qualifications to manage the service effectively, and provides good leadership for the staff. There are appropriate policies and procedures in place to guide staff in caring for the residents and records were well structured and up to date. The Responsible Person does not carry out monthly unannounced visits to the home. This means there is no regular monitoring of the quality of the service. The health and safety of residents and staff is generally safeguarded. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager had previous experience of managing services for mental health service users in residential settings. She holds the Registered Manager Award qualification and will be completing NVQ level 4 in April 07. Through observation and in discussion with the manager, the inspector was satisfied that she was knowledgeable and competent to run the service efficiently. The atmosphere in the home was relaxed and friendly and the residents and staff expressed confidence in the manager’s leadership. They also said she was very approachable and dealt with concerns in a sensitive manner. As a new service, a quality assurance audit is not yet due to be carried out. However, a standard relating to the conduct of the home, requires the Responsible Person to carry out monthly unannounced visits to the service and to report the outcome to the Commission for Social Care Inspection. A requirement is made to address this issue. A comprehensive portfolio of policies and procedures covering all aspects of the service was in place. Individual records were well structured, easy to follow and were up to date. Certificates of safety were seen for gas, fire and electrical installations and portable electrical appliances had been tested. However, there was no date on the fire extinguishers to confirm when they were last tested. This is a requirement. There was a risk assessment and emergency plan in place for the home. Fire alarm tests, fire drills and water temperature tests had been carried out regularly. The cold water system had not been tested for Legionella and a requirement is made for this to be done. A current certificate of employers liability insurance was on display. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 27 Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 1 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 3 3 2 X Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 29 No 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 YA1 Timescale for action 5(1) The registered person must 31/03/07 update the Statement of Purpose to include all the information required in Sch 1 of the National Minimum Standards. 5(1) The registered person must 31/03/07 ensure that irrelevant information about staffs’ terms and conditions are removed from the Service User Guide. 15(1) The registered person must 28/02/07 provide a new care plan for a specific resident that reflects their current needs. 12(3) The registered person must 28/02/07 ensure that written consent is obtained from service users or their representatives for any sanctions or restrictions imposed on them in their best interests. 13(2) The registered person must refer 28/02/07 a specific medication issue to the resident’s GP. 17(2) Sch The registered person must 31/03/07 4 ensure that all complaints are logged in the complaints book. 23(2) The registered person must 30/09/07 9(g) provide a separate lounge for the residents that meets the National Minimum Standards DS0000067643.V316265.R02.S.doc Version 5.2 Page 30 Regulation Requirement 2 YA1 3 YA6 4 YA7 5 6 7 YA19 YA22 YA28 Rainbow Homes (London) Limited 8 9 YA34 YA35 17(1), 19(5) 10 YA39 11 YA42 12 YA42 The registered person must obtain current CRB checks for two specific staff members. 19(5)(b) The registered person must ensure that all staff attend training in all of the induction subjects of the foundation programme. 26(2) The registered person must carry out monthly unannounced visits to audit the service and send the reports of findings to the Commission. 13(3) The registered person must provide evidence that the water system in the home is tested for Legionella. 17(2) Sch The registered person must 4.14 provide evidence that fire extinguishers have been tested within the past year. 28/02/07 30/04/07 28/02/07 31/03/07 31/03/07 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. Refer to Good Practice Recommendations Standard YA19 The registered person should support a specific resident to register with a local GP. YA19 The registered person should approach appropriate local advocacy services, for example Mind, as a resource for the residents. Rainbow Homes (London) Limited DS0000067643.V316265.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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