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Inspection on 12/06/06 for Rainbow House (Holiday Centre)

Also see our care home review for Rainbow House (Holiday Centre) for more information

This inspection was carried out on 12th June 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Centre provides good holidays for people with a learning disability and the guests enjoy their stay. The Centre is managed well with a clear sense of leadership and direction. The views of the guests are sought about what they would like to do and how they would like to spend their holiday. The guests enjoy the meals and their individual choices are taken into consideration by the chef.

What has improved since the last inspection?

The care plan format has improved and is now much easier for staff to use, providing clearer information and guidance to staff about how to meet the needs of the guests. The system in place for organising the mix of guests staying at the Centre at any one time has improved so that there are less times when the mix is difficult for some reason.Recent recruitment means that the Centre is fully staffed with permanent members of staff rather than using volunteers and agency staff for a number of shifts which has been the situation up until now. Staff receive regular supervision, both informally and formally. A quality assurance process has been implemented which involves using a variety of means to monitor the quality of the service provided. A formal two week period of induction has been instigated by the organisation for all new staff The Manager and staff are reviewing the way in which activities are arranged during the week to improve opportunities for smaller groups to go out together and a wider range of activities to be provided.

What the care home could do better:

A requirement has been made about the need to replace the wallpaper in one of the bedrooms which has had some tough wear and tear in the last fortnight. The quality assurance system is in the early stages and this will be further developed throughout this year.

CARE HOME ADULTS 18-65 Rainbow House (Holiday Centre) 15 Hooks Hill Road Sheringham Norfolk NR26 8NL Lead Inspector Mrs Lella Andrews Unannounced Inspection 12th June 2006 11:15 Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rainbow House (Holiday Centre) Address 15 Hooks Hill Road Sheringham Norfolk NR26 8NL 01263 821310 01263 821310 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) www.break-charity.org BREAK Mrs Lyndsey Connell Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9), Physical disability (9), of places Physical disability over 65 years of age (9) Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Those accommodated with a learning or physical disability may be under the age of eighteen years. No unaccompanied child under the age of five may be accommodated. No unaccompanied individuals may be accommodated during the weeks set aside for family groups. 4th January 2006 Date of last inspection Brief Description of the Service: Rainbow House is owned and managed by the BREAK organisation which is a charity based in Norfolk and provides a variety of services to children and adults. Rainbow House (referred to throughout the report as the Centre) is a large detached house situated in a residential area of the seaside town of Sheringham. To the front of the Centre is a large, heated indoor swimming pool and an enclosed garden. The Centre provides holiday stays for children and adults with a wide range of disabilities. All guests have a single room. The bookings are arranged so that there are either groups of children or groups of adults staying at any one time. The service users are referred to throughout the report as guests. The fees for the centre are from £500 to £700 per week. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was carried out to the Centre between 11.15am and 5pm on Monday 12th June 2006. The information gathered during that time is covered within this report, along with information provided by the Manager prior to the Inspection, comment cards completed by guests and relatives and other information gathered about the service over the past year. Monday is the “changeover” day at the Centre and so guests went home during the morning and a further group of guests arrived during the afternoon for their weeks holiday. A new Manager of the Centre was appointed in November 2005 and became registered with the Commission in February 2006. The Centre has made a lot of improvements over the last six months and all of the requirements from the previous report have been met, including some which had been outstanding from more than one Inspection. What the service does well: What has improved since the last inspection? The care plan format has improved and is now much easier for staff to use, providing clearer information and guidance to staff about how to meet the needs of the guests. The system in place for organising the mix of guests staying at the Centre at any one time has improved so that there are less times when the mix is difficult for some reason. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 6 Recent recruitment means that the Centre is fully staffed with permanent members of staff rather than using volunteers and agency staff for a number of shifts which has been the situation up until now. Staff receive regular supervision, both informally and formally. A quality assurance process has been implemented which involves using a variety of means to monitor the quality of the service provided. A formal two week period of induction has been instigated by the organisation for all new staff The Manager and staff are reviewing the way in which activities are arranged during the week to improve opportunities for smaller groups to go out together and a wider range of activities to be provided. 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. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 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 House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 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, 2, 4 and 5 Quality in this outcome group is good. Information about the Centre is provided in written, pictorial and interactive formats to make it easier for prospective guests. Information about the needs of the guests is gathered prior to their stay. EVIDENCE: The Centre has a Statement of Purpose which is only available in written format at present. The Manager said that a group of staff are going to progress the review of this document which was started during the training weeks earlier this year. The Service User Guide is available in a much easier format using simple language and photographs. There is also an interactive version for use with computers. A copy of the Service User Guide is in each of the bedrooms for the guests to refer to during their stay. The fees for individual guests is dependent on their needs and this is individually communicated to guests/carers/social workers when an initial referral is made. Confirmation of fees is provided by the organisation in writing. The booking form contains the statement of terms and conditions and covers what is provided within the fees. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 9 The assessment of guests needs has improved over the last twelve months. Staff contact carers for additional information if the booking forms do not contain the necessary detail. Information is also obtained on arrival from the person who brings the guest to the Centre. As guests come to the Centre from all over the country it is not practical for the Manager to meet and assess all guests needs. The Manager said that all prospective guests are invited to visit the Centre prior to staying and that she offers to carry out an initial visit if the guests are fairly local or if there are specific issues. The mix of guests has been an ongoing problem for many years at the Centre. The organisation has worked hard to lessen the problems associated with providing a service to nine guests who do not know each other and who may have very differing needs. The bookings co-ordinator has spent time at the Centre and one of the deputy managers at the Centre now spends time each week at the office with the bookings co-ordinator. A risk assessment is carried out by the Manager about prospective bookings and any relevant information highlighted by staff during a guests stay is communicated back to the bookings co-ordinator. The Manager has access to the bookings system on the computer and so can be more involved in this way also. Whilst it is likely that there will always be occasional difficulties with the mix of guests the system is now more likely to work positively for both guests and staff. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome group is good. The care plans are greatly improved and now provide clearer information in a much more easy to locate format. Risks are assessed and guidance provided about how to minimise risks. EVIDENCE: The Centre has recently started to use new care plan formats which are more detailed and in a format which makes it easier to locate specific information. This has been a very recent change and future Inspections will be able to assess how successful it is but the initial feedback from staff is positive. Senior staff are responsible for transferring the information from the booking forms on to the new care plan formats and all staff are responsible for maintaining the records during the guests stay. Risk assessments are carried out and guidance is provided about how to manage those areas assessed as being of medium or high risk. The newer Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 11 staff received risk assessment training during their recent induction and the Manager said that this training will be provided to all staff shortly. The staff work hard to encourage the guests to make their own decisions about what they would like to do and how they would like to spend their time. This is an area in which improvements have been made recently with the staff being encouraged to plan activities in a more flexible way to enable guests to have more choice. The staff are responsible for looking after guests money whilst they are at the Centre and clear records are kept of expenditure. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16 and 17 Quality in this outcome group is good. Guests are supported to take part in a range of leisure activities and the focus is for them to have a good holiday. The quality of meals provided is good and the individual needs and choices of the guests is taken into consideration. EVIDENCE: The staff are clear that their aim is to provide the guests with an enjoyable holiday and they work hard to do so. Traditionally there has been a planned outing each afternoon and the majority, if not all, of the guests would take part in that. However, the Manager has instigated some changes to this format so that individual needs can be better met. The staff are now being encouraged to plan activities on a more flexible basis which will offer more choice and the opportunity for smaller groups to go out together. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 13 Staff undertake driver training so that they are able to drive the two minibuses that the Centre has. A recent improvement to the transport situation is that the Manager has obtained the use of a seven seater vehicle for use at weekends and evenings which belongs to the day service run by the organisation. This will enable smaller groups to go out together in a more “domestic style” vehicle rather than the mini buses. Guests who arrived during the Inspectors visit were seen sitting in a group with staff discussing what they would like to do. There is also time set aside on the first morning of their stay to put together a programme of activities for the week. Guests told the Inspector about a range of activities that they have taken part in during previous stays. These include the zoo, cinema, swimming, meals out, local attractions and shopping. Through the Centres quality review the Manager has identified that the guests have not been able to use the swimming pool very regularly and has taken steps to address the problem by organising further training for staff and additional time for the Centre to have the pool as it is also used by community groups. This review has also identified that the play equipment outside is in need of some maintenance and that additional games/equipment for use in the Centre needs to be purchased. The comment cards received from guests and relatives state that there is always lots of things to do and that the guests enjoy their stay. As the guests are at the Centre for a holiday it is not appropriate for the staff to enable them to be a part of the local community, however, many of the facilities in the town of Cromer are used during guests stays. The Centre has a payphone for the guests to use to maintain contact with relatives/carers if they wish to. The cordless office phone can also be used if guests or relatives wish to use it. The Manager said that there have been some prospective guests and their relatives who have visited to look around prior to a holiday. Guests are supported to send postcards to friends and families whilst they are at the Centre and a book is put together during their stay as a memory of what they have been doing. Guests were arriving during the Inspectors visit and were accompanied by relatives. This can be a very busy time but each of the relatives was met by staff and given time to discuss the needs of the guests as well as hand over medication and money for their stay. The staff were observed to manage this situation calmly and with confidence. Staff are understanding of the potential concerns that relatives may have about leaving their relative at the Centre and communicated positively and kindly with relatives. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 14 The guests told the Inspector that one of their favourite things about their holiday is the meals that they have. They said that they are able to have a choice and that the chef comes to speak to them about what they would like to have. The chef has recently updated the menus which have continued to have three choices for each meal, including a vegetarian option. The chef came out of the kitchen to meet relatives whilst the guests were arriving at the Centre. The care plans include information about any dietary needs and guests individual food and drink likes and dislikes. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome group is good. The healthcare needs of the guests are met and medication is managed effectively. EVIDENCE: The care plans contain information about how the guests prefer to receive personal care and information about any equipment that they may need. The staff also check this information with the relatives when they bring the guests to the Centre. A complaint was made in October 2005 about the personal care provided at the Centre. This was investigated by the organisation and some aspects were found to be substantiated. The organisation took steps to review some aspects of practice following this complaint and no further complaints have been made about these issues. The guests health needs are given a priority and staff have received training about a range of health issues such as epilepsy, diabetes, first aid and medication. The Manager said that staff received training to administer insulin Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 16 during the training weeks earlier in the year and that the District Nurse maintains an overview of this situation. The Managers internal audits have highlighted some areas relating to the administration of medication which could be improved and action has been taken to address these. The Centre now has a homely remedies policy as part of the overall medication policy/procedure. Staff receive formal medication training and then are assessed by one of the management team at the Centre prior to administering medication. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome group is good. Guests and relatives are given opportunities to raise any concerns/complaints and these are dealt with appropriately. Staff receive training with regard to child and adult protection. EVIDENCE: The Centre has a complaints procedure which is available in alternative formats if required. The Service User Guide includes information about who to speak to if a guest is unhappy about something. The comment cards completed by guests confirm that they are made aware of this. Guests and relatives are provided with a questionnaire when they leave which asks them about different aspects of the service. In discussions with guests they were able to tell the Inspector the name of a member of staff that they would talk to if they were unhappy about something. They also said that staff are always kind and ask them if they are happy with everything. The Manager maintains a record of complaints. There have been two complaints made in the last year. Both complaints were investigated by the organisation, one of which had been passed to the organisation from the Commission for them to investigate. The Commission was satisfied with the investigation carried out and the records kept. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 18 The Centres policies and procedures aim to protect the guests from any form of abuse. Staff who have recently completed the new induction programme said that they received information about the most relevant policies and procedures. They also received training with regard to the protection of vulnerable adults. Staff access child protection training also. The Manager has made two referrals to the Adult Protection Unit in the last year. One situation related to two of the guests whilst another was in relation to staff. Both were handled appropriately by the Manager and the organisations own procedures were followed in relation to the situation involving staff. The Centres adult protection procedures have been rewritten following a previous requirement and are now much more clear. One of the comment cards completed by a guest states that one of the good things about being at the Centre is that they “…felt safe and looked after.” Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome group is adequate. The Centre receives hard wear and tear which is starting to show in some areas despite the programme of redecoration and refurbishment. EVIDENCE: All of the bedrooms have been redecorated with new flooring fitted over the previous eighteen months. The rooms have also been personalised with pictures and TV/dvd players and CD players. The staff personalise the room depending on the needs and wishes of each guest. One of the bedrooms had a lot of wallpaper stripped off by a recent guest and has not been replaced. As the Centre is full for the rest of the summer it can be difficult for the maintenance staff to find enough time for a bedroom to be empty to redecorate it. However, the Manager is aware of how this particular room looks for future guests and will discuss it with the maintenance staff to see if a suitable short term repair can be made prior to it being completely redecorated after the summer. A requirement is made about this. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 20 The dining room, activity room and soft play room have been decorated within the last twelve months. New carpet has been fitted to the guests area on the second floor. The Manager has a maintenance plan for other areas in the Home which are starting to look a bit shabby. The second floor of the Centre is no longer mainly used as volunteers accommodation and is going to be used for additional office space. There is already one bedroom on the second floor and a second is planned which will increase the Centres numbers to ten. The Centre does all laundry on the premises. Following the quality review some changes have been made to the way in which laundry is done with all rooms now having their own wash basket so that each guests laundry can be washed separately. This has only recently started to be implemented and will be kept under review. The Centre was clean and free of offensive odours on the day of the Inspection. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome group is adequate. The gap between the volunteers leaving and the new staff starting has meant that a lot of agency staff have been used at the Centre which reduces the consistency provided to the guests. Staff receive training and support to carry out their roles. EVIDENCE: The organisation recently made a decision to stop using residential volunteers and trainee support workers as part of the staffing structure. They have been recruiting for the last few months but due to the length of time that CRB disclosures have taken to be returned there has been a period of a few weeks when a lot of agency staff have been used. The organisation and the Manager are aware of the difficulties that this presents, particularly during the most recent half term period. However, the new staff have all recently started work and have just completed their two week induction period. Two staff on duty at the time of the visit had started at the Centre within the previous two days. They both said that the induction that they received was relevant, interesting and informative. They have also started to receive the induction provided by the senior staff within Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 22 the Centre and said that the staff that they have met have been helpful and supportive. The Manager is aware of the need to provide good, effective induction for the new staff so that they feel confident about their roles before the busy summer holiday period and has plans for this to be carried out with the support of the senior staff. The Manager has been involved in providing some of the training within the two week induction that has recently been implemented for all new staff within the organisation. She said that other staff can also access specific training sessions within the induction as a way of updating their skills and knowledge. The staff who were working at the Centre in January attended two weeks of training and development. The format and content of this period of training was different to that previously provided annually and the Manager and Operations Manager have obtained feedback from the staff and are using this to start planning the next two weeks training to be provided next winter. The Manager has also identified additional training that the staff have requested, such as updated practical moving and handling skills, risk assessment and carrying out supervision. The organisation has a training department and the Manager works closely with the staff there. The Manager said that 80 of staff have completed or are in the process of completing NVQ Level 2. The new staff have been registered for LDAF training. The senior staff are undertaking NVQ Level 4. The situation regarding induction and training reflects the work carried out by the Manager to assess the training and development needs of individual members of staff and to work with others in the organisation to plan the necessary training. Since she started working at the Centre the Manager has carried out formal supervision for all members of staff. This will now be shared between herself and the two deputy managers. Training with regard to the provision of supervision is provided by the organisation. A selection of files show that appropriate recruitment procedures are being followed. The files contain the necessary checks on identity and references, including CRB disclosures. Staff said that they were interviewed formally and that references were taken up prior to them starting work. Guests told the Inspector that they like the staff, that they are friendly and that they are kind. Staff were seen to communicate positively and kindly to the guests in an informal manner. The completed comment cards state that Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 23 the staff are kind, caring and that it “…is great to see how well they all work together”. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome group is good. The management of the Home has improved greatly with a clear sense of leadership and direction. A formal process of quality assurance has been implemented which takes the views of the guests into consideration. The health and safety of the guests and staff is taken seriously. EVIDENCE: The Manager has made a big difference to the management of the Home and has brought about a lot of improvements in the short time that she has been there. The Manager also officially manages the day centre that the organisation runs next door to the Centre but spends the majority of her time at the Centre. This situation remains under regular review between the Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 25 Manager and the Operations Manager to ensure that it continues to benefit the services and to not be too much of a burden to the Manager. There are two deputy managers and three senior support staff who also make up the management team. The deputy managers both spend approximately one day per week away from the Centre as they are involved in other services also, for example one of the deputy managers spends one day per week providing management support at the day centre next door. The Manager has provided a sense of leadership and clear direction to the staff team. The staff team have had some difficulties within the team over the last year but these seem to have improved since the last Inspection (January 2006) which is pleasing to see. Staff, both new and more experienced, said that the Manager provides good support, has good communication skills and that she is approachable. The deputy managers and senior support staff have a day per week when they are allocated to carry out administrative tasks. They said that this is a positive step and is likely to have contributed to the improvements in some of the records. The management staff have recently not been able to take all of their administrative days due to difficulties in staffing but now that new staff have started they have planned these again. The management team provide an oncall system. The Manager said that she receives very good support, both formally and informally, from her line manager who is the Operations Manager. She meets with him regularly and said that she can always contact one of the senior managers of the organisation if she needs to discuss any issues. The health and safety of guests and staff is taken seriously. The organisation has a member of staff responsible for health and safety and he was at the Centre at the time of the visit carrying out an annual audit. The Manager is going to implement monthly health and safety checks that an identified member of staff will carry out. The Inspector saw a selection of maintenance/service certificates for the moving and handling equipment and fire safety equipment. The Manager said that restrictors are fitted to the windows on the first and second floor and that the hot water is regulated. It is recommended that the bath temperatures are recorded and that monthly checks are carried out randomly on the hot water outlets. The accident book was seen and this is completed adequately with the Manager signing to confirm that she has seen it. The new staff received health and safety training within their induction. All staff receive first aid and fire safety training. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 26 The Manager has made a good start at producing an annual quality assurance report. This is the first report, known as Rainbow Quality Review and covers a range of aspects of the service provided at the Centre. An action plan has been drawn up from issues highlighted within the quality review. The Centre has a range of ways in which the views of the guests and other stakeholders are obtained. For example, the Centre provides a questionnaire to each guest and their relatives for them to complete about the quality of the service that they received at the Centre. The organisation also carries out monthly visits as per regulation 26. It is recommended that the views of health professionals involved at the Centre and the purchasers/social workers are sought as part of the quality assurance process. Staff meetings take place on a regular basis as does staff supervision in which the views of staff are sought. The Manager plans to build on the initial quality review and to incorporate an overview of the processes mentioned above into the annual quality assurance report. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 27 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 3 3 X 4 2 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 3 X Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 28 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 YA24 Regulation 23 (2d) Requirement It is required that the wallpaper is replaced in the bedroom where it is ripped. Timescale for action 12/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA39 YA42 Good Practice Recommendations It is recommended that the views of placing authorities and health professionals are gathered as part of the quality assurance process. Iti s recommended that a system of checking the hot water temperature regulators are working is put in place. Rainbow House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 House (Holiday Centre) DS0000027335.V300080.R01.S.doc Version 5.2 Page 30 - 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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