Inspection on 22/01/08 for Rainbow House (Holiday Centre)

This inspection was carried out on 22nd January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rainbow House (Holiday Centre) 12/06/06

Rainbow House (Holiday Centre) 04/01/06

Rainbow House (Holiday Centre) 04/05/05

Rainbow House (Holiday Centre) 27/10/04

Rainbow House (Holiday Centre) 13/07/04

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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 House (Holiday Centre) 15 Hooks Hill Road Sheringham Norfolk NR26 8NL Lead Inspector Lella Hudson Unannounced Inspection 22nd January 2008 09:15 Rainbow House (Holiday Centre) DS0000027335.V358411.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.V358411.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.V358411.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 Position vacant Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10), Physical disability (10), of places Physical disability over 65 years of age (10) Rainbow House (Holiday Centre) DS0000027335.V358411.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. 12th June 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.V358411.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star (1*). This means the people who use this service experience adequate quality outcomes. This report contains information that has been gathered about the service since the last Key Inspection which took place in June 2006 which includes an unannounced visit to the Home which was carried out on the 22nd January 2008. Information was gathered from surveys which were sent to guests, relatives and staff. Information was provided by the previous Manager within the completed Annual Quality Assurance Assessment. During the visit to the Home the Inspector spoke to the acting manager and staff as well as observing staff supporting guests. A tour of the accommodation was also carried out. There were two guests staying at the Centre on the day of the visit. During the visit to the Home the Inspector was accompanied by an expert by experience. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The previous Manager and one of the deputy managers left the Centre in November 2007 and another manager from within BREAK services is currently managing the service in an acting capacity. BREAK are actively recruiting to this position and a deputy manager has already been appointed. What the service does well: The views of the guests are sought about what they would like to do and how they would like to spend their holiday A range of information is sought prior to guests coming to stay at the Centre so that care plans can be written to provide guidance to staff about how to meet individuals needs The staff work hard to provide guests with a good holiday Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 House (Holiday Centre) DS0000027335.V358411.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.V358411.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information about the guests needs is gathered prior to their stay EVIDENCE: The initial information about guests needs is provided through the booking form. This asks for information about a range of needs that the guest has, including mobility, communication, personal care, behavioural support. Staff contact relatives/carers for additional information if they need to clarify something from the booking form or if they need more information. On the day of the guests arrival a member of staff spends time with the guest and their relative/carer to establish whether there have been any changes in the needs of the guest. As guests come to stay at the Centre from all over the country it is not practical for the Manager to individually assess each guest although guests are invited to visit the Centre prior to their stay if they wish to. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 9 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): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments contain information about how to meet the guests needs but would benefit from being more detailed. Guests are encouraged to make choices about how they wish to spend their holiday. EVIDENCE: Over the last two years the care plans and risk assessment formats have been reviewed and improved. The format now being used requests information about a range of needs that guests have. There is a particularly useful section asking for information about how guests communicate different feelings, such as being worried, bored or angry. This is very useful for staff when supporting guests whose verbal communication is limited. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 10 As previously stated, the information about individual needs is gathered together prior to the guests stay. A risk assessment is then put together from the information and this assists the booking co-ordinator when arranging the bookings for the Centre. Staff are asked to read the care plans and other information relating to guests prior to them arriving. The staff surveys contain mixed views about whether staff have enough up to date information about guests needs with an equal number stating “always” and “usually” to this question. Although the care plans and risk assessments have improved over the last few years they would benefit from being more detailed in some instances. For example, one of the risk assessments identified that a guest has aggressive behaviours and is considered a medium risk in this area. However, the information within the care plan does not provide evidence for this assessment and the guidance within the risk assessment about how to manage the risk is not detailed enough for someone considered to be of medium risk. It is recommended that the Manager ensures that the care plans and risk assessments contain detailed guidance about how to meet guests needs. Staff work hard to give guests a choice about what they would like to do during their holiday. The AQAA states that staff have received training with regard to Total Communication and Signalong but this is not recorded on the training records which were given to the Inspector. The Manager said that one of the staff members is responsible for looking at guests communication needs and how these can best be met. The expert by experience observed that the provision of information, such as the fire procedures and the menu, in a pictorial format would benefit some guests. A recommendation is made about this If guests are unable to look after their own money then there are suitable procedures in place for looking after it for them. This system was checked on the day of the visit and the records, receipts and cash were able to be audited. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The opportunities for guests to be supported in activities whilst they are at the Centre could be improved. EVIDENCE: The staff team are all clear that their role is to enable the guests to have a good holiday and they work hard to do so. The previous report reflected the improvements that had been made to increase the flexibility to support guests in smaller groups to access activities both in the Centre and in the local community. Unfortunately these improvements have not been maintained. Evidence gathered from the staff surveys, discussions with staff and the acting manager and looking at records show that there may be several reasons for this. For example, the other holiday Centre that the organisation owned closed last year and some guests were accommodated at this Centre so that they did not Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 12 lose out on a holiday. However, this may have meant that the usual care that is taken with booking guests may have not been able to have been taken and that the mix of guests was not very successful. The Centre has experienced some staffing difficulties since the last Inspection and agency staff have been used on a regular basis. This means that staff do not know the guests, nor the routines of the Centre. Another factor may be that the usual bookings Co-ordinator was on maternity leave for a few months. The records of bookings show that on some weeks there were at least six guests booked in with high needs. On one week there were six guests with high needs and four guests with medium needs, this is not an acceptable mix of guests as the layout of the accommodation and the number of staff on duty are not suitable to meet the needs of the guests in these circumstances. The acting manager is aware of all of these issues and improvements have already been made as recruitment has taken place so that less agency staff are being used and the bookings co-ordinator has returned to her post. The acting manager is reviewing the shift system that is currently worked to ensure more flexibility so that the guests can be supported to access activities at a time of their choosing. Currently most activities take place during the afternoon as this is when there are the most staff on duty. The Centre has a lot of play/activity equipment as well as a soft play room and a sensory room. There is a hydrotherapy pool in the grounds of the Centre. Currently the sensory room is not being used as some of the equipment is waiting to be replaced. The acting manager is aware of the need for staff to support guests to take part in activities within the Home on a more individual basis as well as in going out. For example, during the visit, one of the guests was engaged in an activity with a member of staff but several other staff sat at the dining table with a guest for over half an hour, just “waiting to go swimming”. There has been a change in the catering personnel since the last Inspection at the Centre. The acting manager said that recruitment has recently taken place and so the shortfalls in the staffing for this area should soon be addressed. Staff surveys and discussions with staff show that there have been some difficulties in the transition period with the quality and choice of meals but that this is now improving. The care plans contain detailed information about any dietary needs that the guests have and also about their individual food/drink preferences. This information is also available in the kitchen. The menus show that there is a vegetarian and a salad alternative to the main meal each day. As previously mentioned, the expert by experience noted that alternative formats for the menus may make it easier for some guests to make a choice. See recommendations Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 13 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 adequate This judgement has been made using available evidence including a visit to this service. On occasions, the mix of guests has made it difficult for all guests personal and healthcare needs to be met in a consistent manner The medication system is not currently robust enough to ensure that guests receive the appropriate medication at the correct times EVIDENCE: The care plans contain information about guests needs and how these should be met. This report has already highlighted that due to the poor mix of guests and the high use of agency staff the quality of the service provided to the guests has been reduced in the last few months. However, it is expected that the changes that have been introduced will lead to improvements in this area. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 14 The acting manager and staff team are positive in their aim to provide a good quality holiday to the guests and staff have been frustrated when this has not been possible due to situations beyond their control. The staff team receive training about a range of health issues such as epilepsy, diabetes, first aid and medication. Recently staff have also received training about PEG feeds as now that the other holiday Centre has closed guests who require this form of nutrition are staying at this Centre. All of the staff surveys state that they receive training which is relevant to the guests needs. All staff receive training with regard to the administration of medication. The training records show that this has been provided within the last eighteen months. Following medication errors at the Centre the procedures were reviewed and staff received additional training. The Centre provides suitable locked storage for medication and there are lockable cupboards in bedrooms if guests are able to look after their own medication. Two staff are responsible for checking medication when guests arrive at the Centre and for ensuring an accurate administration record is prepared. The medication was checked against the records of administration on the day of the visit. Some inconsistencies were seen which included one medication not being present for a guest who may need this on an emergency basis. The records did not include any information about why this medication was not present nor any details about what action had been taken to address the situation. One of the guests had brought in some homeopathic medication but there was no written information relating to the administration of this from the parents/carers which the Centres procedures state that there should be. Another of the guests has medication prescribed “as required” (PRN) but there are no clear guidelines about when this should be given and in what dosage. The medication had been administered the previous night but there was no record of how much was administered and the care notes did not provide details about the reason for it being administered. It is required that the medication procedures are followed It is required that there are clear guidelines for the use of PRN medication It is required that medication prescribed for guests is available at all times Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 15 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): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Guests and relatives are given opportunities to raise any concerns/complaints and these are dealt with appropriately Staff receive training with regard to Safeguarding Children/Adults EVIDENCE: The Centre has a complaints procedure which is available in alternative formats if required. Guests and relatives are given a questionnaire at the end of holidays which asks them about different aspects of the service. The staff surveys all, except for one, state that they know how to deal with a situation in which a guest/relative may wish to make a complaint. The AQAA states that there have been three complaints in the last year which have been investigated by the organisation. The Centres policies and procedures aim to protect the guests from any form of abuse. Staff receive training with regard to Safeguarding Children and Adults. One referral has been made to the Safeguarding Adults team since the last Inspection. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Centre receives hard wear and tear which means that it looks shabby in some areas despite an ongoing programme of maintenance and refurbishment EVIDENCE: The bedrooms and communal areas of the Home have an ongoing redecoration and refurbishment programme and the staff try hard to ensure that any damage to the environment is addressed quickly. This can be difficult at busy times, particularly in the school holidays. The entrance hall has been redecorated and has comfortable seating. Guests like to sit in this area and this is now a more pleasant area for them to do so. The lounge has also been redecorated with new furnishings since the last Inspection and is a pleasant room. New overhead tracking has been fitted in Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 17 the bathrooms which is a big improvement which enables staff to assist guests who require hoists for all mobility. The acting manager said that there are plans to refurbish both of the bathrooms on the first floor which will be an improvement. The play/activity room is again in the process of being reorganised. The use of this room is subject to constant change and review. It currently looks very bare and has two televisions which have been put on top of the pool table which means that this cannot be used until the televisions have been moved. The telephone room has equipment stored in it which would make it very difficult for anyone to use it. The sensory room is also not useable at the moment due to equipment being stored in it. Both of these issues had been raised as being health and safety issues in the audit carried out by the Health and Safety officer in October 2007. Despite these being listed as needing urgent action the situation remains the same. It is required that the issues highlighted as needing urgent action in the organisations own Health and Safety audit are addressed. The second floor has now been fully converted to provide office accommodation and a training room for staff. There are also two bedrooms on the second floor, which can only be used by guests who can manage the stairs as the lift only goes to the first floor. The Centre has equipment to assist those with additional needs, for example, the lift, overhead hoists, mobile hoists, door alarms and call system as well as electric beds. The dining room has been decorated and refurbished since the last Inspection. This includes a whole new kitchen area. The acting manager said that new tables have been ordered to replace those recently purchased as the current ones do not meet the needs of the majority of the guests. The tables in place at the moment are large and look institutionalised and so smaller, round tables have been ordered. One wall in the dining room is usually decorated with guests artwork but this is currently bare due to the fact that the Christmas decorations/artwork have been taken down and the Centre has only just reopened after the annual break for staff training. It was noted by both the Inspector and the expert by experience that the majority of the Home, including the communal areas was cold. The acting manager undertook to address this situation. A requirement is made about this. The Home employs domestic staff although there is currently a part time vacancy. The Home was clean throughout with no unpleasant odours. Appropriate systems are in place for the guests laundry. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 18 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): 32, 33, 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Agency staff have continued to be used to supplement the permanent team and this reduces the consistency of the service provided. Staff receive training and support to carry out their roles. EVIDENCE: At the time of the last Inspection the organisation had very recently appointed a number of staff to make up for the shortfalls caused when the organisation stopped using residential volunteers. The new staff meant that the Centre had a full complement of permanent staff but several were still in their induction period. Unfortunately, due to a number of reasons, the Centre has had difficulties in maintaining a permanent staff team and quite a lot of agency staff have been used over the last few months. Although the agencies try to provide staff who have worked at the Centre before the use of agency staff at all tends to reduce Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 19 the consistency of the service provided. In addition to this there have been times when the mix of guests has been particularly difficult and in the last three months there has been uncertainty about the management of the Centre. All of these issues have affected the morale of staff. The responses within the staff surveys confirm that it has been a difficult time for some of the staff. The acting manager and Operational Manager are aware of this situation and are addressing it. The organisation has a formal induction for staff and there is an ongoing training programme. The Centre is closed for a weeks training in January each year and there is ongoing training throughout the year. The staff receive training in mandatory subjects and in additional subjects which are relevant to the needs of the guests, such as the use of PEG feeds, diabetes, epilepsy. The staff surveys confirm that staff feel that they receive training that is relevant to their role. Two of the staff files were seen. Neither of these contained the necessary proof of identity and the references for one of the candidates were such that it would be expected that further investigation of the information provided should have been carried out. A requirement is made about this. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 20 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, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The changes to the management of the Centre have meant that there has been uncertainty and a lack of clear leadership but this is improving. EVIDENCE: The Manager and deputy manager have both recently left the Centre and an acting Manager has been in post for approximately a month. The uncertainty over the management of the Centre has caused staff concerns and there has been low morale within the team. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 21 The senior managers within the organisation are aware of the difficulties and have been providing additional support to the Centre. Recruitment is currently taking place to appoint a new Manager of the Centre. A new deputy manager has already been appointed. The acting manager has been a registered manager within the organisations childrens services and has many years experience of managing a care home. The acting manager is aware of the need for her to increase her knowledge and skills with regard to providing a service for adults with a learning disability and has already taken steps to undertake relevant training and to widen her knowledge in this area. The acting manager has only been in post for a month but the majority of staff feel that she is providing good support to them and some stability to the staff team. The Centre has a variety of ways in which the quality of the service is reviewed. These include guests questionnaires, monthly summaries completed by the manager and sent to the Directors, monthly visits as per Regulation 26 of the Care Homes Regulations. The Operations Manager completed an annual quality review of the service last year which brought together the information gathered throughout the year. A sample of health and safety records were seen. These show that regular maintenance of equipment takes place and that staff receive training with regard to health and safety. Some records could not be found but the acting manager contacted the Inspector after the visit with confirmation of dates that maintenance had taken place. A member of staff has recently been asked to take on the responsibility for fire safety and is in the process of learning about this role. The organisation has a Health and Safety officer who will liase with the member of staff about this role. The “expert by experience” identified that it would be helpful for some guests if the fire procedure was available in pictorial format. A recommendation is made about this. The Health and Safety officer had carried out a health and safety audit in October 2007 and identified several actions that needed to be carried out as a matter of urgency. A look around the Centre showed that many of these have not yet been dealt with. A requirement is made about this. Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 2 35 3 36 X 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 2 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 2 X X 2 X Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement It is required that: - the medication procedures are followed - that clear guidance is provided for the use of PRN medication - that the prescribed medication is available at all times It is required that the heating is appropriate throughout the Centre It is required that the information listed in Schedule Two of the Care Homes Regulations is kept for all members of staff It is required that the issues highlighted as needing urgent action in the organisations own Health and Safety audit are addressed. Timescale for action 22/01/08 2. 3. YA24 YA34 23 (2) 19 22/01/08 31/01/08 4. YA42 13 (4) 29/02/08 Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 24 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 YA6 YA7 Good Practice Recommendations It is recommended that the care plans and risk assessments contain more detailed guidance about how to meet the guests needs It is recommended that some of the written information available to guests is provided in alternative formats Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Rainbow House (Holiday Centre) DS0000027335.V358411.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!