Inspection on 07/07/05 for Rainbow Lodge

This inspection was carried out on 7th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rainbow Lodge 20/10/06

Rainbow Lodge 27/01/06

Rainbow Lodge 11/02/05

Rainbow Lodge 03/08/04

Rainbow Lodge 19/02/04

Rainbow Lodge 13/08/03

Rainbow Lodge 13/12/02

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

CARE HOME ADULTS 18-65 Rainbow Lodge 15 Trinity Road Scarborough North Yorkshire YO11 2TD Lead Inspector David Blackburn Unannounced 7 July 2005 09:00 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 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 Stationary 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 Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rainbow Lodge Address 15 Trinity Road Scarborough North Yorkshire YO11 2TD 01723 375255 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Catherine Sleightholm Mrs Catherine Sleightholm Care home only 3 Category(ies) of LD Learning disability (3) registration, with number of places Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 11/02/2005 Brief Description of the Service: Rainbow Lodge is a large semi-detached property occupying three floors. It gives accommodation, on the upper floors, in three single rooms for adults with learning disabilities. Communal space is provided on the ground floor. The property is the private home of Mrs Sleightholm who, together with members of her family, provides the care and accommodation for the three residents. They are accommodated as members of the family. Mrs Sleightholm and members of her family provide personal care, meals, laundry and a domestic service. They are the only staff. Residents are encouraged to be involved in all aspects and activities of daily living according to their individual abilities and capabilities. Mrs Sleightholm provides a variety of in-house activities. Residents also attend day care placements and a number of activities organised outside the home. A large private garden is used for outdoor activities. Residents have easy access to the towns facilities and amenities through the homes central location and use of the registered providers motor vehicle. Full use is made of the local health services including doctors and dentists. Access to more specialised health and social care services is accessed through the doctor or Mrs Sleightholm. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection on which this report is based was the first to be carried out in the inspection year April 2005 to March 2006. It was undertaken over 5.5 hours including preparation time. The focus was on a number of key standards together with any subject to requirements and recommendations at the last inspection. An inspection of some parts of the premises including bedrooms was carried out. A number of policies, procedures and records were examined. Discussions were held with the registered provider, who is also the manager, a staff member, the three residents and a visiting social care professional. The residents, seen in private, made complimentary comments and gave positive feedback on the care and services provided in the home. What the service does well: Good assessment procedures were in place to ensure any person admitted would have their personal needs, hopes and choices fully identified, understood and met. Case files were easy to follow and understand. The information on each resident clearly showed in great detail their needs and how they would be met. A resident said “I feel well looked after.” Residents were encouraged to make full use of the local community and the use of the registered provider’s motor vehicle ensured easy access to facilities and amenities. A resident said “I go out every day when the weather’s good. I like to do some of the shopping for the home.” Residents enjoyed good contact with family and friends. One resident said that her friend from the day centre often came to tea. The premises were clean, warm, and free from offensive odours. Proper attention was given to the maintenance of hygiene. Staffing cover was provided by the registered provider and members of her close family some of whom had achieved relevant qualifications. Residents and the visiting professional were complimentary in their comments about the staff and the care and services being offered in the home. The home was properly managed. Appropriate attention had been given to matters of health and safety to ensure the home was a safe place in which to live and work. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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 standard(s) 2. Residents were assured their needs and choices would be properly assessed and met. EVIDENCE: The last admission to the home had taken place over 10 years ago. Assessments had been completed as part of the admission process. Criteria for admission were shown in the Statement of Purpose and within the policies and procedures of the registered provider. The registered provider said she expected the funding authority to carry out the assessment process and produce the initial care plan using their selection criteria. The registered provider had produced a pre-admission assessment pro-forma that would be used for any prospective resident admitted on a selffunding basis or to support those publicly funded. She was confident this assessment would make full use of and take into account the views of existing residents, family and advocates, visiting professionals and other interested parties. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7. Residents’ needs, choices and preferences were well recorded ensuring they could be properly understood and met. EVIDENCE: The case file of each resident was examined. They were well organised. The original care plan was on file. Reviews had taken place with members of the funding authority and copies were seen. The visiting professional confirmed that formal reviews were held annually. The registered provider had devised a system of written monthly evaluation and reviews. These had been signed by the residents. The care plans gave a clear picture of each resident’s needs and the actions required of the registered provider to meet those needs. The registered provider said she discussed the care needs with individual residents. They confirmed they were aware of a care plan. A record of significant events was maintained. The care plans gave an indication of the way in which individual care was to be provided. The registered provider was keen to ensure that residents controlled their own lives. They said she supported them in making day-to-day decisions. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 10 The registered provider acted as appointee for one resident. The record of transactions had lapsed in recent months. This should be reinstated. Any money was held in a bank account in the resident’s name. The resident said she was happy with the arrangements made on her behalf. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 17. Residents’ use of local facilities and amenities, regular contact with family and opportunities for social interaction were promoted and maintained enabling them to have a number of different life experiences. Residents’ dietary needs were well met through the provision of varied and nutritious meals. EVIDENCE: None of the service users could undertake paid or voluntary employment. None was able to take advantage of local further educational classes. Some service users had day care placements either at the centre attached to the home or at an external location. One resident said “I enjoy the centre. We do all sorts of things. I’ve got a certificate for gardening.” Service users were encouraged to make full use of the facilities and amenities in the local community. A full risk assessment had been carried out for each resident in relation to activities outside the home. One resident said “I like to go out. I go shopping and have to cross the road. Cath (registered provider) always tells me to be careful.” Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 12 Each resident had regular contact with family and friends. This was maintained through visits and telephone calls. Some families were able to visit their relatives at the home. Residents had made friends at day centres. One said “I have a special friend at the centre. She comes to tea quite often. It’s nice.” Residents were provided with a varied and substantial diet. The menu devised by the registered provider often on a daily basis reflected the likes, dislikes, choices and preferences of residents. No record of the food being provided was maintained. Two residents had hospitality trays in their rooms though hot and cold drinks were available throughout the day. Residents said the meals were “very nice” and “enjoyable.” The registered provider knew what they liked and “always gave nice food.” One resident said “All the meals are nice. When the weather is warm we often have a barbecue in the garden.” The visiting professional said “Residents are always telling me how good the meals are.” Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20. Residents’ social and health needs were promoted through good attention to way care was offered and proper medication procedures. EVIDENCE: The care plans recorded the needs of each resident. All residents could selfcare though some assistance was required. The registered provider gave the necessary supervision, encouragement and prompting as required. All care was given behind closed doors. All facilities had privacy locks. The residents confirmed they went to bed and got up when they wished. Times of rising could be compromised by the need to be ready for day care transport or for appointments. Residents said they chose and bought their own clothes. They were assisted by the registered provider who ensured clothes were age, sex and personality appropriate. The care plans showed the input of health and social care professionals. Residents and visiting professionals were complimentary in their remarks about the manner in which care was offered. Proper procedures were in place for the ordering, receipt, storage, administration, recording and return of medication. The registered provider should undertake accredited medication training. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22. Residents had the confidence their concerns and worries would be listened to and acted upon. EVIDENCE: A revised complaints procedure was available in draft form. This must be published and a copy given to each resident to replace the one presently in their rooms. The procedure showed how to complain, to whom and the timescales for response. Clear reference was made to the regulatory authority whose name and address were given. Residents showed the inspector their copy of the procedure. All said they would approach Cath (registered provider) or Rachael (staff) if they were unhappy. If nothing was done they would speak with their care manager. None of the residents expressed any worries or concerns about life in the home. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24, 29 and 30. Residents were provided with a homely, comfortable and safe place in which to live. EVIDENCE: Rainbow Lodge is a large semi-detached house occupying three floors, the upper two providing the bedroom accommodation for service users. Communal space was on the ground floor together with the registered provider’s personal accommodation. The property was well maintained and in good condition. Clear evidence of work in upgrading and modernising the house was seen. The home was well decorated. Furnishings, fixtures and fittings were of a good quality and in a serviceable condition. Lighting, ventilation and heating were sufficient given the location, size and layout of the premises. There was no visible indication to suggest the property was a care home. Residents said they were very happy with their bedrooms. “My room’s nice. I have a lot of my things here.” The rooms were all well personalised. New floor covering was required to one bedroom. The home was clean, warm, tidy and free from unpleasant odours. The laundry was located in the kitchen. Proper procedures were in place for the Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 16 promotion and maintenance of hygiene and the elimination of cross infection. Laundry was only undertaken at times when food was not being prepared. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 35. Residents had the confidence they would be offered a consistency of care and the proper meeting of their needs through the knowledge, experience and skills of the small staff team. EVIDENCE: The registered provider together with members of her close family provided all the required care. Her daughter held a National Vocational Qualification in care to level 3. She was undertaking the Registered Managers (Adults) NVQ 4 Award. The registered provider had many years experience in a number of care settings. These included providing care to those with disabilities. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. Residents were able to live in a properly managed, safe and secure environment. EVIDENCE: The registered provider had no formal care qualifications. She was aware of the need for any manager to have achieved a National Vocational Qualification in care and management to level 4 by 31st December 2005. A questionnaire had been distributed to each resident. All three had been returned. All replies were positive and none raised any concerns or dissatisfaction. A number of records were seen. They were being completed in a correct manner. The food record was out-of-date. This must re-commence. Health and safety policies and procedures were seen. Proper attention was being given to matters of health and safety. A new fire detection system had Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 19 been fitted. A number of reports and certificates were seen with regard to the safety of the premises. The registered provider must update her training in first aid, fire safety and food hygiene. Fire drills must be carried out in accordance with the recommendations of the fire service namely every six months. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 1 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rainbow Lodge Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 1 1 x J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 21 YES 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 22 Regulation 22 Requirement The draft complaints procedure must be published, included in the Service User Guide and given to each resident. A new carpet or other suitable floor covering is required to one bedroom. A record of the food provided for residents must be kept on a daily basis. The registered provider must undertake training in first aid, fire safety and food hygiene. (outstanding from 30/04/05) Fire drills must be carried out at least every six months. Timescale for action 31.07.05 2. 3. 4. 24 41 42 16(2)(c) 17(2) Schedule 4.13 9 30/09/05 31/07/05 30/09/05 5. 42 23(4) 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 7 20 37 Good Practice Recommendations Details of all financial transaction carried out on behalf of residents should be fully recorded. The registered provider should undertake accredited training in relation to the safe handling of medication. The registered provider is reminded of the need for any J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 22 Rainbow Lodge manager of a care home to have obtained a National Vocational Qualification in care and management to level 4 by December 31st 2005. Rainbow Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 4, Triune Court Monks Cross York YO32 9GZ 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 Lodge J53-J04 S7689 Rainbow Lodge V236864 070705 Stage 4.doc Version 1.40 Page 24 - 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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