Inspection on 29/06/05 for Rainbow Lodge Nursing Home

This inspection was carried out on 29th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rainbow Lodge Nursing Home 07/10/08

Rainbow Lodge Nursing Home 13/12/06

Rainbow Lodge Nursing Home 07/11/05

Rainbow Lodge Nursing Home 18/11/04

Rainbow Lodge Nursing Home 28/06/04

Rainbow Lodge Nursing Home 09/02/04

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

CARE HOME ADULTS 18-65 Rainbow Lodge Nursing Home 14 Madeley Road Ealing London W5 2LH Lead Inspector Gavin Thomas Unannounced 29 June 2005 at 12.20pm 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 Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rainbow Lodge Nursing Home Address 14 Madeley Road, Ealing, London W5 2LH 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) 020 8991 5060 020 8567 1414 Mr & Mrs Gopaul Mrs Luce Argita Gopaul Care Home 20 Category(ies) of Mental Disorder - excluding learning disability or registration, with number dementia (20) of places Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home will only accommodate service users over the age of 65, if they were in the home prior to their 65th birthday. Date of last inspection 18 & 25 November 2004 Brief Description of the Service: Rainbow Lodge is a three-storey turn of the century building situated in a residential area in Ealing close to local facilities and transport. The home is a Care Home for Nursing for service users with mental health problems and accommodates twenty people. Mr and Mrs Gopaul own the home and are the Registered Providers. Mrs Gopaul is the Registered Manager. The accommodation consists of four single bedrooms and eight double rooms. There are bedrooms on each of the floors. There is a dining area and a few stairs to the lounge area on the ground floor. The dining room is comfortably furnished and is a designated smoking area. There is also a second quiet room on the first floor. The kitchen and the laundry are on the ground floor. There are toilets and bathrooms on each floor. There are no lifts in the building so it is suitable only for service users with good mobility. There is a large secluded garden at the rear of the building and parking spaces for several cars in front of the home. The local community services are easily accessed. Staff support the service users to undertake some small tasks, such as looking after their own laundry. Registered Mental Health Nurses, care staff, domestic staff and a cook are employed to provide care and practical support to the service users. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of five hours. A partial tour of the premises was carried out with the Registered Providers. The Inspector spoke at length with three service users. The three service users gave examples about life in the home for them as individuals. The three service users made positive comments about staff support, the benefits of group therapy and the quality of food. The service users gave examples about their past and how the home has helped them to build their confidence and improve the quality of their lives. The Inspector observed staff interacting with service users in a pleasant manner. The atmosphere in the home was calm and relaxed. What the service does well: What has improved since the last inspection? What they could do better: Although the home had distributed surveys to service users and relatives, a more detailed quality assurance and monitoring system could be improved upon. This was discussed with the Registered Providers at the time of the inspection. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 6 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 Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 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 Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 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) 1 & 2 The home’s Statement of Purpose and Service User Guide are well written providing service users and prospective service users with details of the services the home provides. Only minor amendments were required for these documents. Thorough assessment and admission processes were in place. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The Statement of Purpose was revised in June 2005. Although both documents contained a wealth of information, a further revision of the Statement of Purpose was required to include all of the criteria as set out in Schedule 1 of the Care Homes Regulations 2001. A revised version of this document was submitted to the CSCI on 7th July 2005. Details about the accommodation must also be included in the Service User Guide. The Registered Provider and the Charge Nurse are responsible for conducting assessments with prospective service users. All prospective service users are invited to the home as part of the assessment and admissions process. The Registered Provider said that all future service users would be notified in writing of the outcome of their assessments. The home has not had any service user vacancies for some time. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 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, 7 & 9 A good care planning system was in place to adequately provide staff with the information they need to support service users in achieving their goals. Risk taking processes were detailed and devised in accordance with service users assessed needs. EVIDENCE: Care plans were in place for all service users. All Care Plan Approach meetings were up to date. Care plans are updated every month and formally reviewed every six months. All service users attend their Care Plan Approach meetings. Service users contribute to the review of their care plans. Service users are encouraged to attend self – advocacy groups. Service users also attend in- house group therapy sessions. Service users manage their own finances. Staff provides advice and support to enable service users to manage their finances properly. This was observed at the time of the inspection. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 10 Risk assessments were in place for all service users. The two risk assessments examined for the purpose of this inspection were well written and reviewed regularly. The Registered Providers said that risk assessments are discussed with service users individually and as a group. Service users are reminded about the dangers of smoking in unauthorised parts of the home. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 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) 11, 12, 13, 14, 15 & 17 The home is well established and provides service users with good advice about integrating in the community. Good practice systems were in place for empowering service users and enabling them to develop their skills and abilities through various group and one to one therapeutic support. EVIDENCE: The Registered Providers said they operate an open door policy. A system was introduced within the last year whereby service users have the opportunity to meet with the Registered Providers on a monthly basis. A programme of activities was in place. This included community meetings, which are held weekly and music therapy, which is held twice weekly. Service users are encouraged and supported to participate in life skills such as cooking, laundry, shopping and general domestic duties. Some of the service users attend group therapy sessions at various locations within in the community. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 12 Day trips are arranged by the home. Holidays are arranged by service users and/or their relatives. The home supports service users in maintaining positive relationships with relatives and significant others. A room is available in the home for service users to meet with visitors in private. The menu is devised on a weekly basis with input from service users. The record of food served now includes any specialist diets. The dining area was adequately furnished. Meal times are flexible. Although service users are encouraged to eat as a household, meals are served in accordance with service users commitments. Three service users spoken to said the food was good. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 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 & 19 Personal support in this home is offered in such a way as to promote and protect service user’s privacy, dignity and independence. The health needs of service users are well met with evidence of good multi disciplinary work taking place when required. EVIDENCE: Supervision and verbal prompting are the common levels of support provided for the current service user group. When necessary, staff provide a higher level of support for intimate personal care. This is identified with the individual service user and recorded on the service user’s care plan. Screens are provided in double rooms. One service user confirmed this. Service users daily routines are flexible. However, there is an expectation that service users are prompt for group work and other appointments. The staff team is well established. Members of the staff team are from different ethnic groups including Irish, White UK, Afro – Caribbean, Mauritian and Irish. This balance reflects the ethnicity within the service user group. The Registered Providers said that monitoring systems were in place to ensure that there was a consistent approach within the staff team. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 14 All service users had access to primary health care treatments. All service users were registered with a GP. Service users are accompanied to medical appointments with a staff member. Referrals to specialist health care professionals are made via the GP. The Registered Providers said that service users health needs were being managed in accordance with their assessed needs. Service users health needs are reviewed and monitored regularly. Service users health needs were set out in their care plans. Three service users said that group therapy has helped them to cope with their mental health needs. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a good complaints system in place, with evidence that service users feel that their views are listened to and acted upon. Staff are provided with up to date information on adult protection and how to support individual service users via crisis intervention systems. EVIDENCE: A complaints procedure was in place. The complaints procedure now includes the timescale for investigating any complaints received. A complaints record was in place. This record should include the outcome of a complaint such as if a complaint was upheld or not. The Registered Provider said that the home had not received any complaints since the last inspection. An adult protection policy was in place. This policy was very brief. The Registered Provider said that this policy had been reviewed and updated but was not available for inspection purposes. The Registered Person was required to submit a copy of the revised policy to the CSCI. The home was in receipt of a copy of the ‘No Secrets’ guidance document. Staff attended adult protection training in February 2005. The Registered Provider said there were no known concerns regarding the safety or protection of service users. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The standard of décor in the home was satisfactory with evidence of improvement through maintenance and future planning. EVIDENCE: There have been no changes to the premises since the last inspection. The home was clean and well presented throughout. The home is within easy walking distance to Ealing Broadway, public transport routes and local amenities. The home does not use any form of CCTV. A program of routine maintenance was in place. The home was in the process of being redecorated at the time of this inspection. Furniture and fixtures provided in communal rooms were judged to be of good quality. A policy on the control of infection was in place. This policy was last revised in July 2004. Hand washing facilities were prominently sited throughout the home. The laundry room is situated on the ground floor. The cupboard used in the laundry for storing cleaning detergents was unlocked. This cupboard must be kept locked at all times. The Registered Provider said that an approved contractor carried out an assessment of the water services and facilities within the last year. Double valves have been fitted to the showers as recommended Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 17 by the contractor. The Registered Provider confirmed that there were no other recommendations outstanding. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The home has a well-established staff team who works positively with service users to improve their whole quality of life. Overall training opportunities are good. However, all training must be recorded on the training programme. EVIDENCE: A training and development programme was in place. Induction and foundation training modules were also in place for new staff. Individual training records were kept on staff files. The staff files examined indicated that staff had attended more training than the training identified on the home’s training and development programme. The training and development programme must be updated to reflect all training undertaken by the staff team. All staff attend on to one supervisions every two months. The Registered Providers said that in addition to this, on going support is provided for staff as individuals or as a group. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 19 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) 39 & 42 A review of the home’s performance has commenced through consultations with service users and relatives. These processes must be developed through a programme of self – review and on going monitoring. Overall health and safety systems were well maintained. EVIDENCE: The home was working towards quality assurance and monitoring systems. Surveys had been carried out with service users and relatives. The results of these surveys had been analysed and published. The home is now registered under with the Data Protection Act 1998. A quality assurance policy was in place. This policy must include the frequency for reviewing the quality of the service and the methods in doing so. A quality management policy was also in place. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 20 A copy of the home’s annual development plan was not available for inspection purposes. A copy of this document was supplied to the CSCI on the 7th of July 2005. Two service users spoken to were satisfied with the quality of service. This included staff support. Both service users said that the home provided support systems, which has helped them to improve their confidence and well-being. The Registered Provider said that an independent health and safety audit had been carried out. The outcome of this audit was not available for inspection purposes. The Registered Provider confirmed that all bathing and showering appliances were thermostatically controlled. Hot water temperatures for bathing and showering appliances are tested regularly. Records indicated that hot water is delivered within a safe range. Approved contractors carried out routine safety checks as follows: Gas appliances – December 2004 Electrical appliances – January 2005 Fire appliances – June 2005 Fire safety systems were in place. In accordance with records examined, four fire drills have been carried out to date for this calendar year. However, the record of fire drills must include the length of time taken for evacuation and all the names of those attending each fire drill. Weekly fire checks are carried out on the fire detection system. Staff attend accredited fire safety training annually. In house fire safety training is held periodically throughout the year. Fire safety audits are carried out monthly. A fire safety audit is carried out monthly. The Registered Providers said that all of the current service user group are smokers. As a result, weekly fire safety checks are carried. It was noted that a large number of cigarette ends were disposed off directly in the garden. This was judged to be a potential fire hazard. An appropriate container must be provided and used in the garden for the safe disposal of cigarette ends. Eleven staff had valid First Aid qualifications. The Registered Providers said that there is at least one staff on duty at all times with a valid First Aid qualification. All staff had attended Food Hygiene training. A legionella test was carried out in September 2004. The results of this test were satisfactory. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 21 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 2 3 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rainbow Lodge Nursing Home Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 22 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 1 Regulation 5(1)(b) Requirement Details about the accommodation must be included in the Service User Guide. The cupboard used for the storage of cleaning detergents in the laundry room must be kept locked at all times. The training and development programme must be updated to include all training underatken by the staff team. The record of fire drills must include the length of time taken for evacuation and all the names of those attending each fire drill. An appropriate container must be provided and used in the garden for the safe disposal of cigarette ends. Timescale for action 31/8/05 2. 30 13(3)(4) (a) 18(1)(a) (c )(i) 17(2) Schedule 4 (14), 23(4)(e) 13(4)(c ), 23(4)(a) 31/7/05 3. 35 31/8/05 4. 42 31/7/05 5. 42 31/7/05 6. 7. 8. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 23 No. 1. Refer to Standard 22 Good Practice Recommendations The record of complaints should include the outcome of each complaint investigated, such as if a complaint was upheld or not. Rainbow Lodge Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 Nursing Home G61-G10 s10960 Rainbow Lodge v214287 290605 Stage 4.doc Version 1.40 Page 25 - 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!