Inspection on 07/09/07 for Rathmore House

This inspection was carried out on 7th September 2007.

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

The inspector 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

Rathmore House 09/08/06

Rathmore House 29/11/05

Rathmore House 16/12/04

Rathmore House 09/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Rathmore House 31 Eton Avenue London NW3 3EL Lead Inspector Pippa Canter Unannounced Inspection 10:00 7 September 2007 th X10015.doc Version 1.40 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 Rathmore House DS0000010331.V333593.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 Older People. 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. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rathmore House Address 31 Eton Avenue London NW3 3EL 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) 020 7794 3039 020 7794 6169 michael.mckeon@ccht.org.uk Central & Cecil Housing Trust Post vacant at present therefore email address is incorrect above. Care Home 20 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2007 Brief Description of the Service: Rathmore House is a listed building that has been adapted to become accommodation for older people. It is situated in a residential area of Swiss Cottage bordering Belsize Park. The home is owned by Central and Cecil Housing Trust. The aim of the service is to provide care to elderly people of both sexes, aged 65 years and over, who require a high level of support because of having dementia. The current scale of charges is recorded as £784.76. Permanent care will be provided for service users assessed as having dementia and who may need some nursing care. Accommodation for service users is over three floors. There is a shaft lift, which gives access to all floors. There are a total of 20 bedrooms. Thirteen of which have ensuite facilities comprising a toilet and a hand basin. All floors have assisted bathrooms/showers and additional communal toilets. Since the last inspection there has a re-organising of the communal accommodation. There are now two lounge-cum-dining rooms on the ground floor. All rooms are linked via a call bell system. Service users have access to landscape grounds and a secure garden. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day, which lasted from mid-morning until mid-afternoon, about six and a half hours in total. The manager was available and assisted the inspector along with additional input from staff on duty, visitors and people living in the care home. Records such as care plans, assessments and menus were examined. The care plans were also cross-referenced with other records, such as complaints and accident and incident reports. A partial tour of the building was made. Four service users were asked for their views of the running of the service and talked about their experiences of being in the home, though some were unable to give them due to their level of disability. Staff were observed fulfilling their roles and responsibilities and were involved in general discussion with the inspector. Service users and staff were spoken to during both, and lunch was observed being served during one of the unaccompanied tours. Some staff were asked about aspects of care, and of their experience of working at the home. Staff recruitment, supervision, and training records were examined. We carried out a period of observation in one of the lounges and during the lunch time meal. This is the short observational framework inspection. Evidence from this is included in the report. Prior to the inspection we looked at all the information we had about the home, including notifications of accidents or serious incidents and previous inspection reports. The manager had returned an Annual Quality Assurance Assessment, which confirmed some useful information about the service. Comments cards for service users, relatives and staff had been sent to the home. To date two staff and two relatives have replied. Other surveys were sent out to Care Managers and a GP surgery and Commissioning agents but to date these have not been returned. Any feedback received is reflected in this summary as well as the main body of the report. We reviewed all the evidence and it has allowed us to form a judgement about the outcomes for people living in the home. At the end of the inspection, general feedback was given to the manager. A feedback form will be sent along with the draft report so the manager can let us know how he felt about the inspection process. What the service does well: The service has a block contract with the London Borough of Camden (LBC), therefore there is strict criteria regarding admission to residential care. This Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 6 includes people being admitted to the home have been assessed by social services. A competent person from the home also assesses the person to make sure that the home can meet their needs. All people living in the home have a care plan which covers health, personal care and social needs. The arrangements for health care needs are well established with a good standard of physical and personal care being maintained. Some of the communal areas have been redecorated and greater attention has been paid to the bathrooms to make them more inviting places. 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 Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 , Standard 6 does not apply - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are fully assessed before they move into the home. Plans are in place to meet these needs at the stage that they move in EVIDENCE: The service has both a service user guide and a statement of purpose. It is planned to have an updated service user guide that is more accessible to people with Dementia. The new format should include pictures. As this service is part of a block contract paid for by the London borough of Camden, all referrals are through social service’s care management team. A social worker assesses each person, with input from other professionals where this is indicated. The home receives the community care plan. An inspection of four case records identified that the home undertakes their own preRathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 10 admission assessment visiting the prospective service user either in hospital or at home. Where it is beneficial, the new referral has been invited to the home to have a meal and spend time in the company of the staff and the other residents. The admission process informs relatives and advocates of the need for their involvement in supplying life history details, bringing in personal items that are pertinent to their loved one and practical help such as labelling clothes. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a continuous assessment, care planning and review process in order to meet the personal and healthcare needs of the people living in the home. Areas for improvement have been identified by the manager and plans are in place to address them. EVIDENCE: A sample of four care plans and the previous two weeks daily records were looked at. These covered a range of health, personal care and social needs. In each case we met the person concerned but were not able to discuss their care with them due to their level of disability. We did, however, compare the care detailed in the care plan with the care being received on a day-to-day basis. In one instance one person did not have a care plan relating to the pressure sore although it was clear from entries that this was receiving the correct attention. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 12 An inspection of the care plans, daily recordings and discussions with the manager highlighted that a more person centred approach needs to be taken. This viewpoint was echoed by one of the relatives in a survey that was returned following the inspection. The comment made was “They are very caring, but I think lack the imagination to respond to the individual needs of the patients.” “ in my opinion the care home as it exists now treats everyone the same.” When talking to and observing staff they know the individual preferences of each person but this is not always reflected in the care they receive. Overall the standard of physical and personal care is maintained to a good standard but the social care is not always to the forefront. The service had planned to adopt a more person centred approach and expand on the social profiles of the people living in the home. This was to be done through a project called “Me, Myself and I”. This project had a poor response from relatives i.e. supplying relevant details and the art therapist, who was to head the project, leaving. Although there has been this set back, there are plans to re-introduce the project with the new activity co-ordinator to take the lead. The service must identify ways in which relatives can be encouraged to be more proactive in the care of their loved ones. The arrangements to meet the health care needs are well established and documented in the care records. All residents are registered with a General Practitioner (GP) and the manager confirms that the home has a good relationship with the GP and the Community Nursing Services. Discussions with the acting manager highlighted the need to have a wider skill mix with in the nursing team and the recruitment of a registered general nurse is indicated. Observation of the staff interacting with people in their care showed that they respect the privacy and dignity of the residents. However greater attention needs to be paid to the language used in the care plans and care records. An example of this was the use of the term “nappy” sack which is a phrase used for infants and not adults. Language is an indicator of attitude and approach, which in this case is not in line with best practice. Please see requirement 1 A sample medication audit was carried out, this included storage, ordering, receipt and administration of medication. Since the last inspection in august 2006, arrangements for the storage of medication has been improved. Medication is stored in a secure room within lockable facilities. A record of the ambient temperature is being maintained and it fluctuates between 22 Cto 24 C. A fridge is available and this temperature is also being monitored, however it was apparent the fridge needs to be defrosted. It is also necessary to record the minimum and the maximum temperature of the fridge. All medication is administered by qualified staff. The nurses undertake a weekly audit of the MARS sheets and the general arrangements and where noncompliance is observed this is recorded. However it is not clear if any areas of non- compliance are addressed. One name kept recurring over seven weeks, Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 13 when the nurse doing the audit had identified that a colleague had left gaps on the medication administration records. It was unclear what action had been taken. Please see requirement 2. A monitored dosage system is in use and an inspection of the shelves and cupboards identified that the practice of overstocking had improved. At the time of the inspection, no one living in the home had been prescribed controlled drugs however a close look at controlled drugs register showed that is was being kept appropriately. A “doom kit” was also available for the disposal of unwanted medication. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has recognised that the daily life and social activities of the people are important and are addressing these to ensure that a consistent approach is maintained. EVIDENCE: In March 2007, the provider carried out an audit regarding social activities. This clearly showed that this area needs considerable improvement. The main areas identified needing attention were care plans were not being developed around social activities; activities were not being done by staff on a daily basis because of other commitments; activities not being publicised and staff are not recording when service users participate in activities. The four care plans seen were comprehensive and did identify wishes and preferences. However these was not always reflected in the daily records, which related mainly to health and personal care needs. It would seem from the daily accounts that people get up, receive personal care, have their meals and then go back to bed. There was limited information about the activities the person had engaged in, their mood and behaviour and how they had Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 15 interacted with their environment. The care records did not always reflect real strategies for staff to adopt to channel challenging behaviour. A relative has commented “I think the patients lack intellectual stimulus. Everything should be done to keep such patients in the real world, walks, outings visits to exhibitions. By noticing what is in the patients’ rooms and helping then to maintain plants, photographs, books and to keep their rooms individual.” This is an areas that is being addressed. A new activity programme has been introduced. An activity co-ordinator is in post and has attended an activity training day and further training is planned. The service aims to book shows every six to eight weeks however more engagement with staff is indicated. On the day of the inspection a group of five people were observed in one of the lounges. The television was on but two of the people adjacent to the screen would not be able to see it. For the whole hour no one watched the programme and this would be an indicator as to whether the programme was appropriate. Two people were asleep, one was engaged in reading a newspaper and another was busy tidying her handbag. The fifth person was disengaged for most of the time. Staff came in and out of the room, some interacted with residents and others did not. During that time no one sat with the residents for a prolonged period and engaged them in conversation or an activity. This should not be just the responsibility of care staff but also the domestic and laundry staff, who can be involved in supporting people with everyday tasks such as folding clean towels, napkins, dusting ornaments etc. Please see requirement 3. The catering arrangements in the home are under contractual arrangements with an external catering group. The menu was on display catered for meat eaters, vegetarians and cultural preferences. The food served at lunchtime looked appetising. People who required assistance with eating and drinking were supported in a sensitive and caring manner. One observation made was that staff did not always remind people what food items were on their plate for their main course or in their bowl for pudding. People said that they liked the food they were served. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the care home are safeguarded by the home’s policies and procedures EVIDENCE: The Commission For Social Care Inspection has not received any complaints directly. The service has a robust complaints policy and procedure, which is on view around the home and contained within the service user guide. Through the advent of leadership training, all senior staff in the home will have the confidence to manage concerns appropriately. People using the service were observed raising queries with staff and these were answered promptly and sensitively. The service has systems in place in order to protect vulnerable people. There is a robust adult protection policy and procedure linked to the local authority guidance. Staff receive appropriate training and aware to be vigilant for any signs in changing behaviour. The service has a thorough recruitment and selection process, with appropriate checks being made in respect of eligibility to work (visas), validated references and criminal records bureau checks. There is a system in place to monitor and audit the personal monies. These are randomly checked by external auditors and monitored through the monthly visits by the provider. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People generally live in a comfortable, homely and clean surroundings. EVIDENCE: A tour of the building revealed that some communal areas have been redecorated. A recommendation was made at the last inspection as assisted bathrooms were being used as storage areas. These have improved and consideration has been given to making them more attractive to use. A storage facility has been created. New flooring has been laid in the main hallway and a small lounge along with new lighting. As part of the improvements to the service a conservatory is planned. The project is to be funded through fundraising and an internal grant award. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 18 Scaffolding had been erected to the rear of the property. The reason is to identify the cause of damage to a ceiling on an upper floor. The window frames were also noted to be in a poor state of repair and appearance. The manager has confirmed that this is to be rectified. Please see requirement 4 The premises were noted to clean and generally odour free although a malodour was detected in one room. Cross infection procedures are in place and there are sufficient aids and adaptations to meet the current needs of the people living in the home. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Developments are in place to make sure that the staff team have the necessary background knowledge and skills to meet the individual needs of the people living in the home EVIDENCE: “The staff are very skilled and understanding.” “The staff have patience and understanding” The above comments were received from a relative via a postal survey. The people living in the home, who were part of the case tracking process, were unable to give their views due to the level of disability. However, during the visit we indirectly observed staff working with people, and having warm and affectionate relationships with them. Feedback from a relative is was “They (the staff) are very caring, but I think lack the imagination to respond to the specific needs of the patients.” Training records showed that there had been a training programme in place since the last inspection. Staff have updated their training in respect of manual handling, first aid, health and safety and food hygiene training. Feedback from staff also confirmed that the training they receive is indicative of their role, Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 20 helps them understand the individual needs of the people in their care and keeps them up-to-date with new ways of working. Half of the staff group have completed a five-day recognised training in “Communication and Care Giving in Dementia” and it is intended that they cascade this training to colleagues. Care staff must be supported and enabled to develop the skills, knowledge and abilities so that they can respond to the person with dementia as a unique individual; supporting and enabling them to maintain or regain skills and abilities whilst offering care in those areas where they are experiencing specific difficulties. Feedback from staff is that they require more training in managing challenging behaviour and this is an area identified by the manager as requiring further development. The home has experienced problems in both the organisation and management and conflict between nursing and care staff. This had come about because of the new registration as a nursing home, meant that newly employed nurses took the lead role, rather than senior care staff. In the absence of a registered manager, the interim management arrangements have provided stability but meant development has been slow. This inspection highlighted that there is an improved team spirit and the management arrangements will be finalised. These changes should have a positive effect on the running of the home and staff working in a person centred way. Prior to this inspection, the recruitment and selection process has been examined. A sample of staff personnel records were inspected at the head office with input from representatives of the Human Resources Department. This showed that the organisation has a thorough and robust recruitment and selection process. Allied to this, the care home has updated all staff files with the CSCI proforma, which has a photograph attached and kept in alphabetical order. Staff have confirmed that they have regular support and supervision along with an annual appraisal. New staff have a three month mid-term appraisal and an end of probation appraisal after six months. This also includes supervised practice. Feedback from a staff member and a relative was that staffing levels should be increased. A relative said that the care staff were very “hard working”. Discussions with the manager a new rota was introduced in August 2007. The revised rota is designed to deploy more staff during the busiest periods, namely in the morning and management will be represented over a seven day period. The purpose is to afford more flexibility around routines in order to meet individual needs of the service users. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home will be provided with strong leadership and management in order to sustain improvements to support the quality of life of the people who live there. EVIDENCE: The registered manager left his post prior to the inspection in August 2006. Pending the appointment of a new manager, a nurse-in-charge and a general manager were given the responsibility of managing the home. The nurse in charge having responsibility for all clinical decisions. The provider has had little success in recruiting a suitable candidate for the vacant manager’s post and has chosen to maintain the current management arrangements. The local Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 22 office has received confirmation that the general manager has applied for registration. During discussions with the provider and the general manager, they have demonstrated a good level of awareness of the strengths and weaknesses of the service. Through the completion of the Annual Quality Assurance Assessment and discussion, the general manager provided evidence that there are plans in place to address many of the issues raised in this report. We are confident that suitable management arrangements are in place. The judgements in previous sections of this report have contributed to the judgement in this outcome area, which is based on information gained between this site visit and the information already held by the Commission For Social Care Inspection. There is a clear vision on how the home can be best managed to meet people’s individual needs and so maximise their quality of life. A comprehensive review of all job profiles has taken place and the service is working towards key targets as part of the company’s corporate standard. The general manager has acknowledged that there needs to be greater involvement of service users and their relatives in the development of the service. The inspector would advocate that one area to be clarified with the people living in the service and their relatives is the impact of The Mental Capacity Act on the care service. Staff have confirmed that they have regular support and supervision along with an annual appraisal. New staff have a three month mid-term appraisal and an end of probation appraisal after six months. This also includes supervised practice. We discussed the records of people’s personal finances that were handled by the home. This was an effective system that safeguarded people, and provided a clear audit trail. The records are checked regularly by two senior staff and as part of the Regulation 26 visits, receipts are kept for all purchases. The service continues to promote a safe environment to live and work in. A sample of health and safety documents were looked at and these were found to be accurate and up-to-date. Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 24 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 OP10 Regulation 12(4) Requirement The registered person must make sure that all practices, including written records, within the home are conducted in a manner that respects the dignity of the people who live there. The registered person must make sure that when medication administration records are not signed this is fully investigated and the action taken recorded. The registered person must make sure that all people living in the home have a programme of suitable activities. This must include those people with complex needs, and those who are nursed in their rooms. This is so that all people living in the home have a full a life as possible The registered person must inform the Commission for Social Care Inspection when the repairs and/or replacements of the window frames has been completed. Timescale for action 30/11/07 2 OP9 13(2) 31/10/07 3 OP12 OP14 12 & 16 (m) & (n) 30/11/07 4 OP19 23(2)(b) 30/11/07 Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Rathmore House DS0000010331.V333593.R01.S.doc Version 5.2 Page 27 - 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!