Care Home: Rachel House

What the care home does well Service users spoken to gave generally positive feedback about the home. One commented that “I like it here, it is alright.” While another said “Staff come with me if I want to buy new clothes. I like them to help me.” Care planning was of a good standard, as was record keeping generally. The home was well maintained, both internally and externally. Service users have a large measure of control over their daily lives, and are involved in the day to day running of the home. What has improved since the last inspection? There have been improvements to the service since the previous inspection, and the inspector was pleased to note that all of the requirements set at the last inspection are now found to have been met. Risk assessments are now in place for all service users, and records are maintained of medical appointments. The home has arranged for a visit by the local fire authority which has now taken place. Appropriate facilities are now provided for sleep-in staff. What the care home could do better: Despite these improvements, there are still some issues that must be addressed, and a total of four requirements have been made in this report. The home must ensure that medications are stored and recorded appropriately,Rachel HouseDS0000022872.V378224.R01.S.doc Version 5.3 and that systems are in place to help reduce the risk of financial abuse. The home must ensure that all necessary health and safety checks are carried out. Key inspection report CARE HOME ADULTS 18-65 Rachel House Rachel House 103 Sixth Avenue Manor Park London E12 5PS Lead Inspector Rob Cole Key Unannounced Inspection 30th October 2009 09:45 Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Rachel House Address Rachel House 103 Sixth Avenue Manor Park London E12 5PS 020 8514 2556 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) rachellhouse@hotmail.com Ms Estelle Moyo Ms Estelle Moyo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th August 2008 Brief Description of the Service: Rachel House is a three-bedded care home for people with mental health support needs. A private individual Estelle Moyo owns the home and is also the Registered Manager. Newham Registration and Inspection Unit initially registered Rachel House in August 2000. The home offers 24-hour care and accepts emergency placements. The premises are a terraced property in a residential area of Manor Park, with easy access to Ilford shopping area. A range of culturally diverse services and amenities are located in the Romford Road, which is within walking distance. The home is well served by several bus routes, which includes the 25 and 86. Ilford, Manor Park and Woodgrange Park British Rail stations are approximately a mile away. Unrestricted car parking is available. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 30/10/09 and was unannounced. The inspector had the opportunity of speaking with all three service users and the homes deputy manager, who was present throughout the course of the inspection. The manager of the home was also present for part of the inspection. The inspector was also able to talk with a visiting CPN. In addition to these discussions, the inspector was able to observe staff as they carried out their duties. The inspector conducted a tour of the premises, and examined records and other documents. Prior to the inspection, the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CQC. All of this has contributed to the overall inspection process, and to judgements made within this report. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still some issues that must be addressed, and a total of four requirements have been made in this report. The home must ensure that medications are stored and recorded appropriately, Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 6 and that systems are in place to help reduce the risk of financial abuse. The home must ensure that all necessary health and safety checks are carried out. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is the judgement of the inspector that service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation, and the opportunity to visit the home. EVIDENCE: The home has a Statement of Purpose and Service Users Guide in place. Both documents are written in plain English. The Statement includes the homes philosophy of care, which states “We place the rights of residents at the forefront of our philosophy of care. We seek to advance their rights in all aspects of the environment and the services we provide and to encourage our residents to exercise their rights to the full.” The Statement also includes details about the range of services provided and of the homes physical environment. The Service Users Guide includes details of the aims and objectives of the home, and of the staff team. The manager of the home informed the inspector that all service users are provided with their own copy of the Guide. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 9 There have been no new admissions to the home since the previous inspection. Therefore pre admission assessments were not checked on this occasion, but will be tested as part of the next key inspection of the home. The home does however have an admissions procedure in place. This states that pre admission assessments will be carried out, and that prospective service users would be given the opportunity of visiting the home before making a decision as to move in or not. The home accepts both planned and emergency admissions, and policies cover both of theses. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is the inspectors judgement that service users have a large degree of control over their daily lives, and that they are ale to be involved in the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users, which are of a satisfactory standard. They are drawn up with the involvement of the service users, who sign each plan to indicate their involvement with the plan. Service users spoken to confirmed that they are indeed involved in drawing up their care plans. The plans are person centred, and in part written from the service users perspective, for example one plan states “I like putting on make up and Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 11 dressing in nice clothes.” While another states “I like to have a quiet time to pray.” Care plans cover areas such as mental and physical health, personal care, financial support and community participation. Care plans are subject to regular review. All service users are on the Care Programme Approach (CPA), and there was evidence of regular CPA review meetings. Risk assessments are also in place for each service user. These highlight any particular risk, and include strategies to manage and reduce those risks. For instance, one service user has a risk assessment in place around obesity, the assessment includes information around promoting exercise and healthy eating, along with ensuring that regular blood pressure checks are made. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. For instance on the day of inspection it was seen that service users were able to get up at a time of their choosing, and choose when and what to have for breakfast and lunch. Two of the three service users are able to access the community independently, and both informed the inspector that they can come and go from the home as they please, and that they have their own key to the homes front door. Care plans indicated that service users were involved in the daily routines of the home, such as cooking and cleaning. There was evidence that service users are given the opportunity of being involved in the day to day running of the home. For example regular service user meetings are held. These are minuted, minutes seen by the inspector evidenced discussions around menus, activities and house work. One service user recently had their bedroom decorated, and they were involved in this decision. They informed the inspector “My bedroom was painted red, I wanted them to change it. I like it better now.” Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11,12,13,14,15,16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is the judgement of the inspector that service users have regular access to the community, and that food served in the home is of a satisfactory standard. EVIDENCE: No service users are currently involved in any formal education or employment. Service users spoken to informed the inspector that this is their choice. One service user attends Thursday Club, which is run by the NHS for people with mental health issues. Here they have the opportunity to socialise, play table tennis and have a meal. All service users regularly attend a church of their choice, thus helping to meet needs around equality and diversity issues. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 13 Service users access other community based services, such as shops, the post office, the library and public transport networks. The home also arranges occasional day trips, for example to Southend. Two service users are able to access the community independently, and plan and choose their own social activities accordingly. In house service users have access to a variety of activities, such as television, DVD, music, puzzles and board games and exercise sessions. Service users are able to go and visit family in their homes, and are able to receive visitors at any reasonable time, and can see visitors in private if they so wish. Service users are also able to maintain contact with family by telephone. One commented that “I phone up my brother every Sunday.” Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved in food preparation, and also in choosing and buying food. The home seeks to meet equality and diversity needs through food, and traditional British and Jamaican dishes are regularly served. Service users spoken to expressed satisfaction with both the quality and quantity of food provided. Service users are given choice over meals, and are not all served the same thing. For example one service user said that for the evening meal on the day prior to inspection he had a choice of chicken casserole or shepherds pie. The kitchen was found to be clean and tidy, and fresh fruit was available on the day of inspection. However, it was noted that during the night time the fridge and the main food cupboard were kept locked, and that only the staff had access to the keys. Staff informed the inspector that this was because one service user had diabetes, while another had issues with obesity. There were no care plans or risk assessments in place around keeping food locked away from service users. This constitutes a denial of service users rights to help themselves to food as they choose. If the home is to continue with this practice, it must be able to demonstrate in writing the reasons why this denial of rights is in place, and this must be subject to regular review. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The inspector was satisfied that the home is generally meeting the personal and health care needs of service users. However, greater attention must be paid to the storage and recording of medications to help ensure they are done so in a safe manner. EVIDENCE: Staff informed the inspector that service users are able to manage their own personal care, although staff will offer prompting and encouragement to service users in this area as appropriate. Since the previous inspection the home now maintains clear records of service users medical appointments, including details of follow up appointments. These records indicated that service users generally have access to health care professionals as appropriate, such as CPN’s, chiropodists and GP’s. One service user said “I have diabetes, staff help me to keep a check on it.” Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 15 All service users are registered with a GP. It was noted that one service user has not seen a dentist recently, this was discussed with the staff member on duty, who said that they would now arrange a dentist appointment for this service user. During the course of the inspection one was service user was visited by their CPN, and the inspector was able to discuss the home with them. The CPN said they were very satisfied that the home was meeting the mental health needs of the service user they worked with. They said they would be happy for other clients that they work with to be placed in the home, and that the home was proactive in seeking support and arranging review meetings. The home has a medication policy in place, although this needs to be revised to cover areas such as self medication and the disposal of medications. No service users currently self medicate, or are on any controlled drugs. Medications are stored in two locked cabinets in the office, and in a designated medication fridge also in the office. It was noted that this fridge was not locked, and the medications inside it were not stored in a locked container. It was further noted that the home does not test the temperature of this fridge. Both of these issues need to be addressed. The home maintains Medication Administration Record (MAR) charts. Those examined by the inspector indicated that service users are administered their medication as appropriate. However, the MAR charts need to contain more comprehensive information, as they do not currently include the form of the medication or the dose, and this must be addressed. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The inspector was satisfied that the home has appropriate complaints procedures in place, and that staff have undertaken training in safeguarding issues. However, the home must ensure that there are robust systems in place to reduce the risk of financial abuse taking place EVIDENCE: The home has a complaints procedure, which includes timescales for responding to any complaints received. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. Service users are provided with their own copy of the complaints procedure. The home also has a complaints log, which indicated that any complaints received are recorded and investigated appropriately. The home has an adult protection procedure in place, which was of a satisfactory standard. All staff have undertaken training in safeguarding issues, and those staff spoken to demonstrated a good understanding of their roles and responsibility with regard to adult protection issues. The home holds money on behalf of service users in a locked cabinet inside the office. Service users informed the inspector that they are happy with this situation. When staff then hand money over to service users, both the staff Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 17 member and the service user sign to indicate that this transaction has taken place. Records are maintained of money entering the home, and of money spent. All three service users are paid their benefits directly in to a post office account. Staff and service users will go together to get money from this account, via an automated teller machine (ATM). For two service users, the cards for the ATM are held by the staff in the office. Staff also know the four digit codes to enter in to the ATM to access the account. With two service users, the home receives regular statements from the post office, so checks can be made against what has actually been withdrawn from the accounts, and what is entered in to the homes records. For a third service user, staff informed the inspector that the statements of their accounts were sent to the service user’s mother, and the home did not get to see them, even though the service user has been living at the home since 2001. This means that the home (or any other authorised persons) can not make checks to ensure that staff are not financially abusing the service user. Although there was no evidence that financial abuse is taking place, the home must nevertheless ensure that systems are in place to help prevent the risk of abuse, and to allow for it’s early detection if it does take place. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is the judgement of the inspector that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained, and service users are provided with adequate private and communal space. EVIDENCE: The home is situated in the Manor Park area of the London Borough of Newham. The home is in a residential area, close to shops, transport networks and other local amenities. The home is in keeping with other homes in the vicinity. The home is generally well maintained, both internally and externally. Communal areas consist of a sitting room, a kitchen/dining room and a well maintained garden to the rear of the property. In addition to these areas the Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 19 home as an office which is located in the basement, and a fourth bedroom, which is used for staff who are sleeping in during the night. Furniture and fittings were well maintained, and domestic in character. The home has one bathroom/toilet, and one toilet on its own. Bathrooms were found to be clean, tidy and free from offensive odours. All bathrooms had working locks fitted to their doors. All service users have their own bedrooms, which meet National Minimum Standards on size requirements. Bedrooms were all centrally heated, and had adequate natural light and ventilation. Service users have been able to personalise their rooms, and bring in their own possessions such as televisions. Carpets, bedding and curtains in bedrooms were domestic in character. Bedrooms contained adequate furniture, including chairs, wardrobes and draws. Bedrooms are decorated to a satisfactory standard, and service users are involved in choosing the décor for their bedrooms. The home has taken steps to reduce the risk of the spread of infection. The home was found to be clean and tidy on the day of inspection. Hand washing facilities are situated around the home, and protective clothing such as latex gloves are provided. Laundry facilities are appropriate in scale for the size of the home. COSHH products were stored securely. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were able to demonstrate a good understanding of the needs of service users, and service users expressed satisfaction with the staff generally. EVIDENCE: The home provides 24 hour staffing. This comprises of sleep in staff during the night, and there is an on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. However, the rota did not include the hours worked in the home by the manager. This issue was raised with the manager, who said that they would henceforth include their hours worked in the home on the rota. For much of the time the home operates with one staff on duty. When two staff are on duty this provides an opportunity to support one of the service users to access the community. In addition to the manager, the home employs three staff, and an additional member of staff is employed as a bank worker. Employment files checked Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 21 contained proof of ID, references and CRB checks. The AQAA supplied by the home indicated that they have relevant employment related policies and procedures in place, including polices on equal opportunities and recruitment and election. Through observation and discussion there was evidence that staff have built up good relations with service users, and that they have a good understanding of the collective and individual needs of service users. Service users spoke well of the staff, one commented that “I get on well with all of them.” Staff undertake induction training on commencing work at the home, and 50 of care staff have achieved an NVQ Level 2 in Care or equivalent qualification. Staff have access to training events, and recent training attended includes manual handling, medication and adult protection. There was evidence that staff receive regular formal supervision, and that records are maintained of this supervision. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42 and 43. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an experienced registered manager in place, and the home is generally well run. The home must ensure that all necessary health and safety checks are carried out. EVIDENCE: The homes manager has several years experience of working in social care, and is a Registered Mental Health Nurse. They are supported in the running of the home by a deputy manager. Service users spoken to informed the inspector that they found the manager to be approachable and accessible. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 23 The AQAA supplied by the home indicates that they have relevant policies and procedures in place in line with National Minimum Standards. Those examined by the inspector including admissions and adult protection were of a generally satisfactory standard (although as mentioned previously in this report the policy on medication needs to be revised). Record keeping was of a generally good standard, and confidential records are stored securely. Staff informed the inspector that service users can access their own records upon request. Care plan reviews, staff and service user meetings and staff supervisions all contribute to the quality assurance processes in the home, and the home has mechanisms for seeking the views of service users on the care and support they receive. Fire extinguishers are situated around the home, these were last serviced in February 2009. Fire alarms are tested on a weekly basis. The home holds regular fire drills. Fire alarms were last serviced on the 28/9/08, which is over a year ago, and the home must arrange for them to be serviced at least once every twelve months. Similarly, the home could not evidence that it had in date checks for gas safety and electrical installation, and this too must be addressed. It was noted however that the home had an in date certificate for PAT testing, and in date employee’s insurance liability cover. Hot water and fridge freezer temperatures are regularly checked. Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 3 3 2 3 Version 5.3 Page 25 Rachel House DS0000022872.V378224.R01.S.doc 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 YA17 Regulation 16 Requirement The registered person must ensure that where the home has a denial of rights in place, as is the case with the fridge and food cupboard being kept locked at night, the reasons for this must be clearly recorded and subject to regular review. Timescale for action 31/12/09 2. YA20 13 31/12/09 The registered person must ensure that medications in the home are stored and recorded appropriately. In particular, they must ensure that all medications are stored securely, including those stored in fridges, and that the temperature is checked at least daily of any fridges used to store medication. Further, Medication Administration Record charts must contain comprehensive information about the medication, including its form and the prescribed dose. The registered person must ensure that systems are in place to help reduce the risk of financial abuse, and to enable the home to detect any financial DS0000022872.V378224.R01.S.doc 3. YA23 13 31/12/09 Rachel House Version 5.3 Page 26 abuse in a prompt manner. 4. YA42 13 and 23 The registered person must ensure that all appropriate health and safety checks are carried out, including ensuring that gas safety and the fire alarms are tested at least once every twelve months, and that there is a safety test of electrical installations carried out at least once every five years. 31/12/09 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 Rachel House DS0000022872.V378224.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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