Inspection on 18/10/06 for Kadimah

This inspection was carried out on 18th October 2006.

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

Kadimah 13/10/08

Kadimah 08/12/05

Kadimah 04/08/05

Kadimah 17/02/05

Kadimah 21/12/04

Kadimah 10/03/04

Similar services:

Pinta

Kestrel House, St Anne`s Opportunity Centre,

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Kadimah Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector Tracy McGuire Brown Unannounced Inspection 18th October 2006 10:00 Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kadimah Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755573 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) bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood Mr Darren Young Care Home 11 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (1) of places Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Kadimah is part of the Norwood organisation based at Ravenswood village. The home is registered to provide accommodation and care for up to ten service users, aged between eighteen and sixty five years and one service user over the age of sixty five, those main needs arise from learning disability. The home currently provides care to eleven male service users with learning disabilities and some who have physical disabilities also. The fees for the home are from £700 to over £1,000 per week. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected over a period of 4 days between 10th and 18th with a visit to the establishment taking place on 18th between 10.00 and 4.00 pm. The inspector spoke to service users and staff. Resident files and care plans were seen. Information from inspection records, the Annual Quality Assurance documents and dataset (being piloted by the CSCI) and surveys were used. The inspector toured the building and observed practice throughout the visit. What the service does well: 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. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 6 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 Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 7 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 the following standard(s): 2 The Quality outcome in this area is good. Service users benefit from their needs being full assessed prior to admission. EVIDENCE: Time was spent discussing the admissions process with the manager. Records were examined and the most recent admission records were assessed. The home has a policy and procedure in respect of admissions and this includes a full assessment being sought prior to admission. The inspector saw evidence of a detailed assessment process and documented pre- admission visits. Evidence of service users feelings about the transition was recorded Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 8 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 the following standard(s): 6,7,and 9 The Quality outcome in this area is good. Service users assessed and changing needs are reflected in care plans and supported with risk assessments. Service users are supported to make decisions about their lives. EVIDENCE: The records of 4 service users were case tracked. Service user records were well organised and detailed care plans were in place. Each care plan has detailed references to supporting risk assessments and supports plans. Support plans give more in depth detail and clarification about how the care and support is to be given and ensures consistent approaches. Monthly reports are in place and completed to monitor and review the care of each service user, the monthly reviews are completed by the individual service users key worker. In each service users file there is a detailed section on “choice and decision making”, this in conjunction with individual key work sessions (which are recorded) demonstrate how service users are supported to make decisions about their lives. This is particularly important due to some of the communication needs of service users. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 9 Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 12,13,15 16 and 17 The Quality outcome in this area is good. Service users benefit for varied day and educational activities and utilise the local community. Service users are supported to build and maintain relationships important to them. Service users rights are respected and they have a varied and nutritional menu. EVIDENCE: 4 service users’ records were case tracked and evidence was seen and each service user has an individual day activity timetable in place, examples of day care include, cookery, Wick Hill college DIY course, Stepping Stones, weaving, music, aromatherapy, jewellery making, gardening and know your computer. Staff and service users were spoken to during the visit and they informed the Inspector that they attend day activities in the village and in the local community. In addition they use the local shopping facilities on a regular basis, go out for lunch, pub visits and a regular weekly one to one outing. Service user records seen, record detail of family and friend contact. The monthly report completed by the key worker details any contact and visits with family and friends in the month. One service user spoken to, told the inspector about his family and regular visits to and from them and showed the inspector photographs of his family Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 11 Each service user has an individual file and in the care and support plans service users daily routines are detailed. Service users were observed interacting with each other, spending time alone and interacting with staff. The inspector saw menus on the visit to the home, service users are involved in the menu choice and an alternative is always available if service users change choice. Service users came in for lunch and this is a sociable time. Pictures or examples of the food are on display to assist service users to know choices are available for each meal. Service user records case tracked, also detail that eating and drinking assessment have been completed for some service users who have specific needs. In addition support guidelines and monitoring form are used where required. Weight charts are completed. Staff informed the inspector they are in the process of developing a book of photos of actual meals served to assist in choice. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 18,19,and 20 Service users personal support and healthcare needs are met in the way they prefer. Medication procedures in place are satisfactory. EVIDENCE: The records of 4 service users were case tracked, discussion were held with staff. Service users’ individual care and support plans detail personal support preferences and needs. Updated are noted in the monthly reports and regular sessions with key workers are held to ensure any changes are noted. Each service user has healthcare section on their file, which details healthcare needs. The Inspector saw evidence on file of all healthcare appointments being recorded. A health check form is completed and taken to each GP appointment. Service users also have a “my Health booklet”. The inspector noted a range of healthcare input for service users including: optician, hearing, dentist, chiropodist, dietician, speech and language and physiotherapy. Complimentary therapy such as music and aromatherapy is available for service users. The manager informed the inspector that they are planning to look at training in respect of ageing, palliative care and some dementia care training has been booked. The home has detailed policies and procedures in place in respect of medication. All staff are trained prior to being authorised to administer medication. The inspector observed a staff member undertaking the lunchtime Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 13 medication. The staff member was well organised. The home uses a nomad system and mar sheets and stock looked at was correct with no gaps in recording. All medication is double checked by a second member of staff. Medication is stored in a locked metal cabinet and medication stored in the fridge is checked and the temperature of the fridge recorded. Examples of training in medication were seen on staff records sampled. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The Quality outcome in this area is good. Service users benefit from a good complaints procedure and safeguarding adults is promoted in the home. EVIDENCE: The home has a detailed complaints procedure and a copy in a user-friendly format is available on service users files. Service users have one to one sessions with key workers who are familiar with service users communication issues and the opportunity to raise any comments or complaints is also available during this session. The complaints log for the home was seen and the last recoded complaint was made on 8/6/06. The action was detailed and satisfactory. Service users have access to a drop in advocacy service. The home has policies and procedures in place to safeguard adults. Staff spoken to displayed sound knowledge of safeguarding adults’ issues. Examples of training in the protection of vulnerable adults were seen on staff records sampled. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The Quality outcome in this area is good. Service users benefit from a home that is comfortable , safe and clean and tidy throughout. EVIDENCE: The inspector undertook a tour of the premises. The home is suitable for the current users and was nicely decorated and furnished throughout. Service users spoken to informed the Inspector that they are involved in choosing decoration and furnishings for the home. The carpets and curtains have recently been replaced downstairs. The home has a large lounge, separate conservatory and spacious dining room. There is also the additional flat facility for 2 service users who have their own lounge /dining room and kitchen. The main kitchen is large and is in need of replacing, this has been identified by the manager and is on the maintenance list. The home has suitable bathroom facilities and the manager informed the inspector of plans to refurbish the shower areas in the bathrooms. The home has a separate and suitable laundry facility. The home was clean and tidy throughout. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34 and 35 The quality outcome in this area is good .A competent, well-trained and experienced staff team support service users. Staffing levels are sufficient to meet the needs of the service users. There is a low turnover of staff. The organisation has a robust recruitment procedure. EVIDENCE: Staffing levels in the home are satisfactory and staff were observed working with service users in a sensitive and professional manner. One service user currently has some specific dedicated one to one time, and this was being undertaken by an agency member of staff who displayed good knowledge of the service users needs and those around him. Recruitment in the home is robust and carried out by the human resource department. Some recruitment records were sampled and theses were found to be satisfactory. All checks including CRB are undertaken. One member of staff assumes the responsibility for the co-ordination of the training file. The training file was examined and provided evidence that staff in the home have relevant training and qualifications. Most staff have achieved NVQ level 2 or above of are working towards this. A comprehensive training plan for the home is available and most staff are up to date with all basic training, there is system in place, which identifies when training needs to be refreshed and this is then booked. Samples of staff training records were seen and these include copies of certificates of training achieved. Examples of Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 17 training achieved include first aid, vulnerable adults, NVQ, supervision, food hygiene and health and safety. Staff in the home were positive about training available, the deputy is currently doing a foundation degree and LDAF 4. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The Quality outcome in this are is good. The home is well run, with service users views underpinning the Quality Assurance process. Health and safety is promoted. EVIDENCE: The inspector spent time talking to the manager, staff and examining records. The home manager is registered with the CSCI. The manager has a range of suitable qualifications including NVQ level 4 and Registered Managers Award. The manager has worked in learning disability settings for 16 years. The organisation does not have a formal Quality Assurance system in place currently. The organisation carries out regular monitoring visits to each home and copies of these reports are supplied to the CSCI. Views of service users are sought via individual keywork sessions. The manager discussed with the inspector the benefit of completing the Annual Quality Assurance form (currently being piloted by the CSCI) and has used this to form the basis of a Quality Assurance analysis for the home and using the goals as a development plan. The manager intends to discuss this information with other managers in the organisation. The home has developed its own Quality Assurance check, Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 19 which is completed every 3 months; this also incorporates Health and safety checks. The home has an organised health and safety file and a variety of records were examined including risk assessments, gas, fire, water temperatures and legionella testing. Records seen were all up to date. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations A Quality Assurance system needs to be formalised. Kadimah DS0000011369.V308617.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way, Oxford Business Park South Cowley Oxford OX4 2SU 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. 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