Inspection on 04/08/05 for Kadimah

This inspection was carried out on 4th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/10/06

Kadimah 08/12/05

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 Marie Carvell Unannounced 4 August 2005 at 12.30pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kadimah Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755573 n/k n/k Norwood Ravenswood Foundation Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager Designate Mr D Young Care Home 11 Category(ies) of Learning Disability LD registration, with number of places KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/02/05 Brief Description of the Service: Kadimah is one of sixteen homes for adults with moderate, severe and complex learning difficulties and associated physical disabilities located at Ravenswood Village. Kadimah is registered to provide accommodation and care for up to eleven service users, aged between eighteen and sixty five years of age, whose main needs for care arises from learning disability. The home currently provides care to ten male service users with low to moderate learning disabilities. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection unannounced on a week day afternoon over a period of four and a quarter hours. A tour of the communal areas of the home and several bedrooms, at the invitation of service users were seen. A sample of service user, staff and records required to be kept in the home, including health, safety and fire records were examined. Time was spent with the majority of service users and the manager designate who was on duty at the time of the inspection. In addition time was spent with the Director of Ravenswood Village and the home’s Service Manager. Feedback was given to the manager designate at the end of the inspection. The previous registered manager resigned in January 2005. The current manager designate has recently submitted an application to the Commission for Social Care Inspection for registration. One service user is over sixty five years of age and is outside the home’s registration category and therefore the Organisation must submit an application to vary the registration of the home. At the last inspection in February 2005, four requirements and one recommendation were made. These were regarding reviewing staffing levels in the home, ensuring that all home records are kept up to date, signed by all staff and in good order, that 50 of the staff team achieve NVQ level II by December 2005, that all complaints are responded to within 28 days and that staff receive regular formal supervision. These have been complied with. What the service does well: From discussion with service users and observation, the inspector gained the impression of a relaxed and well managed home. There is a good rapport between service users, staff and the manager designate. Staff on duty were friendly, helpful and professional in their approach to service users and visitors to the home. There is clear evidence that all service users are offered choice and enabled to make decisions about their lives. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,4 and 5 There is a detailed admissions procedure, which includes a full assessment of need and a programme of introduction to the home. Copies of contracts between the purchasing authority and service provider are kept on file, held at the main office on site. EVIDENCE: The ten service users have lived together in the home for many years. One service user’s records were examined. Information regarding the initial assessment and background information was available on file and well documented. Each service user has a copy of the home’s Service User Guide, which includes terms and conditions. This is in pictorial format. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Service users have detailed service user plans and are involved as much as possible with decision making. Appropriate risk assessments are in place. EVIDENCE: The manager designate is currently reviewing and updating all service user plans, this will involve individual service users and staff members. Service users are encouraged to exercise their right to make decisions and choices. All decisions and choices made by service users are recorded. Some processes, such as seeking the views of individual service users are in place to ensure that all are involved in the day to day running of the home. Risk assessments are in place and reviewed on a regular basis. Staff now sign to confirm that each risk assessment has been read and understood. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 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 standard(s) 12,13,15,16 and 17 Service users enjoy a wide range of activities and leisure opportunities, within the Ravenswood site and the local community. Staff assist service users to maintain family and personal relationships. A varied and well balanced diet is provided to service users. EVIDENCE: The opening of the Lifestyle Opportunities Centre, which offers a extensive range of activities and courses, has further enhanced the range of leisure opportunities available to service users. Several service users had attended the Open Day and were discussing which activities to undertake. Visitors are made welcome and the manager and staff team work hard to assist service users to maintain family and personal relationships. Daily routines and house rules are relaxed, with service user preferences recorded in daily records. It was observed that staff do not enter service users rooms without prior permission. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 11 The manager designate is to introduce a new menu giving service users a choice of main meals. These will be in pictorial format and have been agreed by a dietician. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 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 standard(s) 18,19 and 20 Service users physical and personal care needs are well met. Medication is administered in a safe and appropriate manner. EVIDENCE: Service users physical and personal support needs are detailed in service user plans. Personal care given is recorded in service user records. Service user records clearly evidence that regular healthcare checks take place. Medication administration records were seen to be well maintained with no obvious gaps in recordings. All staff that administer medication have completed appropriate training. Medication was stored securely in a locked cabinet. Medication policy, procedure and guidance are in place. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The Organisations complaints procedure needs additional information to be recorded and all staff must be provided with POVA training or updating. EVIDENCE: Service users have a copy of the home’s complaints procedure in the service users guide, which is in pictorial format. The Organisations complaints procedure, updated in December 2004 does not include the name, address or telephone number of the Berkshire CSCI. Staff have not received training in the Protection of Vulnerable Adults or Abuse Awareness. The home has an e-mailed copy of the Multi- Agency Procedures However, the manager designate and staff team have not yet had the opportunity to read the document. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The home is comfortable, safe and meets the needs of the service users. EVIDENCE: Several service users expressed their satisfaction of the facilities in their home. The premises were seen to be clean, fresh, comfortable and homely. Service user bedrooms are appropriately furnished and personalised to reflect the service users interests. Bathrooms and toilets are fitted with appropriate aids and adaptations to assist service users with independence. The rear garden is enclosed and is used by service users in the warmer weather. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None EVIDENCE: KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 41 The home has been without a registered manager since January 2005. One service user is outside the home registration age group. Accident records are not maintained in accordance with the Data Protection Act 1998. EVIDENCE: The previous registered manager resigned in January 2005 and the deputy manager was appointed as manager. The manager designate has recently submitted an application to the CSCI for registration. Service user and home records are kept secure and generally up to date and in good order. The manager designate is currently reviewing and updating service user records. Accident records are not maintained and used in accordance with the Data Protection Act 1998. The Director of Ravenswood Village confirmed this. All KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 17 records must comply with the instructions given on the accident recording book in order to meet the Data Protection Act 1998. KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 4 4 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 KADIMAH Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 x x H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 19 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. 2. Standard 22 23 Regulation 22(7) 13(6) Requirement The registered individual is to include additional information in the complaints procedure. The registered individual is to arrange for all staff to receive training in POVA procedures and Abuse Awareness. That a application to vary the conditions of registration to include LD(E) is submitted. That records are maintained in accordance with the Data Protection Act 1998. Timescale for action 04/11/05 04/11/05 3. 4. 37 41 4 17 04/11/05 04/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard none made. Good Practice Recommendations KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI KADIMAH H52-H01 11369 Kadimah V235094 040805 Stage 4.doc Version 1.40 Page 21 - 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!