CARE HOME ADULTS 18-65
Kairos Community Trust 59, Bethwin Road London SE5 0XT Lead Inspector
Ornella Cavuoto Unannounced Inspection 3rd February 2006 10:00 Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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 Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kairos Community Trust Address 59, Bethwin Road London SE5 0XT 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) 0207 701 8130 0207 701 8130 Kairos Community Trust Mr Lee Pierce Slater Care Home 16 Category(ies) of Past or present alcohol dependence (16) registration, with number of places Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd September 2005 Brief Description of the Service: The Kairos Community Trust rehabilitation centre sited at 59 Bethwin Road provides a therapeutic programme for individuals with support needs related to alcohol/drug dependency that have completed a detoxification programme. The programme is of 12 weeks duration after which service users move on to alternative accommodation. Service users commit to the programme by signing a contract, which includes regular attendance at counselling and daily attendance at group meetings at which personal weekly objectives are agreed. The service is based in a detached house over three floors and is located close to community facilities. The home has a stair-lift, which is not currently needed for present service users, but which is maintained should the need arise. The service is accessible via public transport. A number of bus routes run within walking distance of the home with Underground and train stations sited slightly further away. Accommodation at the home consists of seven double and two single bedrooms. There are a number of communal areas on the ground and second floors and a patio to the rear of the building. Toilet/bathrooms are located on each floor. The home operates the Minnesota method of treatment based on the twelve steps of alcoholics/narcotics anonymous. A care plan is devised between service users and staff by the end of their second week at the service and is subsequently reviewed half way through what is a three-month programme. Links are maintained with service users when they leave the service and they are able, if appropriate, to move on to supported housing, which is run by Kairos Community Trust. The contract, which all service users must agree to upon admission, makes it explicit that the use of alcohol or mood altering drugs is not tolerated. The staff team consists of a Team Manager, four full time staff, one part time staff member and a staff member who works on a sessional basis. There is also one volunteer who lives in. A cook is employed to cook regular main meals but service users participate in this and a range of household activities. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 7 hours. The deputy manager was present for the duration of the inspection whilst the registered manager arrived later to assist with the inspection process. The responsible individual was also present for a part of the inspection. The inspection involved speaking to six service users, a tour of the premises was undertaken and care records were inspected. What the service does well:
The majority of staff at Kairos have worked for the service for a number of years and provide a stable team that is very well experienced and qualified to meet the needs of the service users. This was reflected in the comments made by service users who were extremely positive about the staff and the support they have received. One service user spoken to commented, “It’s got a good reputation which is well deserved”. Another said, “The staff make you feel safe. You know they will be on it straight away if anything is going on that shouldn’t be.” Finally, one of the service users stated, “It feels like home even though there are rules which people have to stick to”. The service ensures that there is information available for potential service users to enable them to make an informed choice about whether to attend the programme. The service ensures that a full needs assessment is obtained from the referring local authority to make sure that they can meet service users needs prior to their admission. The care plans and risk assessments carried out with service users are detailed and clearly show that service users have been involved with drawing up the care plans and risk assessments. Reviews are carried out regularly with input from the social worker. The service provides a comprehensive programme of support for service users to maximise their opportunities to address their drug and alcohol use and related problems. This includes supporting service users towards the end of the programme to look at ways they can structure their time positively by providing information about volunteer schemes and educational opportunities. Also, service users are supported to develop support networks with those that are also in recovery form misusing substances. For example, getting service users involved in the Fellowship, which involves regularly attending Alcoholic, Narcotics or Cocaine Anonymous meetings and getting a sponsor in place who will provide ongoing individual support. The service itself also has an aftercare group that service users can attend indefinitely as long as they remain abstinent form drug and alcohol.
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 6 The service has robust adult protection procedures in place and the majority of staff have received training in this area. The home provides a warm homely environment. All service users are expected to share a bedroom. The home is not wheel chair accessible but there is a stair lift for those who may require it. Staff are well supported to be able to work effectively with service users in that they all receive internal and external clinical supervision. Service users are asked for feedback about the service through the use of service user questionnaires. What has improved since the last inspection? What they could do better:
The service needs to revise the individual written contract issued to service users to ensure that it includes all the information required by the standard such as the services and facilities service users can be expected to receive. All service users need to have a care plan drawn up with them as soon as possible after their admission and that all care plans are signed by service users. A record should be kept on service users’ files of the dates individual sessions are held with service users and a brief note made of what was looked at with the service user in relation to their care plan. The service needs to ensure that for all medication staff take responsibility for administrating that an accurate record is kept of when this is dispensed to staff. The medication policy needs to be reviewed. Service users should be consulted about their wishes around death and dying and these should be recorded. All required documents and checks in relation to staff recruitment must be obtained prior to staff working for the service.
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 7 All staff need to receive supervision targeted at looking at general performance issues such as identifying training needs on a regular basis. The service needs to use the information obtained from the service user satisfaction surveys to draw up a report that is made accessible to service users, stakeholders and also to CSCI. The service needs to submit to CSCI an up to date fire risk assessment and building/environment risk assessment and copies of recent inspection reports in respect of fire safety and maintenance certificate of the gas boiler’s annual check. 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. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 8 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 Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 9 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): 1,2,3&5 Potential service users have the information they need to make an informed choice about where to live. The service ensures a full needs assessment is obtained prior to service users are admitted. Potential service users know the service will meet their needs and aspirations. Each service user has an individual written contract but some amendments are required. EVIDENCE: The Statement of Purpose and Service User Guide contain all the information required by regulation and the standard. The previous requirement that revisions had to be made to include details of changes to key personnel has been met. There was evidence from the service user files that were examined that the service had obtained a full needs assessment from the local authority prior to service users being admitted. All the staff working with the service are very experienced and knowledgeable around working with individuals with addiction problems. Service users entering the service are provided with clear information about the purpose, duration and requirements of the programme. Consequently, potential service users know the service will be able to meet their needs. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 10 All service users whose files were inspected had a written contract that was signed by service users. Although, this clearly outlined the terms and conditions of occupancy including period of notice it needs to include more information about the services and facilities service users can be expected to receive such as rooms to be occupied, fees charged and what they cover, arrangements for reviewing needs and progress and updating the care plan. Subject to a requirement. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 11 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 Care plans comprehensively address service users’ needs although not all service users had a care plan in place. EVIDENCE: Four service user files were inspected. All but one service user who had been admitted to the service for approximately 3 ½ weeks had a completed care plan. Subject to a requirement. The care plans that had been completed were detailed and comprehensive identifying short term and long term goals and had been generated from the information provided by the care management assessment. Although it was evident that service users had been involved in the care planning process one care plan had not been signed. Subject to a requirement. All service users have a review between approximately 6-10 weeks with their key worker and the allocated social worker of which there was evidence in service user’s files. The service also uses other mechanisms for monitoring service users’ individual progress towards achieving the objectives they have identified in their care plans. These include the weekly objectives group held with all service users involved in the treatment programme and one to one
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 12 counselling sessions. However, recorded notes of these are not kept. Evidence of the individual sessions being held should be provided as it forms part of reviewing the care plan with service users. Therefore, it is advised that dates of when individual counselling sessions are held are recorded which are signed by the staff member and the service user and a brief general note made of issues discussed. All service users had a comprehensive risk assessment in place that aims to identify risks in relation self-harm, violence or aggressive behaviour, health, and triggers and warning signs in respect to their drug and alcohol use. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 13 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 & 15 The service supports service users to look at opportunities for further education. Service users are supported to develop and maintain appropriate personal and family relationships. EVIDENCE: An essential part of the programme at Kairos is that service users are expected to take responsibility for themselves and their behaviour. Consequently, unlike other rehabilitation treatment programmes no restrictions are placed on them when they enter the programme. They are allowed to leave the project freely within the boundaries of having to attend the group programme and individual sessions and there are also curfew times. Service users will be urine tested or breathalysed and asked to leave if it is found they have used drugs or alcohol. However, this gives service users opportunities to become engaged in activities outside of the home if they so wish. However, attendance of Alcoholics Anonymous (A.A) Narcotics Anonymous (N.A) or Cocaine Anonymous (C.A) is compulsory as part of the programme. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 14 Furthermore, towards the end of the programme the service does support service users to begin to look at ways they can structure their time. They have links with a community based education organisation “Next Steps” who come in every ten weeks to give service users a presentation on how they can become involved in a six week course that is held at Brixton College and supports individuals with developing their skills and knowledge in information technology (IT), Maths and English. Another local organisation, St Giles Trust with which Kairos has links provides Peer Advocacy support giving service users information about ways that they can access opportunities in voluntary work. The service also holds peer support groups with those service users who require it, help to improve their reading and writing skills. Service users have often had difficulties with relationships past and present due to their substance misuse. This is explored with service users whilst on the programme within group and individual sessions. Resolving these issues is seen to be an important part of their recovery to support service users to continue to remain abstinent from using drugs and alcohol. Consequently, many service users will be encouraged to end unhealthy relationships in which using substances may have been a major part of the relationship and could be detrimental to their recovery. Also, intimate relationships within the house are strictly not permitted and will be grounds to ask a service user to leave. Instead, new more positive and healthy relationships are encouraged with individuals who are also abstinent. One way of doing this is through meeting people and developing a support network via the attendance of A.A, N.A and C.A groups. Also to support service users the service has an aftercare group that they can attend indefinitely as long as they remain abstinent which is held at Kairos. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 15 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): 20 &21 The service needs to ensure that the recording of the administration of medication is completed more accurately and the service’s medication policy needs to be reviewed. The service needs to sensitively consult with service users on their wishes around death and dying. EVIDENCE: A number of requirements were made at the last inspection in respect to the home’s handling and administration of medication. These were checked and were all found to be met. These included that all medication to be returned to the chemist must be stored in appropriately labelled containers, that a record is maintained in the home of any homely remedies that are held and dispensed, that a list is maintained of all staff who are trained to administer medication with a sample of their initials and signatures and finally that all service users have a photograph on their medication files. However, in checking a sample of MARS sheets it was identified that although staff are administering two doses of medication to one service user who is responsible for self administering the second dose themselves in the evening staff are only signing that one dose of medication has been dispensed. All service users have risk assessments to ensure they are able to self-administer medication but if staff are taking responsibility for administrating the
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 16 medication they need to ensure that this is accurately recorded. Subject to a requirement. In addition, the service ‘s medication policy was inspected. It was found that the policy could be more specific and detailed in parts. For example, in respect to the use of homely remedies and the home’s procedure for the administration of medication. Therefore, it was agreed that a referral would be made for a regulatory pharmacist to either visit or contact the service to carry out a full inspection of the home’s medication systems, policies and procedures and the service to make any adjustments as required. At present service users are not consulted about their wishes on death or dying. The manager who has worked for the service for some years reported that to date there has never been a death on the programme. Although the programme is for a reasonably short period of 12 weeks many of the service users move onto live in the shared houses that Kairos provide as part of their aftercare programme and many stay in these houses for many years and continue to have contact with the service. Consequently, it is considered important that the service consults with and record service users wishes in respect to this area. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 17 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): 23 Service users are protected form abuse, neglect and harm. EVIDENCE: The home has robust policy and procedure on blowing and all staff members have undertaken training in this area. There is also a policy on aggressive behaviour that specifies that physical as a last resort. adult protection and whistle training or are due to attend how to manage violent and restraint should be used only All service users control their own finances /personal allowance. They are required to pay a contribution of their finances towards their care that they pay direct to the service and a receipt is issued. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25,26,27,28 &29 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. The home is not wheelchair accessible. There is a stair lift but there is no additional specialist equipment, as service users at this home do not have any specialist physical needs. EVIDENCE: There are seven double bedrooms in the home and one single room. Service users are expected to share as a means of encouraging openness and challenge as part of the programme. The single room is available to ensure that women entering the programme are never expected to share with men. Although there are requirements within the national minimum standards that 80 of rooms be single rooms by 2008, this would defeat the aim and purpose of the programme within this home. All service user bedrooms inspected had all the required furniture and fittings to meet individual needs and lifestyles and service users are able to bring in personal belongings with them.
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 19 There are toilets and bathrooms on each floor that are more than sufficient to meet individual needs. There are a number of communal areas including a meeting room where groups are held and a dining area and kitchen on the ground floor and a large communal lounge on the second floor which is a well decorated, comfortable and nicely furnished. There are also rooms for private meetings to take place such as individual counselling sessions. The home has a small patio area to the rear of the building. Service users at this home do not require specialist equipment as they are fully able but there is a stair lift available and at the time the inspection took place one service user was using this as they had had a leg amputated previously. The home is not wheelchair accessible and the lay out of the building would prove too difficult for it to be adapted for wheelchair use. Therefore the recommendation that the home should consider having an assessment undertaken under the Disability Discrimination Act 1995 is not to be restated. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 34 &36 Volunteers’ job descriptions have been amended to ensure clarity in respect to jobs to be undertaken and any remuneration to which they may be entitled. Competent and qualified staff support service users. An effective staff team support service users. The recruitment procedure needs to be more robust to fully ensure that service users are supported and protected. Overall the home has comprehensive supervision arrangements in place but not all are being carried out as regularly as they should be. EVIDENCE: Previous requirements that the volunteers’ job description is amended and that volunteers are only used in accordance with the volunteers’ policy and volunteer duties are clear to all staff have been met. Staff working at Kairos have substantial experience and are qualified to work in the specialist field of substance misuse. All staff are trained counsellors and the majority of the staff team are continuing to build on their knowledge and skills by undertaking further educational courses. For example one staff member is studying for a Msc in Addictions Counselling and Psychology whilst another has nearly completed a Diploma in addictions. Other courses being studied by staff include a course on group analysis, a diploma in psychodynamic counselling and the NVQ Level 3 in care. The registered manager reported that there is a budget for ongoing training. It is advised as part of identifying training for staff
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 21 the Registered Manager should look into the courses offered in relation to DANOS, the Drug and Alcohol National Occupational Standards. Service users spoken to were clear that staff are more than able to meet their needs with one commenting, “ I have achieved self-confidence and am able to talk about my issues” whilst another said, “I have learnt a lot about my addiction and I am stronger.” Overall, an effective staff team supports service users with the numbers and skills mix of staff on duty ensuring that the individual and collective needs of service users are being met. The staff have regular staff meetings held every week of which minutes were seen. These covered issues related to service users and other practical matters in relation to the day to day running of the service. A previous recommendation was made in relation to the registered manager giving consideration to employing more female staff to reflect a gender balance between the composition of staff and service users. This was discussed further with the registered manager who stated that employing a female would definitely be prioritised when next recruiting staff. Female service users spoken to did not express any concerns about the composition of the staff team in that it had not caused them any problems in terms of feeling supported or being able to openly discuss issues. In relation to recruitment, four staff files were checked. It was identified that for one staff member the required identification documents had not been obtained and three of the files did not include an up to date photograph. Subject to a requirement. In addition, for one staff member a Criminal Record Bureau Check (CRB) had been accepted form a previous employer. This is a breach of the Care Standards Act 2000. After July 2004 portable CRB checks were no longer deemed acceptable. An immediate requirement was issued on the day the inspection was held stating that a new CRB application should be completed as well as a POVA First check for the staff member in question. Notification from the home has been received to inform CSCI that this has been completed meeting this requirement. Overall, staffs’ needs in relation to supervision are very well met. All staff receive clinical supervision provided by an external supervisor as well as internal clinical supervision received fortnightly to look at the work being carried out with service users. The deputy manager who has received training in this area provides this. Evidence was seen that this is being carried out regularly and that all staff have had an annual appraisal. The manager also provides supervision which is more performance related looking at staff issues in relation to training or any other problems/issues they may be experiencing at work but this has not been carried out regularly. Subject to a requirement. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. Service users benefit from a well–run home. Although, service users’ views are being obtained this information is not presently being used effectively. Generally the health, safety and welfare of service users are promoted and protected but evidence needs to be provided that an up to date environment and fire risk assessment has been completed. EVIDENCE: The present registered manager has been in post since June 2005. Prior to taking up the post as manager he was working as the deputy manager. He has 6 years experience working in the addictions field and is a qualified counsellor. He has also undertaken a course in supervision. More recently, the registered manager has just started the NVQ Level 4 in care and management and is also intending to complete the Registered Managers Award (RMA). The service issue service users user satisfaction questionnaires in the last week of their stay. A sample of these was seen and all were very positive about the staff and the programme. However, the results of these questionnaires are not
Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 23 drawn together and fedback in an annual report which is made accessible to service users, other stakeholders and also CSCI. Subject to a requirement. The service has robust health and safety policies and procedures in place and health and safety audits are carried out. A copy of the last audit was sent to CSCI following the inspection. All staff are currently undertaking a health and safety compliance course at John Ruskin College. It was reported that a fire safety inspection was held on 1/02/06 that made recommendations but a copy of the report had yet to be received. However, fire drills and weekly fire tests, which were identified as not having been carried out regularly at the last inspection, were checked and found to be in order. A food safety/inspection was held on 27/01/06. The report had been submitted to CSCI prior to the inspection and included some recommendations. The annual maintenance check of the gas boiler had also been carried out recently and the service was awaiting the certificate. A copy of this and of the fire inspection report needs to be sent to CSCI. In addition, a copy of the fire safety risk assessment and an updated building /environment risk assessment for the service also needs to be sent to CSCI, as these were not available on the day of the inspection. Subject to requirements. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 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 4 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 2 3 X 2 X X 2 X Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 25 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 YA5 Regulation 5 (1) (b) Requirement The registered person must ensure that the individual contract issued to service users is revised and contains all the information outlined within standard 5 of the National Minimum Standards (NMS) The registered person must ensure that all service users have a care plan drawn up with them as soon as possible after their admission and that all care plans are signed by service users. The registered person must ensure that staff record the administration of medication to service users accurately to ensure the MARS (Medication Administration Record Sheets) reflect all medication that has been dispensed to the service user. The registered person must ensure that the medication policy is reviewed and adjustments made recommended by the regulatory pharmacist. The registered person must ensure that all the necessary
DS0000007078.V281187.R01.S.doc Timescale for action 31/08/06 2. YA6 15 (1) (2) 31/05/06 3. YA20 13 (2) 31/05/06 4. YA20 13 (2) 30/06/06 5. YA34 19 (4) & Sched 2 31/05/06 Kairos Community Trust Version 5.1 Page 26 6. YA36 18 (2) 7. YA39 24 (2) 8. YA42 23 (4) documents as specified with Schedule 2 of the regulations are obtained prior to a staff member being allowed to commence work in the home. The registered manager must 30/06/06 ensure that all staff receive all forms of supervision provided within the home on a regular basis. The registered person must 30/09/06 ensure that the results of the service user questionnaires are drawn together in an annual report, which is made accessible to service users, stakeholders and also to CSCI. The registered person must 31/05/06 ensure in respect to health and safety - That the recommendations as specified within the food safety inspection report are adhered to. - A copy of the recent fire safety inspection report - The certificate for the recent maintenance check for the gas boiler - Copies of a fire safety risk assessment and building /environment risk assessment should all be submitted to CSCI. 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 YA6 Good Practice Recommendations The registered manager should consider making a record of the individual sessions held with service users the dates of the sessions with a brief and general note of what is discussed in respect to service users care plans. The registered manager should consider consulting service
DS0000007078.V281187.R01.S.doc Version 5.1 Page 27 2. YA21 Kairos Community Trust 3. YA32 users about their wishes about death and dying and that these are recorded as part of the personal details held on service users or within their care plan. The registered manager should consider looking into the training involved in the Drug and Alcohol National Occupational Standards (DANOS) in relation to staff development and training needs. Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Kairos Community Trust DS0000007078.V281187.R01.S.doc Version 5.1 Page 29 - 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!
