Inspection on 04/01/07 for Kairos Community Trust

This inspection was carried out on 4th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kairos Community Trust 03/02/06

Kairos Community Trust 22/09/05

Kairos Community Trust 01/03/05

Kairos Community Trust 02/11/04

Kairos Community Trust 12/03/04

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Kairos Community Trust 59, Bethwin Road London SE5 0XT Lead Inspector Ornella Cavuoto Unannounced Inspection 4th January 2007 10:00 Kairos Community Trust DS0000007078.V318512.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 Kairos Community Trust DS0000007078.V318512.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. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 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 kairosbethwin@talk21.com 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.V318512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 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. The service makes information available to potential service users by sending them an information booklet, through emails and answering telephone enquiries. A copy of the most recent inspection report is kept on display in the foyer of the home making it accessible to all current and prospective service users who where possible are always required to visit the service for an assessment prior to admission. Monthly fees charged are £360.00. Additional charges are made for those service users who attend the service on a DRR Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 5 (Drug Rehabilitation Recommendation) as part of a condition of a probation order, which may involve compulsory testing at £7.00 per test. This information was given to CSCI January 2007. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present for the duration of the inspection and facilitated the inspection process. Two members of staff were spoken to briefly as well as a professional who has regular contact with the service. In addition, a total of eleven service users were also spoken to including a service user who had completed the programme. Three of the service users spoken to were case tracked. Other methods used included inspection of care records and a tour of the premises was carried out. What the service does well: What has improved since the last inspection? The service has made changes to the statement of terms and conditions signed by service users to ensure that a statement regarding fees has been included. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 7 At this inspection all service users were found to have a care plan in place that had been drawn up with their involvement. The service has addressed issues with regards to recruitment ensuring all the necessary documents have been obtained to check staffs’ suitability before allowing them to commence work. Improvements have been carried out with regards to quality assurance in that the results of customer satisfaction questionnaires have been put in a report and this has been made accessible to service users. The service has ensured that matters in respect to health and safety, for example an up to date fire risk assessment and building risk assessment are in place. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 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.V318512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 &5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed. Each service user has an individual written contract. EVIDENCE: Four service users’ files were examined. The service carries out its own detailed assessment with service users prior to admission of which there was evidence included in the files inspected. Three of the files also included a copy of the needs assessment carried out by the local authority although one had been obtained post admission. The other file had evidence that a copy of the needs assessment had been requested but the service user had also already been admitted. Although the needs of service users are thoroughly assessed by staff and generally the service does ensure a copy of the needs assessment is obtained it is advised that the service make efforts to be consistent and try to always obtain this information from the local authority prior to the admission of service users (See Recommendations). All service users whose files were inspected included a written statement of terms and conditions that had been signed by the service users. At the last inspection it was identified the document needed to include more information specifically the fees charged, arrangements for reviewing needs and progress and updating care plans. At this inspection it was identified that a statement Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 10 regarding the fees of the home had been added. In respect to the other information regarding the service this has been included in a folder that is issued to all service users on admission. Service users spoken to confirmed this. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. All service users had a care plan in place that comprehensively addresses their needs and is reviewed. Service users are supported and encouraged to take responsibility and make decisions about their lives whilst at the home. Service users are supported to take responsible risks as part of an independent lifestyle. EVIDENCE: Subject to a previous requirement that all service users should have a care plan drawn up with them as soon as possible after their admission and the service user should sign them, this has been met. All the personal files inspected included evidence of a completed care plan and all had been signed except one although this had just been completed the previous day. Care plans were detailed and comprehensive. They identified short and long terms goals and specified the aims/goals of the service user in relation to their Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 12 rehabilitation and also the support and responsibilities of the staff in respect to addressing personal and social support and any health care needs. It was evident from the care plans that service users were involved in the drawing up of the care plans. Service users spoken to confirmed this. Reviews are held after approximately 6-10 weeks of a service users’ stay and is carried out with their allocated counsellor and social worker to look at their progress and identify continued support that is required and move on options. There was evidence of reviews having been arranged and completed within service users’ personal files. Also, at the last inspection it was reported that there were other mechanisms in place for the monitoring of service users’ individual progress towards achieving goals identified in their care plans such as a weekly objectives group and one to one counselling sessions although a record of these sessions had not been maintained. However, at this inspection evidence of these had been included in service users’ personal files. The programme offered by Kairos promotes that service users take responsibility for themselves and their behaviour. As a result they are supported to make their own decisions and choices. Service users spoken to confirmed this with one service user commenting, “ They (staff) suggest things but they can only guide you then it’s up to you.” It is compulsory as part of the programme that service users have to attend at least two A.A meetings (Alcoholics Anonymous), N.A (Narcotics Anonymous) or (C.A) Cocaine Anonymous depending on their previous use of substances. These meetings are based on the principles of peer support and service users can also access a sponsor who continues to provide them with independent support and guidance throughout their recovery. Also, in respect to finances all service users manage their own money. There was evidence in all the personal files looked at that risk assessments had been completed with service users. These identified risks in respect to aggressive and self -harming behaviours and also any behaviour that may pose a risk to individual service users’ recovery and result in a relapse. The aim is to support service users to take responsible risks and provide information on which they can base decisions. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service supports service users to look at opportunities for training and education. Service users are supported to be part of the local community. Where appropriate service users are supported to maintain and develop personal and family relationships. The programme offered by the service is aimed at promoting the rights and responsibilities of service users Service users are offered a healthy, nutritious diet based around their choices, which they all take part in preparing for the group although a record of meals prepared is not maintained. EVIDENCE: Towards the end of the programme service users are supported to look at ways they can structure their time after they leave and access educational or training opportunities. The service has links with a community based education Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 14 organisation “Next Steps” who come 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 knowledge and skills in Information Technology (IT), maths and English. Another local organisation, St Giles Trust provides service users with information on ways they can access opportunities in voluntary work. In addition, it was reported that a day programme as part of the aftercare support provided by Kairos is to begin at the end of January. This is to be held three days a week and also aims to hold workshops and provide information about how to access college courses and training. One service user who graduated from the programme on the day the inspection was held stated they were hoping to attend the new day programme. As mentioned there is an emphasis within the programme provided by Kairos on individual responsibility. Consequently, apart from the first day of admission and for those service users coming to the service straight from prison the first week of their stay where they are not allowed to leave the premises unaccompanied, there are no restrictions on their movements. Service users are allowed to leave the project freely within the boundaries of having to attend the group programme and individual sessions. Curfew times must also be adhered to. This allows service users to spend time away from the service and to make use of the local facilities such as the shops, a local gym, library and as mentioned to attend A.A or other similar meetings locally. Those service users spoken to confirmed this with one describing how despite having concerns about coming to the service found that “It’s like still living in the community here”. Where appropriate service users are supported by staff to maintain and develop relationships with family and friends and where service users have children support is given to ensure regular contact with them is maintained. One way of encouraging service users to meet people and to develop a support network is through attending meetings such as Alcoholics Anonymous (A.A). However, as part of the programme and service users’ rehabilitation they will be encouraged to end unhealthy relationships in which using substances may have been a major part of the relationship and the other person is still using as this could prove detrimental to their recovery. Also, intimate relationships between service users on the programme are strictly not permitted to keep service users focused on the programme. They are informed of this prior to admission and it is also specified as part of their statement of terms and conditions that they sign. Although there are restrictions in place that service users are expected to adhere to, for example as mentioned there is a curfew in place it was clearly evident from speaking to service users and through general observation of how the programme is run that the daily routines of the house and house rules generally do promote independence, individual choice and freedom of movement, for example service users are given a key to the house and as Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 15 stated previously apart from an initial brief period on admission they are allowed to leave the premises as they wish within the boundaries of the programme. Staff are very accessible to service users spending time and interacting with them. One service user commented, “Staff are always available. They are very giving of their time.” There is unrestricted access to the home and the grounds. One area of concern related to this was that none of the service users’ bedrooms had locks. It was reported that this was in line with the philosophy of the programme a fundamental element of which is to build up trust and honesty amongst service users and also between them and the staff. Service users spoken to specifically those that were female reported they felt comfortable with this. One of them said, “There is a code of respect and we all comply with it so I don’t feel concerned about not being able to lock my room”. Evidence gathered during the inspection indicated that service users are offered a healthy diet and that they enjoy meals and mealtimes at the service. The inspector was invited to share a lunchtime meal and the food was well presented, tasty and nutritional with choice available. A cook is employed to provide the main mid-day meals but a rota is devised to involve all service users in preparing and cooking the evening meals through the course of the week, which includes shopping for the produce needed. All service users are consulted about what is to be cooked and service users with specific dietary needs are catered for, for example it was reported that one service user who was a vegan had been allowed to purchase their required food products to ensure their needs in this area were met. In addition to main meals a range of snacks and drinks are available to service users at all times. It was generally evident that this system works well but as the home does not follow a menu plan it could not be fully identified if the diet received by service users was sufficiently varied and balanced. As a result a record of meals cooked should be maintained. This would also inform service users what has previously been cooked to prevent any repetition. Furthermore, it was established that service users are not given any instruction or training around basic food hygiene before being allowed to work in the kitchen and this needs to be addressed (See Requirements). Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way they prefer and require. Service users’ healthcare needs are met by linking into community service such as GPs and clinics. The service’s medication policies and procedures for dealing with medicines protect service users. EVIDENCE: None of the present service users at the service require support with personal care. In respect to other support all individual service users are allocated a counsellor who works with them throughout their stay to maintain consistency. Service users spoke highly of the support they received from staff, one said, “My counsellor is very supportive”. There was evidence from care plans that service users’ individual health care needs are addressed. A G.P who has worked with the service for many years holds a weekly surgery at the home ensuring any health care issues are addressed. It was reported that in respect to dental care service users are Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 17 linked in with a practice locally and service users can access chiropody if needed from another local voluntary agency, St Giles. Since the last inspection the service was visited by the regulatory pharmacist to check that the home’s medication system policies and procedures. It was found that these were satisfactory and no requirements or recommendations were made. The service has a policy whereby it takes responsibility for holding service users’ medication but does not administer it. Instead, on a daily basis staff gives or as the staff describe ‘despatch’ medication to service users for them to self-administer. All service users have a self -administration medication risk assessment carried out with them on admission. Evidence of these was seen on service users’ personal files. A new more detailed selfadministration medication risk assessment has also been drawn up that was seen. However, it was noted that neither the risk assessment currently being used or the new one required service users to sign. This was addressed during the inspection with the new form being modified. The registered manager and deputy manager take responsibility for the medication and there were certificates in place that they had received training from a pharmacist. In addition, all staff have completed the first two units of a long distant learning course for the Safe Handling of Medication linked to Hackney College. Evidence of the workbook used was seen. It was reported the other units of the course were not completed, as it was not deemed relevant to the way the service manage medication. A sample of Medication Administration Records (MAR) sheets were checked and all found to be in order (See Recommendations). Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are aware of the complaints policy that is robust although the service does not presently record all complaints. Service users are protected from abuse. EVIDENCE: The service has a robust complaints policy and procedure. All service users are required to sign a form declaring that they have read and understood the policy and a copy of this is kept on their personal files. None of the service users spoken to had any complaints about the service and no complaints had been recorded since the last inspection although it was acknowledged that minor complaints or dissatisfactions are not noted down (See Requirements). In respect to adult protection there were comprehensive policies and procedures in place. A copy of the London Borough of Southwark‘s Adult Protection policy was also available although this had been acquired some time ago and it is advised that a more up to date copy is obtained. The registered manager has undergone adult protection training and this was then cascaded down to the other counsellors. Two counsellors who were spoken to both had an understanding of abuse and action to take if abuse was suspected or identified and it was explained by one of the counsellors that issues of abuse had been looked at in respect to their counselling training. However, it is advised that the registered manager evaluate staff’s knowledge in this area on Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 19 a periodical basis and where it is identified as necessary arrange training (See Recommendations). Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is homely and comfortable but is in need of redecoration and furnishings renewed. The home was clean and hygienic. EVIDENCE: 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. 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. A full tour of the premises was undertaken and although the home is homely and is suited to its purpose it is need of re –decoration in most parts and renewals are required of furniture and furnishings particularly carpets that were noted to be frayed and worn in some parts of the house and were not fitted properly posing a health and safety risk. Also, some carpets in service Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 21 users’ bedrooms were quite badly stained. Some work has been done to refurbish bathrooms and it was reported that there are plans to redecorate but no time scale for this to be completed could be given. This needs to be addressed (See Requirements). The home was clean and hygienic of the day of the inspection and there are adequate laundry facilities that are sited away from the preparation of food. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 &36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support service users. The recruitment policy and practice used by the service supports and protects service users. Staff have access to relevant training and do carry out an induction with new staff but a record of this has not been maintained. The home has comprehensive supervision arrangements in place but these are still not all carried out as regularly as they should be. EVIDENCE: All the counsellors working at the service have substantial experience and are qualified to work in the field of substance misuse either holding or are working towards a counselling qualification and also a specialist qualification in addictions. In respect to recruitment at the last inspection it was identified that for staff member the required identification documents had not been obtained also for another staff member a Criminal Records Bureau (CRB) check been accepted from a previous employer, which is not permitted. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 one and had An Page 23 immediate requirement was issued on the day the inspection was held and following the inspection evidence was sent to CSCI that this matter had been addressed. At this inspection all staff files were checked including those for the two trainee counsellors presently working at the service as part of their studies to gain a Diploma in Counselling. All were found to contain the required documents including appropriate CRB checks and two references. Staff have access to training opportunities with training courses being identified through supervision and through staffs’ appraisals. There was evidence that these had been completed in individual staff files as well as certificates of training courses completed. In respect to mandatory training all staff completed a ‘Safety Compliance’ course that covered all aspects of health and safety in March 2006. In respect to induction although new staff such as one of the trainees reported that they had received an induction a record of this had not been maintained and this needs to be addressed (See Requirements). 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 work being carried out with service users by counsellors. The deputy manager who has a qualification in clinical supervision provides this. The registered manager carries out performance related supervision with staff but at the last inspection it was found this had not been held on a regular basis. At this inspection although this had greatly improved staff had still not received the required six sessions a year as required by the National Minimum Standards (NMS) (See Requirements). Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well run and managed. Service views are taken into consideration as part of self- monitoring. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The present registered manager has been in post since June 2005. Prior to taking up the post as manager he was working as deputy manager and has approximately seven years experience working in the addictions field, is a qualified counsellor and has undertaken a course in supervision. In addition, since the last inspection the manager has completed the Registered Manager’s Award (RMA)/ NVQ Level 4 in management. It was evident that the manager is competent and has the necessary qualifications to ensure the home is well run and this was reflected in the feedback received from service users and also a professional who has regular contact with the home. Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 25 At the last inspection although there was evidence that service users had been issued customer satisfaction questionnaires as part of self monitoring, the results of these questionnaires had not been complied into a report and made accessible to service users, stakeholders and also to the Commission for Social Care Inspection (CSCI). Prior to this inspection a copy of a report outlining results of questionnaires was sent to CSCI, which were overwhelmingly positive. Also, it was seen on the day of the inspection that a copy of the report was placed in the foyer of the home with the last inspection report ensuring these were accessible for all service users. Also, as part of quality assurance monthly provider reports have been sent to CSCI. There was evidence that the service does promote and protect the health, safety and welfare of service users and staff including robust health and safety policies and procedures being place. As mentioned all the staff completed a ‘Safety Compliance’ course last year. One of the staff is qualified to give First Aid and the Manager is responsible for acting as Fire Warden and has had formal training. Regular reports of incidents that have occurred have been sent to CSCI. Maintenance of fire equipment had been carried out, fire alarm call points had been tested weekly and regular fire drills had taken place. Up to date gas safety, electrical wiring maintenance certificates and a legionnaires test certificate were in place. Also, a fire risk assessment and general health and safety risk assessment and audit had been completed. However as mentioned in respect to Standard 17 service users are not given any basic instruction or training prior to being allowed to work in the kitchen and this needs to be addressed (See Requirements). Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 26 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 (1) Timescale for action The registered person must 30/04/07 ensure that a record of meals that are prepared are maintained to ensure that a diet that is sufficiently varied and balanced is provided to service users. The registered person must 30/04/07 ensure that all complaints including low level complaints and dissatisfactions are recorded and addressed. The registered manager must 30/09/07 ensure that the home is well maintained and a programme for re –decoration and for furniture and furnishings specifically carpets in service users rooms and communal areas are replaced. The registered person must 30/04/07 ensure that a record of the induction programme undertaken by new staff and trainees is maintained. The registered manager must 30/06/07 ensure that all staff receive all forms of supervision provided within the home on a regular basis. (Previous timescale of DS0000007078.V318512.R01.S.doc Version 5.2 Page 28 Requirement 2. YA22 22 3. YA24 23(2)(b) &(d) 4. YA35 18(1)(c) (i) 5. YA36 18 (2) Kairos Community Trust 30/06/06 partially met) 6. YA42 12(1)(a) The registered person must ensure that service users are provided with some instruction and training around basic food hygiene prior to being allowed to work in the kitchen. 30/04/07 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 YA2 Good Practice Recommendations The registered person should try to be consistent and always obtain the necessary information specifically the needs assessment carried out by the local authority prior to a service user being admitted to the service. The registered person should try to ensure that staff’s knowledge around adult abuse and adult protection procedures is regularly evaluated and arrange refresher training if necessary for individual staff. 2. YA23 Kairos Community Trust DS0000007078.V318512.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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