Inspection on 10/04/07 for Kalmia & Mallow

This inspection was carried out on 10th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kalmia & Mallow 19/04/06

Kalmia & Mallow 20/10/05

Kalmia & Mallow 09/06/05

Kalmia & Mallow 20/12/04

Kalmia & Mallow 22/04/04

Kalmia & Mallow 30/09/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Kalmia & Mallow Dereham Road Watton Thetford Norfolk IP25 6HA Lead Inspector Debra Allen Key Unannounced 10th April 2007 10:45 Kalmia & Mallow DS0000027529.V335791.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 Kalmia & Mallow DS0000027529.V335791.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. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kalmia & Mallow Address Dereham Road Watton Thetford Norfolk IP25 6HA 01953 884597 01953 883458 kalmia.mallow@craegmoor.co.uk www.craegmoor.co.uk Conquest Care Homes (Norfolk) Limited 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) Manager post vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2006 Brief Description of the Service: Kalmia and Mallow are two interlinked, six bedded bungalows on the outskirts of Watton. Care is provided for up to twelve young adults with a learning disability. The focus of one of the bungalows is on supporting service users with specific behavioural needs. In the other house, staff assist people with quite profound needs, including physical disabilities. The accommodation is purpose built and all on the ground floor. The houses are set in a hollow with quite high banks on three sides so the outlook is restricted. One of the bungalows has a large garden. The other bungalow has a very small area at the back. The service users each have a single bedroom and in both bungalows there are shared bathrooms, lounges and dining rooms. There is parking to the front of the bungalows. The home is owned by the Craegmoor Healthcare organisation and is being managed on a day-to-day basis by Ms Nicola Cressey, who is currently in the process of completing her registration as manager with CSCI. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This inspection was carried out over a period of five hours, during which time we carried out a tour of the premises, met and spoke with a number of people living at the home and had discussions with members of staff, including the deputy manager. Records relating to health & safety, recruitment and individuals living at Kalmia & Mallow, were also inspected. One service user survey and five relative/visitors comment cards were received prior to the inspection. Two requirements have been made as a result of this inspection. What the service does well: Care plans are very detailed and ‘person centred’. Despite people’s very different abilities and health needs, individuality is greatly respected. ‘Pen pictures’ are very clear and ensure staff are able to provide consistent care and support, as required by service users. The service supports people to access a good range of activities and pastimes, both within Kalmia and Mallow and in the wider community. The manager and deputy have an ‘open door’ policy and are approachable and supportive. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 5 Quality in this outcome area is Good. People’s individual aspirations and needs are assessed and each person has a copy of the Service User Guide. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of care plans were looked at on the day of inspection and each of these was found to contain detailed needs assessments, which were completed prior to people moving in. These assessments are regularly reviewed and updated as necessary. For one person who has recently moved in good work was noted with regard to getting to know them as an individual in order to compile their care plan together. Copies of the Service User Guide were also seen. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is good. Individual care plans contain information which reflects service users’ assessed and changing needs. Service users are supported to make decisions about their lives and take risks as part of an independent lifestyle. Service users’ information is kept confidential. This judgement has been made using available evidence including a visit to this service. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 10 EVIDENCE: The care plans that were looked at contained thorough risk assessments, detailed pen-pictures, service users’ likes, dislikes, communication profiles and support requirements. It was evident that a great deal of time and effort has been taken by the staff team in getting to know the service users and their wants and needs and this was reflected in the pen-pictures. One person in particular was noted to have changing health and support needs and appropriate records were seen which confirmed regular reviews and updates were taking place with regard to their ongoing support. Many of the risk assessments were noted to be quite empowering – i.e. supporting people to do, rather than doing for them or being over-protective. The risk assessments included areas such as: using own room as required, road safety, protection from financial abuse and personal care. All documentation looked at was noted to be stored securely, either in the manager’s office or the staff room and therefore confirmed that service users’ information was kept confidential. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 11 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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. Service users are provided with opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community and are supported to have appropriate personal 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. This judgement has been made using available evidence including a visit to this service. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 12 EVIDENCE: The people living at Kalmia and Mallow are supported to lead very individual lifestyles and their daily routines and activities were seen to be quite varied. From the information noted and observations on the day of inspection, it was evident that people’s individual wants, needs and choices are genuinely considered and the two houses, Kalmia and Mallow have separate staff for providing day care. A number people attend Day Centres across the region on various days during the week; one person was noted to have a job while another undertook activities from home. Some of the external activities that were recorded in people’s personal records included bowling, sailing & boat trips, swimming and going into town. The home was seen to have a very well equipped sensory room, which included a ball pool and tilt table. An area for doing art and craft was also seen and regular use of these resources was noted accordingly in people’s daily notes. Evidence and records seen in the care plans supported the fact that the people living at Kalmia and Mallow are able to maintain relationships with their friends and family on a regular basis. Menus are created on a weekly basis, with input from service users and a ‘food diary’ showed what meals people had eaten, including breakfast and packed lunches. The information seen confirmed that people are offered a healthy, balanced and nutritious diet. Care plans contained detailed information of people’s likes and dislikes with regard to food and drink, which helps to ensure they enjoy their meals and mealtimes. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 13 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 & 21 Quality in this outcome area is good. Service users receive personal support in the way they prefer and require and their physical and emotional health needs are met. Service users are protected by the home’s policies and procedures for dealing with medication. The ageing, illness and death of a service user are handled with respect and as the individual would wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The physical, emotional and health needs of the people living at Kalmia and Mallow are quite varied and, again, it was evident that a great deal of time and effort has been taken by the staff team and external professionals to ensure that individuals’ needs are met. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 14 One person’s care plan was seen to include very detailed information with regard to how they like and need to be supported in every aspect of their daily life such as personal care, how they like to be approached/greeted and their personal means of communication, which included speech, photos, pictures and gestures. There was ample evidence seen to confirm involvement with and access to external healthcare professionals such as Occupational Therapist, Physiotherapist, Dietician, Speech & Language Therapist, GP, Nurses, Chiropodist, Dentist and Optician. The home’s policies and procedures with regard to handling and administering medication were seen to have improved since the previous inspection and observations showed Medication Administration Records (MAR) had been completed with no errors or omissions noted. Medicines looked at were stored appropriately and those checked were all accounted for. The home was also noted to have a very good and descriptive ‘Homely Remedies’ policy. Observations, records looked at and discussions with staff confirmed that people are supported with respect and dignity during times of illness and there is a policy in place with regard to a person dying. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 15 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. Service users feel their views are listened to and acted on and they are protected from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the five relative’s comment cards returned stated that they were aware of the home’s complaint’s procedure and none of the five had ever had to make a complaint. The one service user survey also confirmed they knew who to speak to if they were unhappy. The risk assessments, care plans and ‘pen-pictures’ that were looked at, provided good evidence of service users being protected. Staff spoken to on the day had a clear understanding of adult abuse and protection and have received training in the Protection Of Vulnerable Adults. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 16 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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. Service users live in a homely, comfortable and safe environment, which is clean and hygienic. Service users bedrooms suit their needs and lifestyles and promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs and shared spaces complement and supplement their own rooms. Specialist equipment is available, as required, to maximise service users’ independence. This judgement has been made using available evidence including a visit to this service. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 17 EVIDENCE: Kalmia and Mallow were found to be clean, hygienic and pleasantly decorated throughout and both had a very comfortable and homely atmosphere. Service users bedrooms that were seen were very comfortable, individual and personalised. The tour of the premises also confirmed that the toilets and bathrooms offered sufficient privacy for people using them. Service users were seen choosing to use the communal areas and appeared very comfortable in them. One bathroom was found to be locked and unusable on the day of inspection, though the maintenance staff explained the work that was due to be undertaken by contractors in the very near future. Meanwhile, appropriate arrangements have been made for service users to use the staff shower room while this work is being undertaken. Staff confirmed that the installation of a specialist bath had been approved and work would be commencing very soon. Concern was raised during the inspection with regard to people being able to leave the house unnoticed, especially during the night, by way of an external door in the corridor near the unused bathroom. It was pointed out by staff, that all external doors had alarm sensors fitted for that reason. However, the sensor in this instance had fallen off and another did not work when tested. A small sensory garden has been created to the front of Kalmia and Mallow, which can be easily accessed by people using wheelchairs and provide a pleasant view from a number of windows inside the houses. Various specialist equipment was noted throughout the two houses and included a custom-made armchair, hand-rails, wheelchairs and tilting bed. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 18 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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. Service users are supported by an effective staff team, who are competent and qualified and their individual and joint needs are met by appropriately trained staff. Service users are supported and protected by the home’s recruitment policy and practices. Staff receive regular 1:1 support and supervision sessions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken to on the day were very clear about their roles and responsibilities within the home and said they felt the team worked well together and that they had a good mix of skills and experience between them. Information seen in the staff files also supported this. Two staff files were fully examined and found to contain appropriate references and disclosures from the Criminal Records Bureau (CRB). Copies of contracts/job descriptions were also seen on the staff files. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 19 Training records were looked at and confirmed that staff are provided with good and regular training and updates including First Aid, Moving & Handling, COSHH, Health & Safety POVA, Risk Assessing, Communication, Medication, Food Hygiene, Equal Opportunities and Epilepsy Awareness. The Deputy Manager confirmed that an Intensive Interaction course has been booked for May, which should be particularly beneficial to one service user with complex communication methods. Records were seen to confirm staff receive regular 1:1 support and supervision from their line managers. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 20 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, 38, 39, 40, 41 & 42 Quality in this outcome area is good. Service users benefit from a well run home and the ethos, leadership and management approach. 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 and the record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. This judgement has been made using available evidence including a visit to this service. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 21 EVIDENCE: An application has now been received by CSCI in respect of the current acting manager becoming registered. In addition, a deputy manager has also recently been recruited providing a much better ‘management team’ structure within the home. Staff spoken to said they felt very supported by the manager and deputy and confirmed that they had a genuine ‘open door’ policy and could be approached at any time. One relative’s comment card stated that the current manager “is by far the best manager the home has had. There is a great team of ‘happy’ staff and we feel that the home is at last being well run”. The home undertakes a comprehensive Quality Assurance audit, which includes feedback from service users. The most recent Quality audit was completed in March 2007. The home’s policies and procedures are regularly reviewed and updated as required and the regulated checks for fire, environmental health, water and electric were found to be satisfactory, with relevant risk assessments in place. Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 22 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 X Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 23 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 YA27 Regulation 23 Requirement The provision of a specialist bath needs to be completed as soon as possible, in order to meet the needs of some residents with particular physical difficulties. Timescale for action 31/07/07 2. YA29 23 The sensors fitted to external 31/05/07 doors, which indicate when doors are opened and service users are possibly leaving the premises unsupervised, need to be tested and repaired or replaced where necessary as soon as possible. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Kalmia & Mallow DS0000027529.V335791.R01.S.doc Version 5.2 Page 25 - 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. 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