Inspection on 20/10/05 for Kalmia & Mallow

This inspection was carried out on 20th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kalmia & Mallow 10/04/07

Kalmia & Mallow 19/04/06

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 David Welch Unannounced Inspection 20th October 2005 16:00 Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 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.V259616.R01.S.doc Version 5.0 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.V259616.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kalmia & Mallow Address Dereham Road Watton Thetford Norfolk IP25 6HA 01953 884597 01953 883458 kalmia.mellow@craegmoor.co.uk 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) Conquest Care Homes (Norfolk) Limited Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 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 with the other only having 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. The position of Registered Manager was technically vacant although an application has been made to the Commission to register a manager, who has worked for the company in the past as manager of one of their other care homes for younger adults with learning disabilities. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and timed to coincide with the return home of service users from their day care, if applicable, and to observe late afternoon and evening routines. The visit also provided a chance to check on what progress had been made in complying with the 15 requirements and good practice recommendations made following the announced inspection that took place in June this year. The Commission was aware that the management arrangements at the home had been disrupted by the absence of the manager and Deputy Manager and staffing arrangements had been under strain. Ms Block has been in post at Kalmia and Mallow for about 41/2 months, but at the time of the unannounced inspection had been on compassionate leave for about 5 weeks and the Commission has been informed that she was unlikely to return in the very near future. The parent company has been asked to inform the Commission in writing (under Regulation 38 of the Care Homes Regulations 2001) what it intends to do to ensure suitable management of the home until the manager returns. The home’s Deputy Manager was also on extended leave and continuing management was in the hands of the Acting Deputy Manager of the home, with oversight from Craegmoor’s Acting Area Manager. So, the visit was also an opportunity to discuss with staff what support and supervision they had been getting under these very difficult circumstances. Staff described working very long hours in the past few weeks. Some agency staff had been employed. The Acting Deputy Manager said that interviews had been held and 5 new care staff had been appointed, bringing the establishment up to strength. One very new staff member was on duty and she was spoken with about her experience of beginning to work at the home. Other staff were spoken with as they went about their duties. The home was at the time of the inspection accommodating 8 service users, thus there were 4 vacancies. This has been the situation for several months. Two people who were living in the home said that plans are being made for them to move on, perhaps to more independent, but supported, living. More than half the visit was taken up with speaking to service users, sharing the evening meal in Mallow house and observing care practice in communal areas. Six of the eight service users were able to talk abut what it was like living here. The acting Deputy Manager was very helpful in providing an update on progress with meeting previously-made requirements and recommendations. A training matrix, staffing roster, the on-call, out-of-hours list, details of service users’ review dates and supervision log for staff were all available. The Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 6 Acting Deputy Manager later provided the dates on which 13 of the 18 staff had completed Protection of Vulnerable Adults training and the dates on which 4 staff had been trained in physical control and restraint. Further training has been booked for December this year. While some progress had been made in meeting the requirements and recommendations made by the CSCI following June’s inspection, some of which were to be done ‘immediately’, there remained several issues that had not been completed. A letter detailing what the Commission feel must be done as matters of considerable urgency has been sent to Craegmoor under separate cover. These include: • • • • providing a Statement of Purpose, Service User Guide and Complaints Procedure in various, and suitable, formats, carrying out an assessment of the communication needs of two service users in particular, providing timely induction within 6 weeks of staff taking up post and providing regular supervision for staff. What the service does well: The following ‘good’ points continue: • • • • • • • • This is a very open environment with residents able to come and go at will, when they are able to do so. There is lots of shared space. The home is close enough to community resources, including shops, the sports centre, fast food outlets and the paramedic base There is a good range of activities and pastimes with many residents still involved in some way in what goes on ‘outside’. One particularly good point was that every resident has a bank account. Staff usefully shared relevant information with colleagues Staff appeared to have warm relationships with service users. Those residents who were able could make their wishes known and to indicate clearly what they wanted to do. In addition, there is an on-call roster displayed. What has improved since the last inspection? There has been attention to some minor maintenance matters, but redecoration is some areas is still to be done. Some new furnishings have been purchased. Review dates have been sorted out. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 7 Syringes are now stored in a more suitable way. There has been some success in attracting new staff to work here. What they could do better: These matters have been given in detail within the body of the report but can be summarised as follows: • The company still has to provide information, including the Statement of Purpose. Service User Guide and Complaints Procedure in different formats so that everybody living here has a chance of understanding them If staff are to be confident that they are communicating with everybody living here in the most effective way, assessments of people’s communication needs must be done as a matter of urgency Some attention needs to be given to making some areas less ‘institutional’ in character The company has an impressive looking training matrix, but in many respects it shows the majority of staff have not yet completed training in several vital areas. The company has yet to successfully establish a fully stable workforce with low turnover of staff. For understandable reasons, management arrangements have been somewhat disjointed recently and the company must establish some consistency Unannounced Regulation 26 visits must be on a monthly basis • • • • • • 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. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 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 Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 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 and 3. The Commission feels that in some respects service users do not have all the information necessary to make informed choices about living in this home. Neither can it be sure that staff can be totally confident that they are communicating with all service users most effectively. EVIDENCE: Following the previous inspection, the home had been asked to provide its Statement of Purpose and Service User Guide in a format that service users are likely to understand. This might have to be in a variety of formats, including audio, symbols, perhaps even video or DVD. Some of this, almost by definition, would have to be a corporate initiative. The matter was again discussed at this inspection. Staff said that they had not seen these documents in different formats suitable for service users. The staff said that the home had been supplied with software that enable written documents to be ‘translated’ into symbol form, but there had not been time to install it and produce information in this alternative form. Similarly, a requirement had been made in June that service users should have a communication assessment to ensure that staff were communicating with two residents, in particular, in the most appropriate ways. The member of staff who had been asked a year ago by the home to be its Communications Assessor, with 3 hours a week allocated specifically to the work, had, she said, Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 10 been so much involved in ‘hands-on’ care that no assessments had taken place. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 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, 7, 8 and 9. Service users’ needs are reviewed in a timely way. And the people living here are involved appropriately in decisions about their lives, with support available from staff when they take risks. EVIDENCE: The Acting Deputy Manager kindly provided details of when service users had last had a review of their needs and, in one case, the date of the next planned review. Everybody living in both houses had been reviewed since April this year. One person was said to have ‘on-going monthly reviews’. There was evidence to show that service users were making decisions, where applicable, about their lives. These included how they spent their money, what clothes they wore (one person changed clothes at least twice during the inspection), how leisure time was spent, what time they went to bed and what they had for tea. One person phoned out for a takeaway meal, which he paid for directly. Bedrooms were clearly places where residents exercised their personal preferences in terms of the decoration and fittings. One person required a great deal of assistance and spent time in a special chair. Staff helped with things like having a shower before bed. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 12 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): 11, 12, 13, 14, 15 and 17. Most of the people living here lead quite busy and filled lives, have family contact and friends. Mealtimes are suitably relaxed affairs, but some of the environmental ‘ingredients’ providing what should be an enjoyable eating experience are missing. EVIDENCE: One person who had a job in a charity shop said that he does not now do this, which seemed to have left something of a gap in his life. This comparatively very able person could move on in the New Year. Four people attend day care services at least one day a week and sometimes up to four times a week. During the inspection, several service users were playing their own choice of music One person went to the Thursday Club during the evening. Another went shopping with a member of staff. During the inspection, the person who comes in on a weekly basis to do reflexology therapy with service users arrived. Two people took part with evident enthusiasm. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 13 Mealtime arrangements in the two houses are very different. In Kalmia, service users tend to eat independently, some service users preparing their own meal with varying degrees of staff help. One person tended to eat takeaway meals for preference. In Mallow, the meal was prepared for service users and they ate together in the Dining Room. Those who needed help were given it by staff sensitive to the person’s individual needs. Discrete attention was paid by staff to any resident whose dietary intake was linked to their medical condition. The meal was a balance of meat and vegetables with a processed dessert. Access for service users to the Mallow kitchen was restricted, but in Kalmia they could come and go as they pleased, with staff in attendance. The Dining Room in Mallow is a little ‘institutional’ in character, not helped by a serving ‘hatch’ and the room’s bland decoration. The pictures appeared to have been put up simply to fill space and with not much thought about content. The food in the fridge was seen to be in date and the items to be of a suitable quality. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The Commission is confident that personal and health care support by staff for service users is given in a committed and sensitive way. EVIDENCE: Staff were very clear that personal care was given in consultation with service users and this negotiation process was observed during the visit. There was evidence of warmth between service users and staff. Despite the considerable pressure that staff have been under recently they have retained a commitment to the residents. The previous requirement that the home make suitable arrangements to store syringes was checked. It had had been complied with. During the visit, the blood sugar levels of one person were checked on two occasions by staff, as there was some concern. This was done discretely and by the end of the evening were within acceptable limits. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Because of the way in which information is provided, it is hard to imagine that service users can be fully aware of the procedures relating to complaints and while staff are generally kind and understanding of service users’ vulnerabilities, some still lack training in specific aspects. EVIDENCE: Two people living in the home said that plans were being made for them to possibly move elsewhere. Staff confirmed that this discussion was on-going and in the case of one person, at least, they were likely to have an alternative identified in the New Year. The person in question had been involved and was looking forward to a move that would be closer to the family home. The providers had been again asked in June to ensure that all staff were trained in the Protection of Vulnerable Adults, a requirement repeated from the inspection before. A check of the training matrix held on computer in the home suggested that of the 20 staff employed 13 had received this important training by the time this unannounced visit took place. Only 4 staff had received the training since the last inspection. From the information given, it seems that this training is now scheduled for early December, six months after the timescale given. A previous requirement that the home’s Complaints Procedure must be in a form that every resident had a chance of understanding had still not been met. There have been two occasions on which complaints have been made to the Commission in the last 12 months. At both times the providers have been asked to undertake an internal enquiry and report back the findings. It is evident that in one case a member of staff did use an inappropriate approach Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 16 to a service user who was reluctant to go to bed. The member of staff is no longer employed by the home. In a letter to the Commission a member of staff who did not want to give their name raised some issues that were investigated by the company’s Acting Area Manager. She reported back to the Commission and it was possible to check her findings during this visit. Staff had obviously found themselves under some pressure owing to absences and unfilled posts. In these circumstances staff can feel unsupported and isolated. The home’s ‘whistle blowing policy includes the Commission’s name and address and the process had clearly worked in this case. During this unannounced visit: • staffing levels were seen to be acceptable, • the reasons that people went to bed ‘early’ were seen to be as a result of day care commitments the following day, • there was an on-call roster posted on both staff notice boards, • agency staff had been used in emergency, • some residents were remaining at home during the day, • a food hygiene matter had been dealt with by means of disciplinary action and • food was suitably labelled in the fridge. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 29. The purchase of some new furnishings has added to a feeling of comfort in the sittings rooms. But, within the houses in general, some ‘institutional’ characteristics remain, not helped in places by some poor decoration. But, service users do appear to enjoy the generously proportioned communal areas. With only four service users in each house, space is certainly not at a premium. Some attention to quite easily remedied matters such as locks on doors will ensure service user’s privacy. EVIDENCE: At the last inspection the new manager said that she would like to re-decorate some areas of the home, including the bathrooms, to make them more pleasant places. This had not been done by the time of this visit. The shower room and bathroom in Mallow were looking ‘tired’ and rather ‘institutional’ in character. The window in the shower room did not shut properly and on a chilly night having a shower there would not have been an entirely pleasant and relaxing experience for service users. Both areas lack homeliness and those touches that provide the comforts of domestic life. Residents’ bedrooms, in contrast, showed real signs of being personalised. The service users’ interests, hobbies and characters were clearly to be seen. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 18 The lock on the bathroom door in Mallow was broken and it would not be possible to use the facility in total privacy, secure in the knowledge that somebody was not going to come in. Efforts had been made to cover gaps over the window frames in Mallow. Sitting rooms in both houses had music and television, were nicely decorated and quite homely. Some new furniture had been provided in Mallow, with ‘throws’ over the settees and matching cushions. One person who is not independently mobile had specialist equipment provided. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 19 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, 35 and 36. Some issues beyond staff control have not yet been brought by the company to an entirely successful conclusion and the Commission remains concerned about some aspects of the home’s operation. EVIDENCE: Staff worked together effectively on the evening of the visit. Roles appeared to be quite well defined. From the training matrix supplied, two staff were working towards NVQ level 2 and three towards the higher level 3. Only four out of the twenty people currently employed at the home had completed training in physical control and restraint. Thirteen had done Protection of Vulnerable Adults training. The staffing roster was checked. Six staff were on shift during the afternoon, and 5 during the early evening. Day staff went off duty at 8:00pm to be replaced by two waking night carers, one quite new in post. Only one resident had gone to bed at this time. Staff said that most service users went to bed later and it therefore seems unusual that the ‘waking day’ should finish so early in a care home for younger adults that is still quite busy after 8:00pm. This was probably due to the long, 12-hours shifts that most staff were working, beginning at 8:00 or 9:00am. A more usual early and late shift pattern might allow staff cover to remain until 10:00pm when only the most dedicated ‘night birds’ are still up. Two waking night carers is far more Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 20 appropriate in that case, perhaps working a 10-hour shift until 8:00am the next morning. Three new carers had started at the home within the last month. Only one had begun induction. Bearing in mind that one of these people, at least, despite being bright and very keen, had no previous experience and had been engaged to work alone in one of the houses for a 12-hour waking night shift, induction at a very early stage is essential. The training matrix showed that nobody had completed foundation training. The Supervision Log was looked at and records showed that there were no supervisions in June or July, only four in August and one in September. Staff each need at least six individual supervision sessions per year and the record did not show that this was happening. Staff said that the ‘old shift pattern’, with some staff working sessions in the day when few residents were at home, had all but finished. Only one person was still now doing this. Two others had changed to the longer shifts and two had moved on to work elsewhere. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 21 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, 38 and 43. The home has been going through a difficult last few weeks and staff have been under tremendous pressure. The Commission continues to have some anxieties about the management arrangements. EVIDENCE: Staff obviously knew about the difficulties that the home had been experiencing recently, that the new manager was on compassionate leave, that the Deputy was on long term leave and a member of staff was covering the deputy’s post. They looked to a member of staff who had been in post for about 3 years to be ‘senior’ on shift after 6:00pm. Staff said that an experienced manager from one of the other Craegmoor homes in Norfolk had been giving them some management oversight. The company’s Acting Area Manager had also been present at times in the home. Bearing in mind that the home’s manager, in post since June, but yet to be registered by the Commission, as required, might not be back in the short term, the company have been asked to inform the CSCI what it intends to do about interim management arrangements for this home. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 22 Up until July 2005, the Commission had been receiving copies of reports of regular monthly visits made by the company under Regulation 26 of the Care Homes Regulations 2001. No reports have been received at the Norfolk Area Office of CSCI since the beginning of August 2005. Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 2 X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 2 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 X 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kalmia & Mallow Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X 2 X X X X 2 DS0000027529.V259616.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) &5(1) Requirement Timescale for action 09/06/05 2. YA3 14 3. YA8 12(2)(3) and 22(2) The Registered Persons must provide a Statement of Purpose and Service User Guide that contain all the information detailed in Schedule 1 of Care Homes Regulations 2001. The Service User Guide, in particular, must be produced in a format such that every resident and prospective resident can have a chance of understanding it. This might mean it should be available in a number of different formats, e.g. audio, video, symbol-based etc. This is a repeat requirement from the last three inspections. The Registered Persons must be 09/06/05 able to provide evidence that staff are communicating with users in a way that they understand. This will mean that service users with language difficulties will require assessment. This is a repeat requirement from the last three inspections. The Registered Persons must 31/12/05 provide service users with comprehensive, accessible, DS0000027529.V259616.R01.S.doc Version 5.0 Kalmia & Mallow Page 25 4. YA22 22(2) 5. YA23 13(6) 6. YA27 12(4)(a) 7. YA32 18(1) 8. YA33 18(1) 9. YA35 18(1) understandable and up to date information, in suitable formats, about the policies and procedures, activities and services; and appropriate communication support. The Registered Persons must provide a complaints procedure for users in a format that they are likely to understand. This may mean in different formats such as audio, video, symbolbased etc. This is a repeat requirement from the last inspection. The Registered Persons must provide Protection of Vulnerable Adults (POVA) training for all staff. This is a repeat requirement from the last two inspections. The Registered Persons must ensure that all bathrooms, shower rooms and WC’s have a suitable lock that allows service users to have privacy when using the facilities. The Registered Persons must continue their efforts to reach a ratio of at least 50 care staff assessed at NVQ level 2. This is a repeat requirement from the last inspection. The Registered Persons must make efforts to maintain a stable staff team, stem the high turnover of staff and keep sufficient numbers of staff on duty at all times without resorting to current carers working excessively long hours. The Registered Persons must ensure that all staff have induction training within 6 weeks of taking up post and foundation training within 6 months. This is a repeat requirement from the last inspection. DS0000027529.V259616.R01.S.doc 09/06/05 09/06/05 04/11/05 09/06/05 04/11/05 09/06/05 Kalmia & Mallow Version 5.0 Page 26 10. YA36 18(2) 11. YA38 38 12. YA39 26(3) The Registered Persons must ensure that all staff receive appropriate individual supervision at least 6 times a year. This is a repeat requirement from the last three inspections. The Registered Persons must inform the Commission what their intentions are in respect of the management of the home. The Registered Persons must ensure that unannounced visits made under Regulation 26 of Care Homes Regulations 2001 take place monthly. This is a repeat requirement from the last inspection. 09/06/05 04/11/05 09/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations The Dining Room in Mallow House is rather ‘institutional’ in character. The Registered Persons should endeavour to make this shared space, in particular, more homely and pleasant for service users. Some areas are looking ‘tired’ and need decorating. The Registered Persons should ensure that all shared areas such as bathrooms and Shower Rooms are decorated, domestic and homely, in short, pleasant places to use. This was discussed at the inspection in June 2005. This recommendation remains from the previous inspection. 2. YA24 Kalmia & Mallow DS0000027529.V259616.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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