Inspection on 09/06/05 for Kalmia & Mallow

This inspection was carried out on 9th June 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 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 11 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 20/10/05

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 IP25 6HA Lead Inspector David Welch Announced 09 June 2005 09:45 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kalmia & Mallow Address Dereham Road, Watton, Thetford, IP25 6HA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01953 884597 01953 883458 kalmia.mallow@craegmoor.co.uk Conquest Care Homes (Norfolk) Limited Post vacant Care Home 12 Category(ies) of LD Learning disability registration, with number of places KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 December 2004 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 with the focus of one of the bungalows on supporting service users with specific behavioural needs. 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 Craegmore Healthcare organisation. At the time of the inspection the position of Registered Manager was vacant and a new manager, yet to apply for registration, had been in post only for a few days. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place during one day in early June. The inspection lasted for over 8 hours for which the new manager, Ms Lin Block, was present throughout. The Commission for Social Care Inspection (CSCI) had the benefit of some pre-inspection information, kindly supplied by the previous Manager, and some comment cards completed and returned to the Commission by four service users and three of their relatives. During the inspection, six of the eight current residents were spoken with in private. Generally, the feedback from residents was positive and they said they liked living in the home. Some were able to say what they liked best about Kalmia or Mallow. They described how they spent their time at the home. This included going on outings, shopping, activities, day care, training and work experience. The manager had arranged for two members of staff, one in charge of training and the other of the administration of medication, to come in on their days off. Discussion with the staff members concerned was very useful and their willingness to come in was much appreciated. Four other staff, including the manager, Ms Block, were interviewed using a prepared list of questions. Several carers on shift were spoken with informally. The staff comments painted a clear picture of life under the ‘old management’, which was variously described as ‘a nightmare’ and ‘not great’, and the new management that was ‘sorting out a few issues’. The changes to the regulatory role that are likely to take place within the next two to three years were discussed with the manager and also those changes that have already taken place to the reporting format, hopefully to make it more readable, accessible and user-friendly. The intention was to check as many as possible of the standards identified by CSCI as being key to the welfare of the people living in the two houses. Also, what progress had been made in complying with those requirements and recommendations made following the previous inspection. Many of these requirements and recommendations had been outstanding for a considerable period and compliance was now felt by CSCI to be extremely urgent. At a meeting with Craegmoor’s Director of Care, Michael Byrne, on 5th May 2005 he said that it was his hope that both of the Craegmoor homes in Norfolk could achieve compliance as soon as possible, a sentiment with which CSCI wholeheartedly agreed. In truth, the inspection was difficult for the new manager at Kalmia and Mallow as she had been in post for only three days and simply locating certain documents among the wealth of paperwork supplied by the parent company KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 6 was always going to be a problem. Her deputy was very useful in this respect. At the time of the inspection an application by the manager for registration had yet to be received by the Commission. At the end of the inspection, verbal feedback was given to the new manager and this report reflects, but broadens, what was said at that meeting. The CSCI was not given copies of either the home’s Statement of Purpose or the Service User’s Guide prior to the inspection taking place and these were provided on the day of the visit. We undertook to comment on the content of both documents in the draft report. Neither document fulfils either the requirements of legislation or the needs of service users and/or their relatives. Ms Block took a photocopy of the new report format for her information, including the ‘outcomes’ for residents and identification of the ‘key standards’. What the service does well: What has improved since the last inspection? Some progress has been made in complying with the requirements and recommendations from previous reports especially regarding staff training. Some thought has been given to the administration of medication, but there is still work to be done here. A Communications Assessor is a good move. The manager has confirmed that she will use the home’s assessment tool for assessing any prospective new residents. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 7 The carpets have been cleaned, which is an improvement in the quality of life for residents. A decision has been taken to examine shift rosters and to regularise staffing levels during the whole of the waking day and do away with some outdated custom and practice. 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. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 3 Because the home’s Statement of Purpose and Service User’s Guide do not contain all the required information in a variety of formats, prospective service users, and those currently living at Kalmia and Mallow, do not in every case have all the information necessary to make informed choices. While showing kindness and gentle consideration to all residents, staff could not demonstrate effectively that current ways of communicating with every individual was appropriate in all cases. EVIDENCE: The home had been asked in a number of previous inspections to provide a Statement of Purpose and a Service User’s Guide that are relevant and appropriate to the service at Kalmia and Mallow. A timescale of 28th February 2005 was given for this work to be actioned. Neither of the two documents given to us at the inspection fulfils either the requirements of legislation (namely Schedule 1 of the Care Homes Regulations 2001) nor gives the information necessary for service users and/or their relatives in a user-friendly format. There has been some confusion about what information should be given in which document. The Statement of Purpose names the owner of the company, but fails to give the following information: the name and address of the Registered Provider, KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 10 gives out-of-date details about the Registered Manager and provides no information about the qualifications and experience of the Registered Provider sufficient details of relevant qualifications of staff age range of service users whether nursing care is provided the arrangements for consulting service users about the operation of the home emergency procedures such as fire safety contact between service users and their friends and families the arrangements for dealing with complaints sufficient information about how the home intends to meet requirements about reviews details of any therapeutic techniques and the arrangements for respecting privacy and dignity The Service User’s Guide is not in a format for learning disabled people, being print only and in a possibly unsuitable font size, does not give the qualifications and experience of staff, key contract terms, fees, service users’ views of the home, a copy of the complaints procedure nor information about how to contact CSCI, local social services and healthcare authorities. No new service user had come to live in the home since the last inspection. However, the manager said that a referral had been made recently, and she intends to assess the person concerned using the home’s assessment tool, their ‘Outcome Based Evaluation’ document. The manager and her deputy explained how staff communicated with individual members of the resident group. Only two had communication difficulties such that speech was not possible. One person was being further assessed to find out the level of their understanding after the appointment of a new Communications Assessor. While observation confirmed that the person concerned was being sensitively and gently cared for, they had been resident for some time and an investigation into their speech and language levels was certainly overdue. The home should provide information in a range of different formats, for instance, audio, video or symbols, such that service users, and possibly their relatives, can be informed about the operation of the home. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 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 standard(s) 6, 7, and 9. Statutory reviews had, almost without exception, not been held and only one was planned. On this basis we could not be confident that the assessed and changing needs of residents were being met in every respect. Residents were being helped in a sensitive and caring way to make decisions about their lives and the potential risks in them doing certain activities had been well considered. EVIDENCE: We asked for the dates of each resident’s last, and next, planned review. In only one case were there any details of the last review and the manager and her deputy could find only one person with a review planned. The manager said that in a majority of cases, service users did not have social workers. Bearing in mind that the Statement of Purpose given to us said that … ‘There are regular service user reviews which the service user, and where appropriate, relatives and friends/advocates are encouraged to participate’… this is a significant failure to meet the required outcome for people living in the home. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 12 Through observation of the care given by staff to the people in residence on the day of the inspection, and by talking to staff and service users, it was clear that residents were being helped to make decisions about their lives, and in one particular case, having the independence to come and go as they wished. One person had supervised contact with family members and one person’s money was being held for them. A particular example of good practice was that every resident had a bank account at a local building society. Residents took a variety of risks including horse-riding, working in a local shop, helping with chores and cooking and going out alone. These were considered and assessed beforehand. The area of ‘waste’ land at the back of the house is to be fenced shortly. This should take place as soon as possible, as part of it is out of sight and contains the home’s waste pumping station. A detailed examination of Care Plans was not included in this inspection. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16 and 17. Residents on the whole had opportunities for personal development. However, potentially, the chances for social and emotional contact for three people could be improved with regular day care arrangements outside the home. Staff generally support service users well in a range of activities in the local community and further afield. More effort could be made to maintain family relationships in one case and to link three service users, in particular, with an advocacy service. We were confident that staff respected residents’ rights. The food on offer looked appetising. EVIDENCE: One person worked in a local shop on a volunteer basis three mornings a week. Another comes and goes as he wishes. One service user has an interest that involves shopping for items quite far afield. Five residents had some form of education or training during the week, although most were not full-time. Three people were home-based. Everybody did things in the local community and beyond. Three people had no real family contact and in one case arrangements were being made for an advocacy KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 14 service. The other two people had no advocates and really should have somebody independent of the home and placing authority. The staff were seen to interact well with residents on an individual basis. Those residents who wanted to do so could retire to their bedrooms, which were very much their own personal areas to which they had access at all times. The staff encouraged residents to take some responsibility for household chores and, in some cases, for cooking. The front doors of the houses were open at all times during the visit. No personal care was given in communal areas. The home did not employ a cook. Staff catered for up to 6 (at the time of the inspection, four) people in each house. One person was cooking his own meal, helped by a member of staff and another did not fancy what was on offer and went to a local take away for his meal. Residents could, and did, have access with staff to the kitchens. There were drinks available when service users returned from day care or other activities. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 We were confident that services users were generally receiving support according to their day-to-day needs, although a review of everybody’s care would further inform, and confirm, this. Good specialist input from outside health agencies was available. Some aspects of medication administration remain of concern. EVIDENCE: One person needed a lot of help with moving and a hoist was available for this. The previous manager identified three people who at times used a wheel chair. The people living in Kalmia, in particular, took a lot of responsibility for their own personal care and had in many respects only advice and guidance from staff. Where necessary, help from specialist health services was on hand. These included the Community Psychiatric Nurses, a Consultant and the diabetic clinic. One person, because of a medical condition, had lots of health checks and another service user had taken it on himself to arrange a check up, but none of the others had been offered an annual health check and this should be done. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 16 It was extremely useful to be able to discuss with the member of staff responsible for medication the arrangements for administration. This aspect of care was the focus of a recent inspection by the CSCI’s pharmaceutical inspector and a very comprehensive report identifying some shortfalls was presented. As a result, some effort had been made to remedy the failings, in particular, cabinets had been ordered for storing medication more appropriately. These had not arrived and the manager should follow this up as a matter of some urgency. The way in which insulin syringes were being stored was concerning and this was brought to the attention of the manager for immediate redress. The member of staff in charge of medication said that all staff had been trained in the administration of rectal diazepam, but some confusion remained as to what they would do in an emergency, dial 999 for an ambulance or administer the medication. This was compounded by the wishes of the family of one resident. This matter should be sorted out as soon as possible. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Shortfalls in both of the key standards that were checked go some way to undermining the confidence we have that service users know how to access the complaints procedure or that all staff are aware of Protection of Vulnerable Adults (POVA) principles. EVIDENCE: Reference had been made to complaints in notices in two places on the wall of the Mallow hallway. The notices still referred to the National Care Standards Commission, the name by which the regulatory body was known before it became CSCI, but contact details were correct. However, the manager could not put her hands on a copy of the complaints procedure that included all those matters laid down by law and in the National Minimum Standards, although she was sure it existed. The manager explained the nature of one recent complaint to CSCI. A requirement made following the previous inspection was that all staff must have Protection of Vulnerable Adults (POVA) training and the member of staff responsible for training in the home confirmed that this ‘was 50 complete’. One member of staff interviewed said that they had been properly trained in this respect, but another person said that they had yet to have this training. As such, the requirement will be repeated. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. In general, these outcomes were reasonably met, with one or two minor omissions. The open-ness of the houses was welcome and the spaciousness of the communal areas surely appreciated by residents. EVIDENCE: At the previous inspection a hole had been seen under a window in the lounge in Mallow house. The deputy said the hole had been repaired and this was the case, but a similar hole was then found below the other window and this, too, must be repaired. The area of ‘waste ground’ to the rear/back of the property is very marshy, representing the lowest part of a plot that is, itself, in a depression. The area contains a pumping station with which there have been problems in the past. Staff confirmed that quotes for the erection of a fence here have been sought and the sooner this happens the better. A contractor had cleaned stained carpets. Some re-decoration is needed, especially in bathrooms, which seem a little institutional. The home is located on the outskirts of Watton town centre and all amenities, including the nearest bus stop, small shop/newsagent, chemist, pub and KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 19 library, are within a 10 to 15 minute walk. The sports centre, where several service users like to play pool, is much nearer – within a couple of hundred yards of Kalmia and Mallow. All laundry was done in-house. Any incontinence pads were treated as clinical waste and disposed of accordingly. Written guidance for dealing with spillages was seen, but as a corporate document, and mentioned ‘the sluice’ and ‘senior nurse’. Written guidance for staff at Kalmia and Mallow should be location specific. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36. Because training has in the past been deficient and has only in recent months been given a much higher priority by the company, with improvements clearly having been made, CSCI cannot yet be wholly confident that staff have all the skills necessary to provide a sufficiently supportive service to every resident or to meet their individual and joint needs in full. The individual supervision of staff remains totally inadequate. EVIDENCE: The manager and her deputy identified about half a dozen staff who either have NVQ level 2 in care or are enrolled on this course of assessment. With a staff group of about 18 people, there is some way to go before the home achieves a ratio of 50 staff with this assessment. In previous inspections some concern had been expressed about staffing deployments. These were such that carers, working 9.00am to 3.00pm shifts, were only available, especially in Mallow, during the day when most residents would be out. Staffing numbers might be low during the early mornings, evenings and at weekends, when residents might need help to get ready or want to go out. This matter was discussed at the meeting held with Mr Byrne in May and he said then that he hoped things would change in due course. At this inspection the new manager said that there was to be a meeting with staff KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 21 in order to begin the process of changing staffing rosters. The emphasis was on providing staff for the benefit of residents where and when they needed help or company. In addition, staff will no longer perform shifts in only one house – they will be interchangeable. These measures will improve the quality of life for service users. The recruitment procedures were checked in respect of the last two carers appointed and found to be satisfactorily robust. Considerable efforts had been put into complying with previous requirements and recommendations relating to staff training. In line with a requirement made by CSCI following the last inspection, training for staff in mental health problems (13th May 2005 by a Community Psychiatric Nurse), physical control and restraint and POVA had been addressed. The new manager, Lin Block, ‘planned to put together a course for staff’ on challenging behaviour. The member of staff with responsibility for training said that she was hopeful for input from a Consultant offering advice on who might be available to speak to staff further on mental health. The training on control and restraint, although apparently satisfactory, is to be put into the hands of the company’s in-house trainer. The Regional Training Manager is also to ‘look into’ staff undertaking accredited LDAF training. Staff confirmed that they had been inducted, but said that they had not had ‘foundation training’. The new manager, who put together the induction and foundation booklets for the company when previously employed by them, was hopeful that these courses of training had been provided for staff, but could not say with any certainty that they had. She assured us that staff would in future have induction within six weeks and foundation training within six months to Skills Sector Council specifications. The in-house trainer had considered staff training as a whole and this would be finished off on July 4th 2005 after which a staff training profile will be developed. When interviewed, staff confirmed that individual supervision under previous management was ‘non existent’ or, extremely infrequent. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. It is clear that previous management arrangements were not working sufficiently well and the health, safety and welfare of service users may not always have been of the highest standard. The absence of feedback from service users and their relatives, from partner agencies and other professionals, a useful way of gauging the extent to which the service is meeting the needs of service users and stakeholders, means that the company has limited basis on which to make these judgements. The failure of senior managers to carry out the May Regulation 26 visit is disappointing. Linking training in moving and handling to the individual needs of a service user was pleasing. EVIDENCE: Visits by a senior manager under Regulation 26 of the Care Homes Regulations 2001 had been made in February, March and April 2005, but the May visit had been missed. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 23 Training in moving and handling had been done ‘earlier this month’. The postural management plan for one resident had been faxed to the trainer ahead of the course so that it could be considered during the session. This is sensible practice. A physiotherapist is to give two sessions to staff to further consider the programme. This, too, is good practice. The manager said that questionnaires that sought the views of relatives were available, but nothing had been done with them. Neither had partner agencies and other professionals’ views been canvassed. The National Minimum Standards call for this to happen on a regular basis. Staff commented that under previous management things had not always been easy, but they were upbeat about the new arrangements and hopeful of improvements. While a number of service users had regular family contact, three did not and no service user had an independent advocate. The planned date for checking the water system had been missed and should be re-scheduled. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 2 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 KALMIA & MALLOW Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 25 Yes 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) and 5(1) Requirement 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 two inspections. The Registered Persons must be 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 two inspections. The Registered Persons must ensure that every service user has regular reviews within the statutory time. Timescale for action Immediate 2. YA3 14 Immediate. 3. YA6 14(2) Immediate and ongoing. Page 26 KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 4. 5. YA20 YA22 13(2) 22(2) 6. YA23 13(6) 7. YA32 18(1) 8. YA33 18(1)(a) 9. YA35 18(1) 10. YA36 18(2) 11. YA39 26(3) The Registered Persons must ensure that syringes are stored correctly. 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. The Registered Persons must provide Protection of Vulnerable Adults (POVA) training for all staff. This is a repeat requirement from the last inspection. The Registered Persons must continue their efforts to reach a ratio of at least 50 care staff assessed at NVQ level 2 The Registered Persons must deploy staff on duty during the day and at night in sufficient numbers to meet the needs of all service users. This requirement is repeated from the last two inspections. The Registered Persons must ensure that all staff have induction training within 6 weeks of taking up post and foundationn training within 6 months. 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 two inspections. The Registered Persons must ensure that unannounced visits made under Regulation 26 of Care Homes Regulations 2001 take place monthly. Immediate and ongoing. By 16th July 2005 Immediate. On-going 31st January 2005. On-going Immediate and ongoing. On-going. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 27 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. 2. 3. 4. Refer to Standard YA9 YA19 YA20 YA24 Good Practice Recommendations The Registered Persons should make every effort to fence the area of waste land to the rear of the property as soon as possible. The Registered Persons should offer each user the opportunity of an annual health check. The Registered Persons should provide all care staff with the homes policy and procedures for the administration of rectal diazepam to remove any confusion about its use. The Registered Persons should ensure that the minor repairs, maintenance and redecoration discussed during the inspection are attended to. KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI KALMIA & MALLOW I55 S27529 Kalmia Mallow V223930 090605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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