Inspection on 19/12/05 for Kelvedon Project

This inspection was carried out on 19th December 2005.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kelvedon Project 14/09/07

Kelvedon Project 10/10/06

Kelvedon Project 05/09/05

Kelvedon Project 21/03/05

Kelvedon Project 21/05/04

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 Kelvedon Project 43a & 43b Morley Road Tiptree Colchester Essex CO5 0AA Lead Inspector Andrea Carter Unannounced Inspection 19th December 2005-2 January 2006 09:45 nd Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kelvedon Project Address 43a & 43b Morley Road Tiptree Colchester Essex CO5 0AA 01621 815224 01621 815224 s.ashman@scope.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) SCOPE Ms Sarah Lyndsey Ashman Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 6 persons) 5th September 2005 Date of last inspection Brief Description of the Service: The Kelvedon Project consists of two three bed roomed self-contained bungalows. The home provides accommodation to six service users with physical and learning disabilities, under the age of 65 years. The home is situated in the village of Tiptree, which is readily accessible by public transport, to the local towns of Colchester and Maldon. The home has access to the local facilities and shops. The service users have access to a large garden and patio area, including the recent addition of a conservatory externally accessed by both groups of service users. The manager oversees another establishment locally. Her time is managed efficiently between both units, with both staff teams being kept informed of her whereabouts at any one time. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a two week period. A site visit took place on the 19th of December, for a duration of six hours. Fieldwork on this day involved the sampling of files in respect of both service users and staff. Two service users were interviewed and discussion also took place with the unit manager, senior staff member and two care staff on duty on this day. Direct observation of working practices; also support the formulation of this report. In total sixteen standards were inspected of which twelve were met and four had minor shortfalls. What the service does well: What has improved since the last inspection? Since the last inspection on the 5th December 2005 the service has helped to ensure that individual service users plans are reviewed with regularity. Key workers take lead responsibility in this area. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 6 The manager and senior staff member are currently working on the updating of the training profile for all staff for 2006. There is a new induction system that the two senior staff takes a lead role in. organising and presenting This is comprehensive in its format, and is implemented consistently with the appointment of each new staff. The manager and senior staff member are reviewing all training and development of staff for the forthcoming twelve months. 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. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 No service users have been admitted since the last inspection. EVIDENCE: These standards were not inspected during this inspection. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Service users know their assessed and changing needs and personal goals are reflected in their personal plan. Service users are generally supported to take risks as part of an independent lifestyle. EVIDENCE: Two service users files were case tracked, each contained information specific to the needs of the individual. Information relating to personal support, including a full overview of personal preferences, was evidenced within the files. Reviews of the service users care plans takes place with regularity on a monthly basis overseen by the key worker. Reviews with local authorities take place on an annual basis, involving the service user, their family and representatives. Two service users were interviewed, one spoke very highly of their individual key worker and the support and input they receive. The other person appeared to be content and settled living within the home. Observation of the individual’s bedroom clearly showed the personalization of their personal environment which was supported by the key worker and the individuals family. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 10 Comprehensive risk assessments were evident in one individuals file; these were linked specifically to the activities that they participate in on a daily basis, and areas of vulnerability within the home and the wider community. The other file did not evidence risk assessments, therefore the review of this individual should help ensure that any areas of associated vulnerability are clearly identified and addressed through assessment. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 17 Service users generally engage in appropriate leisure activities. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: In discussion with one individuals key worker, a wide range of activities were outlined that were participated within on a daily basis. These included, access to a local day service, swimming, drama and dance, and art. This was evidenced within the service users file, along with comprehensive risk assessments that corresponded to the identified activities. One to one discussion with the individual confirmed the participation and enjoyment of these activities The establishment are still in discussion with the funding authorities in relation to a funded seven day annual holiday, costed in to the overall fee. The menu sheets for the home were sampled and clearly identified a wide range of food is on offer. The current menu included, chicken, chinese, roast and fish. Service users spoken to outlined how they are involved in the weekly Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 12 menu planning; and assist in the purchase of the weekly shop at a local supermarket. One individual commented how they enjoyed the food. Meal times are not set. Therefore there is a degree of flexibility for service users to choose when and where they prefer to eat. The opportunity is also available for individuals to frequent restaurants in the local area also, evidenced by the recent Christmas outing. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Service users receive personal support in the way they prefer and require. Service users physical and emotional needs are met. Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: A key worker system is currently in operation within the home; and discussion with both service users and staff clearly outlined the support given to individuals. Service users files sampled had excellent examples of the individual preferences of each person around their daily routines including waking, retiring to bed and bathing choices. Appropriate aids are available to enhance the ability levels of individuals and promote greater independence. All individuals are registered with the local medical centre. Keyworkers support individuals to access the service or if necessary the GP will attend the home. Consultations take place within the privacy of their own rooms. The dentist and opticians are also accessed locally; with a chiropodist visiting the site regularly Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 14 Individuals files evidence the regularity of access to all healthcare services, and the associated reviews. Currently no individuals within the service self medicate. There is in place an appropriate medication policy and procedure. The service uses the monitored dosage system. One staff member takes responsibility for overseeing the ordering, receipt and all associated documentation. They are extremely organised and fully competent in all aspects of this area. The system is appropriate to the needs of the service and its users and only appropriately trained staff administers medication, evidence of specific training in relation to medication was observed, certificated by and appropriate provider. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 23 and 24 Service users feel their views are listened to and acted on. Service users are generally protected from abuse, neglect and self harm. Service users live in a homely, comfortable and safe environment. EVIDENCE: The service has in place a full complaints procedure and policy. There have been no formal complaints to date for this current inspection year Concerns had been raised earlier in the year by family and associated professionals, around the relationship between to service users, this situation is still on going and meetings have been scheduled to review the situation regularly. Service users have access to the organisations compliant procedure, in an appropriate format, accessible to those that reside within the service. The two senior staff members provide the protection of vulnerable adults training in house. To support this process all staff are issued with the No secrets guidance. The content of the course was comprehensive, but should ensure that the process for reporting a possible abuse situation, is clarified and all staff are informed. Both bungalows presented as clean and tidy and free from offensive odours. The manager oultlined the planned maintenance programmed for the forthcoming months, which included levelling out the door seal areas, to enable appropriate access for wheelchair users. Repair of the roof area is planned; along with protection to the doorframes to prevent damage from wheelchairs. One service users room has planned work for the resiting of an overhead hoist. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 16 Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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): 30 The home is clean and hygienic. EVIDENCE: The tour of the premises evidenced that the home was clean and tidy, and free from offensive odours. Appropriate laundry facilities are located separate from the two bungalows, in a small outhouse building. to the left of the site. An industrial washing machine allows for soiled laundry to be washed at the appropriate temperatures. The home has an organisational pol32icy to deal with infection control. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 and 35 Competent and qualified staff supports service users. Service users are supported by and effective staff team. Service users are supported and protected by the home’s recruitment and policy and practices. Service users benefit form well supported and supervised staff EVIDENCE: The inspection evidenced that currently two staff members are undertaking the LDAF foundation and induction course. Five staff members have gained their NVQ Level II Files evidenced the induction of two new staff members, signatures and dates to induction information should be included to evidence and support the review of individual staff training and development needs. The induction was comprehensive in its format and content, and linked specifically to the needs of the current service user group. The induction should be run Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 19 over a longer period due to the extent of information imparted to staff over a one day period. The manager and senior support staff are currently working on the training and development plan for staff for the forthcoming months, clearly identifying areas of specialist training that will match the current needs of the service user group. All mandatory training is uptodate. Three staff member’s files were sampled and contained all appropriate paper work in relation to recruitment. Individual checks were carried out to ensure the suitability of each staff member. Probationary periods are set to review progress and suitability. Service users are included in the recruitment process. Records of staffing ratios indicated the current rota for both waking and night hours are covered sufficiently by staffing levels, which meet the residential forum guide. An extra staffing member has been appointed to provide extra support during the waking hours and the staffing ratio currently sits at three staff to six service users. Additional hours have been allocated and now there is a five till ten shift to facilitate outings and one to one for service users. Staff meetings take place on a monthly basis and the minutes from the following meetings 15/11/05 and the 4/10/05 were sampled a variety of topics were on the agendas for these meetings. Regular supervision sessions were evidenced for three staff members whose files were case tracked. this took place with regularity and content was specific to the individuals roles , responsibilities and training needs. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of service users are promoted and generally protected. EVIDENCE: The home has in place a system to ensure checks are undertaken with regularity to help support the health and welfare of both service users and staff This was evidenced through appropriate certification, linked to a wide range of areas within the home. In relation to fire checks these are done internally by the home on a weekly basis with timetabled evacuations for both bungalows. There had not been an external service of the fire alarm system since October 2003.This is to be addressed immediately to ensure safe working practices are in place consistently across the establishment. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 21 The home has in place an infection control policy, and is currently upgrading its hand washing facilities in both bathrooms and toilets to allow for the use of liquid soaps and dispensers. COSHH information is being updated and appropriate documentation sought in relation to current products used within the home. The chemicals kept within the home, must be stored within a secure cupboard and not within the kitchen where they are currently readily accessible by all. All newly appointed staff, receive and in depth induction upon comment of their employment. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x X X X x X 2 x Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 23 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 YA9 Regulation 13(4) (b)(c) Requirement The registered person must ensure that any activities or unnecessary risks to service users are clearly identified and risk assessed and so far as possible eliminated. The registered person must ensure that induction training is provided in format acceptable to staff and over a more acceptable timescale. The registered person must ensure that all parts of the home to which the service users have access are so far as reasonably possible free from hazards to their safety. Timescale for action 31/03/06 2 YA35 18(1)(c) 31/03/06 3 YA42 13(4)(a) 31/03/06 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 YA14 Good Practice Recommendations The registered manager should ensure that the service users holiday is part of the basic contract price; and that DS0000017860.V274268.R01.S.doc Version 5.1 Page 24 Kelvedon Project the holiday is a minimum of seven days This is a repeat recommendation carried over from the last two inspections. Kelvedon Project DS0000017860.V274268.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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