Inspection on 05/09/05 for Kelvedon Project

This inspection was carried out on 5th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kelvedon Project 14/09/07

Kelvedon Project 10/10/06

Kelvedon Project 19/12/05

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 Essex C05 0AA Lead Inspector Andrea Carter Unannounced 05 September 2005 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. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kelvedon Project Address 43a & 43b Morley Road Tiptree Essex C05 0AA. 01621 815224 01621 815224 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) SCOPE Ms Sarah Ashman Care Home (CRH) 6 6 Both 6 Both Category(ies) of Learning Disability (LD) registration, with number Physical Disability (PD) of places Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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). Date of last inspection 21 March 2005 Brief Description of the Service: The Kelvedon Project consists of two three bedroomed self-contained bungalows.The home provides accomodation 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 also 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 I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on one day, between 9:30 and 15:10 hours. The inspection commenced with the assistance of the senior staff member on duty and at 11:50 am the manager, Ms Sarah Ashman, arrived and continued with supporting the inspection. Since the previous inspection Ms Ashman has been formally registered as the manager. Nine standards were assessed, with seven being met and two with minor shortfalls. Field work included, direct observation of working practices, discussion with four service users, staff and management. Formal documentation supported the evidence and decisions that formulate this inspection report. Four service user comment cards were received, reflecting generally a positive view of the home and services received. Although there was an indication that sometimes alternative food, activities and a greater involvement in the decision making process within the home would be beneficial. Comment cards were received from relatives and visitors, reflecting again a positive view of the service. One individual outlined that early issues with management are now resolved, but expressed concerns around staffing levels. What the service does well: The service ensures that consultation with individual service users is part of their every day life. Individual care plans are detailed indicating personal preference. Service user holidays are individualised to meet personal need requirements. The manager’s day with the service user group supports and enhances the service user meetings. These are used as a means of discussion and reflection, for forthcoming activity days as an example. Positive family links are evident, with contact being available through a variety of mediums. Observation of staff interaction was positive and supported effective communication and inter personal relationships. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 6 Service users have bedrooms that reflect their individual choices of colour and items. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 standard(s) 7 and 8. Service users are consulted and their individual choices respected. Decisions in relation to their everyday life are supported through consultation and participation. EVIDENCE: Discussion with service users clearly outlined that consultation with management took place in relation to their everyday lives. The care plans sampled contained detailed information in respect of individual’s preference around daily living, communication, mobility, support needs, finance and annual review information. Service users’ group meetings minutes reflected the group decision-making process. Participation within the interview process enabled individuals to make decisions around those who provide their daily care. Monthly meetings with service users and key workers allowed a review of needs and formulation of future aims and objectives. The registered person should ensure this practice is implemented consistently across the service; therefore all individuals are consulted equally. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 10 The updating of the key worker systems should operate so as not to affect service delivery. Documentation within the care plan is to be signed, dated and the role of the individual completing the paperwork stated. The dates for reviews should be identified and adhered to. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 and 16. Service users benefit from a wide variety of age appropriate activities, both within the home, the local and wider community. Individual preference is respected to ensure leisure pursuits are part of the weekly programme. Service users maintain personal relationships with both family and friends. Service users benefit from an environment, which promotes and respects individual rights, within their daily lives. EVIDENCE: Service users access a local day service resource, “Castlegate”, which has a wide range of provision, which includes pottery and computers as examples. The maximum age for attendance at this resource is 40 years; therefore alternative resources are currently being explored as activities for those individuals that exceed this age range. One individual spoken to outlined how he accessed the community resources unaided, by means of his electric Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 12 wheelchair, and was reluctant to pursue alternatives to the day resource now he no longer could attend. Leisure pursuits for individuals were wide ranging and included access to dancing classes, swimming and a social club run on Thursday evenings for people with a disability. Community access is supported, with only one individual currently able to frequent a wide range of community resource totally unaided. Care plans clearly identified personal preference of holiday and these were taken on an individual basis, supported where necessary by staff. Service users spoken to confirmed when and where they had been and their overall enjoyment. Currently individual service users pay for their holidays, as the service is in negotiation with the funding authorities to incorporate the cost into the overall fees. A positive example of the service users opportunity to discuss the forthcoming months activities was a “managers day”. This is held on a monthly basis where the group come together to access a resource of their choice collectively. This promotes contact and discussion, thus enabling the formulation of future activity plans. Links are maintained with both families and friends. This is supported in a variety of ways, which includes contact by letter, telephone and visits to the residential unit. Transport to and from family or friends homes can be supported by the service if required. Conversation with individual service users confirmed involvement in the dayto-day running of the home. Menu planning, food shopping and tasks for house keeping were shared and balanced, incorporating a three-week rota. This enables all service users to be equally involved in the processes. Monthly service user meetings support this. Observation of staff and service user interactions reflected that this was based fully on respect for the individual. Incorporating both dignity and privacy where appropriate. The choice to participate within daily activities lies fully with the service user and the choice is respected. Both bungalows were clean, tidy and had a homely feel to them. Individual bedrooms accessed by the inspector at the request of the service users, clearly reflected personal choice in the colour schemes and personal items. Discussion with service users endorsed the same. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 13 Currently no individuals residing in the home are in paid employment due to the individual’s level of disability. The home operates a no smoking policy. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 17 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) 35 and 36. The staff team are appropriately trained and meets the individual and group needs of the service users. Service users benefit from well-supported and supervised staff. EVIDENCE: The unit manager identifies training collectively and individually. There is a training budjet to cover the forthcoming needs of the service. The training officer post is currently vacant. Individual files sampled indicated four staff have completed NVQ level II and a senior staff member is undertaking NVQ Level III, with a plan for incorporating the assessors role on site. A further five staff have commenced the LDAF induction. The manager is aware of the need to develop a training programme, as well as to update individual staff training profiles to reflect the same. Induction is commenced using the organisation’s induction sheets, although documentary evidence, to support this, was unavailable on the day of Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 18 inspection. A review of this document is required, to ensure it reflects the specific needs of the service. The manager outlined this would be undertaken by the newly appointed senior. Direct observation of shadowing of staff was witnessed on the day of the inspection, with the senior staff member taking lead role in this. Since aspects of the induction are verbally imparted to staff, a suggestion to incorporate a sheet to document information was proposed to ensure evidence of the same. Supervision files sampled indicated regular meetings between management and staff. The introduction of an updated organisational supervision and appraisal system will enhance the supervisory role and compliment the current system. This will incorporate the use of self-appraisal documentation linked to core competencies expected of staff, in their daily working practices. These will enable self-analysis and reflection within the supervision forum; as well as a holistic approach to the skills required when working with this specific service user group. Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 19 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) These standards were not inspected at this visit. EVIDENCE: Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 20 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 x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 2 3 3 x Standard No 31 32 33 34 35 36 Score x x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kelvedon Project Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? No 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 Regulation Requirement Timescale for action 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. Refer to Standard YA7 YA8 YA14 Good Practice Recommendations The registered person should ensure that regular reviews of service users plans are consistent across the service. The registered person should ensure that service users holidays are part of their basic contract price, and that the option is that of a minimum 7 day holiday.This is a repeat recommendation from the previous inspection. The registered manager should ensure that training profiles are in place for all staff.Also to ensure that inductions for new staff are recorded and evidenced to each members file. 3. YA35 Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection First 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. Extracts may not be used or reproduced without the express permission of CSCI Kelvedon Project I56-I05 S17860 Kelvedon Project V247658 050905 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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