Inspection on 23/11/06 for Khaya Project

This inspection was carried out on 23rd November 2006.

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 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

Khaya Project 20/02/06

Khaya Project 05/10/05

Khaya Project 03/03/05

Khaya Project 29/07/04

Khaya Project 24/02/04

Khaya Project 09/09/03

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

CARE HOME ADULTS 18-65 Khaya Project 71 Wellesley Road Ilford Essex IG1 4LJ Lead Inspector Stanley Phipps Key Unannounced Inspection 23rd November to 21st December 2006 15:00 DS0000037133.V321683.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000037133.V321683.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000037133.V321683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Khaya Project Address 71 Wellesley Road Ilford Essex IG1 4LJ 020 8554 7902 020 8554 7902 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) Mr Ndumiso Mafu Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places DS0000037133.V321683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A minimum of 2 staff on duty at all times. Unless residents are not on the premises. The rota to include designated time each week, supernumerary to the minimum 2 staff, for Mr Mafu to operate in his roles as proprietor and manager. There must be two staff on night-waking duty at all times, as there are no sleeping-in facilities currently in the home. 20th February 2006 Date of last inspection Brief Description of the Service: Khaya Project is a care home providing personal care and accommodation for five people ages 18 - 65 with a history of mental illness, who need support in order to live in the community. It is privately owned and run by Mr Ndumiso Mafu, an experienced mental health professional. The home is located in Ilford approximately 5-10 minutes from Ilford British Rail station and town centre and as such lends itself to all the amenities contained therein. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. The home was opened in 2003 and is an ex-residential property built on two floors, which was refurbished in order to set up this service. There are bedrooms on both floors and staff work closely in supporting service users on a twenty-four hour basis. All bedrooms are single, one of which has en-suite facilities. Access between the floors is via two sets of stairs. A spacious conservatory with a music centre is used for relaxation and entertainment. There is a large garden to the rear, part of which is intended for vegetable gardening and the other for leisure. A statement of purpose is made available to all service users and/or their relatives and a copy of the service user guide is given to each service user. Fees range between £1000.00 and £1400.00 per week, which includes the cost of holidays. Fees are individually determined and based on service users’ needs. Service users pay extra personal effects such as toiletries. Prices are variable. DS0000037133.V321683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and a key inspection of the service for the inspection year 2006/2007. This meant that all key standards were covered as well as any other standard for which a requirement was made at the last inspection. The visit was done over two days beginning on 23/11/06 at 15.00 am and was concluded on the 21/12/06. The inspection found further improvements to the service and this is positive as an outcome for service users. Some improvement is still required to fully comply with the national minimum standards for younger adults and they are outlined later in this report. During the course the inspection a Statutory Requirement Notice was served on the registered person for failing to notify the Commission of a notifiable event that concerned him. The notice was subsequently and in the main, complied with, although he must and in future ensure that the failing is not repeated. An assessment of menus, policies and procedures, records, service user plans and the environment was undertaken. Detailed discussions were held with staff, the four service users and the manager during the course of the inspection. Formal interviews were also held with two staff and three service users. The inspection also took into consideration written feedback from service users, staff and external professionals. Towards the end of the inspection, the registered manager informed the Commission of his intention to employ a full-time manager. This is in view of developing the service, as he plans to focus on the strategic direction of the business. In concluding, the Khaya Project continues to offer a consistent and stable service, to individuals with complex mental health needs. This was evidenced by, the high level of compliance with the national minimum standards for younger adults and from the feedback obtained from service users, staff and external professionals. What the service does well: The management and staff continued work closely, sensitively and creatively with service users in helping them to achieve their potential. This is against the background that the service user group has enduring mental health problems. The staff are skilled in positively complimenting improvements made by service users, even if they appear marginal. To this end they work on the strengths of individual service users in order to enhance the quality of life they experience. This also involves having the ability to set boundaries in promoting positive outcomes for individuals living at the Khaya Project. DS0000037133.V321683.R01.S.doc Version 5.2 Page 6 The manager continued to support the staff team and provided them with training that enables them to deal with the challenges of working with the service user group. He has kept a dedicated core group of staff together to ensure consistency in the service delivery. As a result service users remain stable for longer periods and this severely reduces the risk of critical incidents occurring in the home. Other strong areas of the home’s operations include: working with service users to embrace opportunities for personal development and, having an effective staff team on hand to deliver the service. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000037133.V321683.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000037133.V321683.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to have their needs thoroughly assessed to ensure that the home is able to meet them. They benefit from being actively involved in this process. EVIDENCE: From the case tracking of the most recently admitted service user, it was observed that a detailed needs assessment was in place for the individual. Preadmission details were also acquired prior to the service user’s admission. This ensured that identifying the service user’s needs was indeed a thorough exercise. The assessment was carried out by the manager who is qualified and experienced to so do and, this involved the service user and other professionals. In discussion with the service user, he informed that he was happy to have been consulted and involved in deciding what he would like from his placement at the Khaya Project. The outcomes of the discussions were incorporated into a service user plan, which he signed up to. The service user expressed the view that he was confident that the home could meet his needs. He was quite aware of being on the CPA register and what that entailed. The individual’s sister was also involved and he indicated that her involvement was in his interest. He joined the home in August 2006 and felt comfortable with his experience since living there. DS0000037133.V321683.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,9) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users benefit from having their changing needs (including their mental health), reflected and reviewed in their individual plan. Service users are involved in making decisions in their lives and are supported to take risks as part of promoting their independence – within a risk management framework. EVIDENCE: Two service user plans were assessed and they clearly detailed the actions required to meet the identified needs of the individuals involved. The strength of the service user plans is that, although the mental health needs of service users were catered for, so were their physical and social care needs. One professional described the care provided as ‘excellent and individualised’ – recognising the challenging needs of his client. The plans seen were updated with evidence that changes were reflective of the current needs of service users. Both service users were involved in drawing up their plans and, were fully aware of what was in them. A sound system of key working is place at the home and service users worked closely with them. One service user indicated that he was planning to attend a concert uptown and along with his key worker – this outcome was achieved. DS0000037133.V321683.R01.S.doc Version 5.2 Page 10 He was extremely pleased with the experience and stated ‘ that is what life should be about’. Service users were also clear of the role of their community psychiatric nurse/s and/or social workers. Two service users were able to describe what their CPA reviews were about and gave the dates for their next review. It was clear the system of service user planning in the home was effective in meeting the aims and aspirations of service users. There was also a strong sense of user involvement in them. There were effective systems in place to support service users in decisionmaking in relation to their lives. They included; weekly key work sessions, service user meetings, reviews, access to advocacy input, provision of information by staff that is specific to the service user group and informal discussions with the manager and staff. There is also a service user notice board with, information about resources in the community e.g. educational, therapeutic (day centres and groups) and social. It was positive to see the most recently admitted service user attending the Redbridge Resource Centre – a decision he thought he would benefit from. One service user spoke of his key work session, indicating that it was about his physical health and lifestyle. He felt that some of the decisions he made were not always in his best interests and he would even become angry with staff when they were pointing him in a safer direction. In this respect he was of the view that he has to continue working at his weaknesses, which were well documented in his service user plan. In relation to decision making up to three service users were handling their own finances, with the other having, the involvement of the local authority. One individual spoke of engaging the advocacy services in relation to a personal matter and this was also his decision. Risk assessments were in place for all service users. They were updated and linked to individual service user plans. Service users confirmed that they were involved with them and it was the case that they were aimed at promoting; safety and independence. Most of the service users have keys to the home and their private spaces and, an appropriate ‘missing persons’ procedure is in place at the home. This procedure is aimed at ensuring that steps are taken at the soonest opportunity to ensure service user safety. Appropriate guidance is in place for staff to follow and this has been a tried and tested area of the home’s operations. DS0000037133.V321683.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to participate in appropriate activities. They maintain and develop social and personal networks of their choosing. Service users exercise their rights to choice and user involvement at the Khaya Project. All service users were satisfied with the range and content of meals provided in the home. EVIDENCE: Each service user has an individual timetable of their planned activities, which is drawn up with them. They individually and collectively determine the type and level of activities they participate in. Regular service user meetings are held and from the records seen, activities are also discussed in this forum. Some individuals were doing more than others, but this was down to personal choice and interest. In discussion with one individual, he was of the view that he had developed enough living skills to move on and has expressed this view to his social worker. This is being looked at to include, the individual’s capacity to manage his mental health needs with less support. It is positive that this is being looked at. DS0000037133.V321683.R01.S.doc Version 5.2 Page 12 At the Khaya Project, there is great emphasis on working with service users to develop their independent living skills. A small number of individuals attended day centres, and there was little interest in pursuing academic or employment opportunities at the time. Staff were however, providing effective support to enable; independent handling of finance, development of self-esteem and confidence, which could have a positive outcome on what service users go onto in the future. Some service users enjoyed shopping, listening to music of their individual choice and going out socially. One service user wrote ’My hobby is listening to music and staff are fine with that’. All service users were integrated into the local community as they used the post office, cinema, cafes, pharmacy, doctors, and shops. Given that all the service users were placed from outside the local borough, plans are put in place for them to familiarise themselves with the local area. This was evidenced from the records of the most recently admitted service user. In discussion with other service users, it was established that most, had a good knowledge of the local area. One service user likes having a meal in the community, which he stated – ‘I quite enjoy’. Service users get about by using the public transport facilities and staff work flexibly with them to ensure that they enjoy community life. A range of updated community resources are made available to service users. There was a sense of family living at the Khaya Project, although from the incident reports, there were times that staff had to intervene in the interest and welfare of individuals. On the positive side, service users were buying small gifts for each other, some of which was shown to the inspector, just prior to Christmas. A number of service users had visits from their families for their birthdays and plans were in place for visits to service users over the Christmas period. All staff understood the value and importance of family networks and every effort is made to facilitate visits and/or contacts for the benefit of service users. One service user meets up regularly with his sister and is in regular contact with his mother. The parents of another were due to bring him gifts and he was looking forward to the visit. Some relatives were also involved in the service user reviews, which is positive. This is a strong area of the home’s operations. From speaking with service users they all felt that staff respected their rights and most times, listened to what they say. Given that the previous experiences of most of the service user group being one in which they felt that they were not listened to, it is important to them to feel, ‘listened to’ at the Khaya. One service user discussed his disagreement regarding an issue over him wanting exclusive access to viewing the communal TV – privately. However, there was a detailed audit trail about the issue and, how it was handled. Every effort was made to ensure that all service users were DS0000037133.V321683.R01.S.doc Version 5.2 Page 13 supported, without the infringement of any one person’s rights. The home did handle the situation to ensure fairness and equity. During the course of the second visit the service user that raised the concern informed that things were much better. As stated earlier, there was advocacy input in the home and all service users have keys to the front and, their bedroom doors. Rules on alcohol and drug use in the home are clearly stated in individual agreements and service users were aware of them. Service users were also clear about their responsibilities with regard to meals and the domestic arrangements in the home. Service users take responsibility for their breakfast and evening meals with staff support as necessary. The meal arrangements have enabled some service users to develop their culinary skills and this is positive. Service users are actively involved in determining the meals and menus provided at the Khaya Project. From the records viewed, there was evidence that meals were varied, had a good balance and tailored to meet the specialist needs e.g. diabetic needs, of individual service users. Lunch on the first day included lamb chops, roast potatoes and mixed vegetables. Curry goat was on the menu and this was in line with the cultural taste of some individuals. Mealtimes were extremely flexible and all service users were pleased with the current arrangements. This included changing an agreed menu on the day. Meals consumed were recorded. As part of the home’s culture once per week, service users enjoy a takeaway meal of their choice – and most look forward to this. A fresh supply of fruit and vegetables was accessible to service users and though difficult at times, staff continued to promote healthy eating amongst the service user group. Service users were observed enjoying tea and other beverages throughout the course of the visit. Food storage was adequate and staff preparing meals had appropriate food hygiene training. This is a strong area of the home’s operations. DS0000037133.V321683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements remain in place for providing personal support to service users at the Khaya Project. Key work sessions and effective links with multi-professionals ensure that the psychological, emotional and healthcare needs of service users are met. Some improvement is required in the handling of medication to enhance safety in drug administration. EVIDENCE: Interviews and discussions held with service users indicated that they were satisfied with the quality of staff support in the home. It was acknowledged that service users needs were varied and as such the level of input was higher in some when compared to others in key areas such as; personal care and dealing with more complex issues impacting on their mental health such as compliance with medication or an individual’s dietary plan. In one of the cases assessed it was critical to have his medication reviewed in his best interest and staff had to enable and support the individual. Service users’ records detailed evidence of interventions made with them individually, and it was positive that their individual preferences were taken into account. Regular key-work sessions with service users provided good opportunities to ensure that the input of staff matched their expectations. This is enhanced by maintaining a monthly key worker checklist, which takes into DS0000037133.V321683.R01.S.doc Version 5.2 Page 15 account visits and telephone calls whilst individuals are for example in hospital. This ensured continuity of care and provides a good audit trail in tracking the care of an individual. Service users were aware of their mental health support needs and had regular sessions with mental health professionals externally. This is usually well documented in their service user plans. All service users were registered with a local GP and there were records on file of all appointments made and attended. Service users were satisfied with their health generally. This included contacts made with the chiropodist, dentists, opticians and in some cases the diabetic nurse. Service users also had access to specialist health professionals as required e.g. the consultant psychiatrist and/or a community psychiatric nurse to provide for issues regarding their mental health. Staff work closely with them to ensure that appointments are kept and that effective links are made with these professionals to enable the service users to get the best possible care. There were clearly identified dates for the ‘Care Program Approach’ reviews for all service users. In checking with some of the most recent reviews, agreed actions were integrated into the service users plan and this is positive. There was an improvement in how staff followed up health issues on behalf of service users and this was observed from casetracking a change in the needs of an individual. In the case referred to a drug change was effected as a result of staffing interventions – and the outcome for the service user was positive in that he was happier and more settled in the home. It was noted that there was a change in the medication system in the home as the Boots Monitored Dosage System has been introduced. All staff were provided with training in using the new system, which is intended to make supporting service users with medication – a safer experience. The registered manager was closely monitoring how the new system is working. Staff interviewed were comfortable with the new arrangements and demonstrated a good understanding of the drugs used with the current service user group. This included understanding the desired and side effects of the psychotropic used in the home. At the time of the visit, one service user was managing his medication and an appropriate risk assessment was carried out to ensure that this was safe. Another individual had started, but was unable to maintain the responsibility, and hence staff now provides him with medication. It is envisaged that a reassessment would take place at some point to give him another opportunity to regain his independence – in handling his medication. Medication storage and recording was good. However, there was a need for an appropriate mechanism for the disposal of lancets used in the home, as it was treated as part of normal waste. In talking to staff, it became apparent that they would replace the cap on the sharp end of the lancet after use. This is DS0000037133.V321683.R01.S.doc Version 5.2 Page 16 unsafe and puts them at risk. In this respect, training in supporting individuals with diabetes including the handling of devices used e.g. lancets disposal – is required. From discussions with staff, some were able to observe the training provided to the service user in relation to managing his condition (diabetes). However, this training must be provided to all staff supporting the service user with his condition. DS0000037133.V321683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can feel reassured that concerns, when raised would be taken seriously through a timely and thorough investigation, which is in line with the Khaya’s complaints procedure. Satisfactory arrangements were in place to ensure that service users are protected from abuse. EVIDENCE: A satisfactory complaint’s procedure remains in place and is well advertised in the home. Generally, service users and/or relatives are encouraged to talk about issues they may have a concern with. This allows the management and staff, an opportunity to make early interventions to reduce the risk of uncomfortable issues escalating. Service users in the main have the added advantage of raising issues informally and in service user meetings. There were no complaints on record, however various issues were discussed at their service user meetings. Four service users spoken to were aware of the procedure and, importantly who to contact if they were unhappy with how a complaint is handled by the home. One service user’s view of exercising his right was ‘If I can’t open my mouth, then I ain’t West Indian’. This individual felt empowered, being able to raise issues affecting him, which is positive. A satisfactory adult protection procedure remains in place at the home, including clear guidance on ‘whistle-blowing’. All staff had adult protection training and as part of their induction, were taken through the adult protection procedure in the home. A policy for managing aggression is in place and staff had training in this area. Records of aggressive incidents and their management indicated that they were handled safely. In discussion with staff they demonstrated an understanding of protecting service users from abuse. There were no adult protection issues in the home. DS0000037133.V321683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): (24,26,30) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to the environment have enhanced the safety and comfort of the home as a whole. Service users enjoy private spaces reflective of their choice, although some improvement is required to ensure individual safety. Service users also have the benefit of a clean and hygienic environment. EVIDENCE: There were improvements to the environment as improvement works were carried out by; replacing the cracked tile in the laundry area, decorating the walls in the stairwell and repairing the floor covering in the kitchen. All service users were pleased with the quality of the environment, which they regarded as homely. On the day of the visit the home was clean, bright and free from offensive odours. Service users were observed using their environment with ease and the communal spaces had a relaxed feel to it. There was evidence that the home was compliant with local fire service requirements (20/6/06), environmental health (9/6/06) and, the Building Acts and Health and Safety Regulations. The heating, light and ventilation were satisfactory and it was noted that service users contributed to the maintenance of their home. A programme of maintenance was in place for the renewal of DS0000037133.V321683.R01.S.doc Version 5.2 Page 19 the furnishings and fabric of the home. From records seen and discussions with service users, they had replacements of bed linen and were pleased with this. Service users’ bedrooms were inspected by invitation and they were personalised to individual taste. It was noted that some were more elaborate than others, but this was a matter of choice. The most recently admitted service user for example did not wish to have pictures on his wall at the time, but may consider in the future, having some family photos put up. Another had requested new curtains, which he chose and they were fitted. It must be noted that all service users were pleased with their individual furnishings. One service user wanted his room decorated along with a new type of flooring, which was put in relatively quickly. Another wanted his bathroom door decorated and this was also carried out to his taste. All rooms were lockable and provided service users with security and privacy, giving them peace of mind. However, one service user on the ground floor wanted window locks replaced on his sash windows, as the previous locks had come away. This must be provided without delay in the interest of safety. The home was clean and hygienic throughout the inspection. Laundry facilities were satisfactory and policies for the control of infection were in place. Service users are involved in doing their laundry as part of maintaining their independent living skills and most were quite happy with this. Both staff and service users do a good job in ensuring that the home is clean and hygienic. Staff continued to teach and guide service users with regard to maintaining a safe and clean environment. This was observed during the course of the inspection and, is a positive outcome for all service users. DS0000037133.V321683.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A dedicated and appropriately trained staff team is on hand to provide for the needs of service users at the Khaya Project. In essence an effective staff team provides support to individuals. This is enhanced by the robust recruitment practices, carried out by the registered manager. EVIDENCE: Staff observed during the course of the inspection demonstrated good commitment to supporting each and every service user in the home. They understood the needs of the service user group and were skilled listeners and work well in motivating them. All service users were happy with the efforts of staff, with most stating that the carers listen and act on what they say. The views of three of the four external professionals indicated that the staff team works effectively with their individual service users. All members of the staff team have achieved at least an NVQ level 3 in Care, which adds weight to their understanding of the service user’s needs. Some staff have also started a Certificate in Community Mental Health (level 3) and this again would increase their knowledge and awareness in providing support to the service user group. Staff demonstrated a good understanding of the service users’ needs and were observed making appropriate interventions in supporting them. Feedback received from external professionals confirmed that DS0000037133.V321683.R01.S.doc Version 5.2 Page 21 staff had been making appropriate referrals to them, when service users’ were in need of specialist input. This is a strong area of the home’s operations. There were no additions to the staff team and hence the recruitment practices of the home could not present anything new. There is a stable staff team in place and this was achieved by the robust recruitment practices of the registered manager. However, a random check was carried out on the file of one staff and the recruitment details required by regulation were in place. Staff did have the minimum three-monthly probationary period, a statement of their terms and conditions and a copy of the GSCC code of conduct. This was a strong area of the homes operations, as all staff currently in post had been thoroughly vetted prior to working at the Khaya Project. Service users have the peace of mind knowing that staff working with them, are thoroughly screened. A training and development plan is in place for each member of staff and a training budget is in place to facilitate this. Training is identified through various channels i.e. supervision, appraisals and reviewing the needs of service users. There was evidence that a structured induction was provided to all staff and this included the statutory mandatory induction training. Staff also had the training in equal opportunities and consideration is being given to extending this to equality and diversity training. This would be beneficial given the diverse needs of the service user group and the registered manager recognises this. Some of the immediate training planned included first aid and, health and safety refresher as well as the training for the Certificate in Community Mental Health – level 3. During staff interviews, they had a clear understanding of the philosophy of care for the home and service users informed that the staff understood, what their strengths and weaknesses were. One service user stated that; ‘the staff knows when I am having a bad time and they are quite good in helping me out – respect to them’. Sound guidance is in place that enables staff in most cases to provide good quality care to service users. DS0000037133.V321683.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,42,43) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager remains in place and leads a committed group of staff in supporting service users. Management systems enable service users to receive a good standard of care at the Khaya Project. This is enhanced by the sound health and safety practices in the home. EVIDENCE: The registered manager is qualified in the field of Mental Health and has acquired his NVQ level 4 in Management and Care. His most recent training included; Breakaway techniques and Updates in Employment Law. He is actively involved in all aspects of the home’s operations including the supervision of staff. There is a positive relationship between the service users and the registered manager and this is due to the level of commitment and involvement with their care. All service users were of the view that the home was managed effectively. External professionals interviewed, all expressed that the service is well managed, with one individual maintaining that the home was ‘excellent’. Another described the work with one of the clients placed at DS0000037133.V321683.R01.S.doc Version 5.2 Page 23 the Khaya Project as highly effective, stating; ‘ my client has had long periods of stability and this (khaya Project) has been the most successful placement, he has had’. This is positive. Quality monitoring of the home included: regular CPA reviews for all service users, carrying out service user surveys, updating policies and procedures, regular staff supervision and updating the annual development plan for the service. The registered manager has also started the process of achieving the ‘investors in people award’ and is using some of the feedback gained to improve the service. Once this is achieved, it would have a positive impact on staff and the service as a whole. In discussion with the registered manager, he outlined some of the considerations for the home based on consulting service users and staff. They included; providing service users with a computer and internet access, installing hand dryers as opposed to hand towels and introducing automatic air refreshers for bathrooms. It was clear that the registered manager is keen to develop the service for the benefit of service users living there. Health and safety practices were assessed and found to be in order. This included; fire drills, call point testing, portable appliance testing, having appropriate emergency signage, and recording of accidents/ incidents in the home. Safety certificates were in place for gas (13/2/06) and electricity (31/3/06) and, the emergency lighting (31/3/06) was externally examined. In addition staff, also carry out a weekly test on the emergency lighting. There were visits in 2006 from environmental health, the fire department and a central heating engineer and, the outcomes were satisfactory. Risk assessments were in place for all safe working practice topics, as well as for substances in relation to COSHH. Staffing induction covered health and safety in detail and they (staff) were clear on their responsibilities for maintaining a safe environment. The home has two staff, that are qualified in first aid and all other staff have had basic first aid training. Sound arrangements were in place for infection control and as such service users and staff benefit from good safety arrangements at the Khaya Project. There was a business and financial plan for the home, although it was linked to another service in the borough of Greenwich. The plan was discussed with the registered manager and it satisfactorily detailed arrangements for the Khaya Project. The registered person has private arrangements in place for auditing his accounts. During the course of the inspection the registered manager was away and the financial arrangements for the home in his absence were satisfactory, despite the home carrying an empty bed. Adequate insurance cover was in place for the home. Lines of accountability in the home were in some respects clear. Service users were aware of that the manager leads the service and at one point there was a DS0000037133.V321683.R01.S.doc Version 5.2 Page 24 deputy manager. However, most service users do not see the deputy manager on a regular basis and he was not on the staffing roster. A senior member of staff (qualified up to NVQ 4 in Care) takes charge, in the absence of the manager and given her experience and qualifications – is quite able to so do. There is no written evidence that the deputy manager had ceased employment with the home and he was reported to be giving advice as a consultant. As a matter of fact in the pre-inspection questionnaire completed by the registered manager – the deputy was down to act in the absence of the manager, which was not the case in the manager’s most recent period of absence. His involvement needs to be clarified for the benefit of service users, staff and the project as a whole. Following the conclusion of the inspection, it was made known to the Commission that the registered manager was planning to recruit a manager for the home, so that he could go on to develop the service. This may benefit the service, however he needs to have a clearly defined structure for the service and to ensure that it is reflected in the home’s statement of purpose. DS0000037133.V321683.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 x 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 2 DS0000037133.V321683.R01.S.doc Version 5.2 Page 26 NO 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 YA20 Regulation 12,13 Requirement The registered manager is required to; 1) obtain an appropriate container for the disposal of lancets and 2) Ensure that staff have training in managing diabetes to include disposal of sharp devices. The registered manager is required to fit window locks on the bedroom windows (VR), by the timescale set. The registered manager is required to clarify and detail the role of the deputy manager in the home. Timescale for action 28/02/07 2. YA26 13, 23 28/02/07 3. YA43 17 (2) Schedule 4 [6](d)&(e) 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000037133.V321683.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000037133.V321683.R01.S.doc Version 5.2 Page 28 - 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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