Care Home: Khaya Project

What the care home does well The management and staff continue to work closely, sensitively and creatively with service users in helping them to achieve their various levels of potential. This is against the background that the resident group has enduring mental health problems. The staff are skilled in positively complimenting improvements made by residents, even if they appear marginal. To this end they work on thestrengths of individual residents in order to enhance the quality of life they experience. The manager continues to support the staff team, providing them with training that enables them to deal with the challenges of working with the resident group. He has kept a dedicated core group together to ensure consistency in the service delivery. As a result residents 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: providing opportunities to residents for personal development, having an effective staff team on hand daily to provide the service and the positive influence that is provided by the registered manager in leading the service at the Khaya Project. What has improved since the last inspection? Staff have received training in managing diabetes and lancets are now appropriately disposed. Bedroom locks have been installed to the ground floor bedroom window. A water cooler/dispenser is now available for residents` use. Some improvements have been made to various aspects of the environment to include bedrooms, and a new lawn has been laid. An emergency light has also been added in the conservatory as well as lights installed in the back garden and corridor. Refresher training in has been provided for staff in health and safety, and first aid. What the care home could do better: CARE HOME ADULTS 18-65 Khaya Project 71 Wellesley Road Ilford Essex IG1 4LJ Lead Inspector Stanley Phipps Unannounced Inspection 7 May – 22nd 2008 14:55 th Khaya Project DS0000037133.V363182.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 Khaya Project DS0000037133.V363182.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. Khaya Project DS0000037133.V363182.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 khayaproject@btconnect.com 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 Mr Ndumiso Mafu Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be acommodated is: 5 Date of last inspection 23rd November 2006 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. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 5 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. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was unannounced and was carried out over the period 7/5/08 through to the 22/05/08. At the time of the visit the registered manager was available to provide evidence as part of the inspection process. There were three residents in the home, most of whom looked settled and comfortable in their environment. They all made contributions to the inspection process as did the staff on duty on the day. An assessment of medication practice, menus, policies and procedures, records required by regulation, residents’ care plans and the environment was undertaken. Discussions were held with the registered manager and two members of staff along with formal interviews. The inspection also considered: information provided in the Annual Quality Assurance Assessment (AQAA) provided by the registered person, verbal feedback from external professionals, along with comment cards that were returned from staff and residents. Prior to the inspection an Annual Service Review was undertaken on the service, which looked at the operations of the home by reviewing several documents submitted by the registered provider to the Commission. One such document is the Annual Quality Assurance Assessment (AQAA). The outcome of this review was positive, indicating that residents were receiving a good standard of care and support from the management and staff at the Khaya Project. It must be noted that the previous registered had left since the last inspection visit and the Registered Provider Mr Ndumie Mafu reapplied for the registered manager’s post and was subsequently registered as the registered manager of the service. This ensured that there was consistency in the service provision, which was also evidenced by the general compliance with the national minimum standards and it’s associated regulations. What the service does well: The management and staff continue to work closely, sensitively and creatively with service users in helping them to achieve their various levels of potential. This is against the background that the resident group has enduring mental health problems. The staff are skilled in positively complimenting improvements made by residents, even if they appear marginal. To this end they work on the Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 7 strengths of individual residents in order to enhance the quality of life they experience. The manager continues to support the staff team, providing them with training that enables them to deal with the challenges of working with the resident group. He has kept a dedicated core group together to ensure consistency in the service delivery. As a result residents 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: providing opportunities to residents for personal development, having an effective staff team on hand daily to provide the service and the positive influence that is provided by the registered manager in leading the service at the Khaya Project. 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. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents continue to have access to information in making a decision about the suitability of the home. They benefit by having detailed assessments carried out on them and have opportunities to view the service before deciding to live at the Khaya Project. EVIDENCE: At the time of the inspection, there were two new residents living in the home and the assessment and admission practices were evaluated in great detail. However, from the files were viewed it was clear that each individual had a thorough assessment prior to agreeing to live at the home. There was also evidence that assessment summaries were obtained from referring authorities. In many respects, there was little room for residents to be move into the Khaya Project without the management and staff being satisfied that they could provide for the needs of the individual. The admissions process is robust and protects prospective residents from being inappropriately placed. This is positive. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 10 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents benefit from having their needs (including their specialist needs), reflected and reviewed in their individual plan. There was evidence that they take decisions with support, and maintain their safety and independence within a risk management framework. EVIDENCE: From the care plans viewed, it was clear that residents are involved in planning their care, which ensures that they are not only aware, but accept responsibility for their direction. As part of this arrangement, they have the benefit of a key worker who works closely with them in setting up and reviewing their individual plan. The care plans viewed were updated and individualised, detailing the specific needs of residents – including their mental health needs. They were borne out of the assessments carried out initially with them and residents spoken to showed an awareness of what was in their individual plan. Staff interviewed had a good understanding of the residents’ needs, which was good evidence to indicate how closely staff the staff team was engaged with them. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 11 The needs of the resident group are quite complex and though they were fairly comfortable in the home, most needed a high level of support to influence and achieve their goals. Staff play a major role in enabling residents to make decisions about their goals and objectives. Examples can be drawn from supporting residents to move on to enabling individuals to pursue their educational aspirations. Once agreed the actions are detailed in the care plans so that an audit trail is available. This is positive. Residents’ meetings are held regularly on Fridays, where key decisions are made, including what type of takeaway they plan to have. From the residents’ minutes, one of the key decisions deliberated upon was the choice between having a barbecue or going to Southend – on - Sea on the 9/5/08. In this respect it was clear that they are enabled to participate and contribute to the home’s operations. A system for risk assessment and risk management is in place at the home. In all cases they were linked to each resident’s care plan. Staff spoken to understood the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. Linking the risk assessments to their care plans ensure that staff are knowledgeable about the needs, risks and safe management of each individual resident. Both the care plans and risk assessments were updated as a result of being regularly, which is positive. A missing persons’ procedure is in place at the home. Staff routinely use this at the home and to good effect. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to participate in their community, in appropriate activities and are able to maintain and develop social and personal networks of their choosing. Most times residents are supported to exercise their rights, which are respected and promoted by staff in the home. At the Khaya Project staff provide meals that are reflective of service users’ choice and nutritional requirements. EVIDENCE: There was evidence that residents were supported to develop and maintain their living skills however restricted they might be. This is true despite having varied and complex levels of needs, and motivation. This presents a challenge for the staff team and from observation they were aware of the challenges in providing care and support to the resident group. Residents have an individual programme of activity, which is specific to their choice and interests and all staff were expected to work in accordance with this. Two residents attend a day centre - weekly, one attends college, while another plays football on average one or twice per week. Staff are key in motivating and reassuring residents in achieving their objectives almost on a daily basis and al residents Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 13 spoken to were appreciative of this – though one did admit that it is hard at times. Residents continue to make use of the community facilities such as the cinema, the day centres, shopping arrears, and the local parks. They also attend the local cafes, post office, the pharmacy, the GP and shops in and around the area. Most of them were familiar with the community facilities and so make good use of them and again the staff are very instrumental in enabling this. Residents receive support in a flexible manner to enable them to enjoy accessing and using the community resources. It was clear that residents were engaging with their community in an effective manner. One resident has been even supported to attend a nightclub, which he is really proud about. The staff support around him to fulfil this objective is extremely good, ensuring that he is safe and leads to as possible – a fulfilled life. The views of external professionals and the residents supported the fact that residents receive excellent support in this area. This is positive. However, it was noted that although residents are given the opportunity to pursue their spirituality – no what took up this pursuit at the time of the visit. More importantly the management and staff respected the wishes of each individual living at the home. From assessing residents’ records, talking to the staff, residents and community professionals, it was noted that residents are encouraged to develop and maintain relationships with their friends and families. Relatives are also invited to and in some cases attend social events in the home such as birthday events. The levels of family input vary from individual to individual, however with the staffing support, residents reported that they live as a family at the Khaya Project. In this respect they (the residents) felt inclusive, while living in the home, which is positive. During the course of the inspection staffing interactions with residents were appropriate and more importantly respectful. Residents were addressed by their preferred names and staff were observed checking with them their preferences around food and personal support. Advocacy information is made available to residents and the key worker system is used as a means of ensuring that the rights and needs of residents are respected and provided for. It was reported that residents are encouraged to take part in the electoral processes, but quite often decline to so do. This was confirmed in discussions with two residents. All residents were registered on the electoral register. A range of menus were available on the day of the site visit, and from the records seen, meals consumed were duly recorded. Residents confirmed that they choose what they want to eat and that they are given advice on eating healthy. All residents spoken to were happy with the content and quality of the foods provided and this included a fresh supply of fruits and vegetables that were available on the day. Some residents are supported to prepare meals as Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 14 a part of enhancing their skill development, which is positive. A good supply of food was available in the home and residents informed that they could eat when they liked. Although the storage of food could be improved (covered in standard 42 of this report), the nutritional needs or residents are satisfactorily met at the Khaya Project. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. However, there was evidence that on one occasion the healthcare needs of a resident was at risk of being compromised. Residents’ healthcare is enhanced by the improved practices by staff in the handling of medication. EVIDENCE: Feedback received from residents was positive with regard to how they received personal support from staff working in the home. This is usually coordinated through the key-worker system. Residents are able to independently manage their personal care and most times may require a bit of prompting to achieve this objective. It was also clear that the staff had a system for determining individuals’ preferences and dislikes, which made the relationship between the residents and staff – a positive one. Residents have their individual style of dress, which was consistent with their choice, culture and personality, and this was promoted in the home. Residents are generally given good support to ensure that their health needs are provided for. They were all registered with a GP and records assessed Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 16 indicated that arrangements are in place for them to see other health professionals such as the dentist, the community psychiatric nurse, the psychiatrist, the diabetic nurse, chiropodist and the opticians. They also have the benefit of getting support to attend their outpatients’ appointment should they require this. This included records held on Care Programme Approach reviews held with residents and the members of multi-disciplinary team Feedback received from external professionals was positive about the staffing awareness of residents’ needs. Records bore evidence that all community appointments were documented as they occurred and this is evaluated via a monthly key worker checklist. In examining one of the residents file, the recording following an incident involving the resident gave reason to believe that the healthcare needs of the individual was placed on a lower priority than it should have been. In fact the management of the resident’s behaviour took precedence over his diabetic care, which could have resulted in adverse outcomes for the resident concerned. This was discussed in detail with both the staff member making the entry and the senior staff on duty, as they were interviewed individually about the matter. From the interviews, there is a suggestion that more was done for the resident than was actually recorded, but naturally this could not be evidenced. This must improve. It is therefore imperative that the quality of recording be reviewed and monitored to accurately reflect and promote the healthcare given to residents. At the time of the visit, all residents were receiving support with medication, as they were unable to independently manage this task, although one individual was identified for an assessment to manage his medication independently. A medication policy was in place to guide staff in the safe handling of medication in the home. The safety is enhanced by ensuring that all staff receive training in drug administration prior to supporting residents in this area. Medication storage in the home is was good and the disposal of lancets has improved. There was evidence from the recording systems in the home to confirm that drugs stocks are appropriately recorded and monitored at the Khaya Project. Residents are therefore assured that their health care support needs with regard to medication - are well provided for. Khaya Project DS0000037133.V363182.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): (22,23) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A satisfactory complaints procedure is in place and widely available to all residents and staff. Safeguarding adults’ practices within the home generally protects residents from abuse, although this could be enhanced by ensuring that staff are provided with refresher training in safeguarding adults. EVIDENCE: A satisfactory complaints procedure is in place at the home and is made widely available in appropriate formats to all residents. From discussions held with staff and residents, they felt able to raise issues of concern, should they feel the need to. The complaints record was analysed and in the main, complaints were logged and dealt with in line with the home’s complaints’ procedure. Staff interviewed demonstrated a clear understanding of the importance supporting residents to raise concerns should they be unhappy about any aspect of the service. A concern was raised by the local police regarding the staff at the khaya Project – failing to bring residents to the police station to make a statement following a period of unannounced absence from the home. This was discussed with senior staff from the Commission and it was made clear that there was no legal basis for the concern. The management embraces a culture of enabling staff, residents and their relatives to raise issues of concern as and when they arise. This is so that early interventions are made to put things right, rather than allow them to escalate. This is a positive approach to not only dealing with complaints, but to also improving the quality of service provision. There was evidence that staff had safeguarding training and that a policy was in place to direct them in dealing with safeguarding issues. However, this Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 18 policy needs reviewing to define the forms of abuse so that staff can feel more assured of tackling the various types. A policy on dealing with aggression is also in place and available to staff working at the home. There were no safeguarding issues in the home at the time of the visit. Two staff members were interviewed as part of the Commission’s a ‘Thematic Probe on Safeguarding’ during the course of the inspection and it was clear that they both had training in safeguarding adults. However, there is a need for at least one of the individuals interviewed to go on refresher training with regard to safeguarding adults. This was discussed with the manager and the staff concerned, at the inspection. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 19 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents live in a clean, purpose built and suitably designed home that matches their needs and lifestyles. They enjoy using their facilities, which are homely and personal, including their shared spaces. The home is clean and hygienic and fit for its purpose. EVIDENCE: Although the inspection was unannounced, the home was clean bright and airy on the day of the site visit. There was also decorative works done to enhance the homely feel to the environment and residents seemed quite happy with it. Feedback from residents indicated that they were pleased with the quality of the environmental facilities provided at the Khaya Project. Residents were observed negotiating their way was around the home with relative ease. It was noted that residents had options of where to go dependent on what they wished to do e.g. watch television, relax or engage with an activity of their choice. It was noted that a number of improvements were made to the environment, which enhances the quality of life for the residents living there. They included: the installation of a water dispenser, emergency, and outdoor lights. The lawn Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 20 in the rear garden has also been re-laid. In discussions with two of the residents, they expressed their satisfaction with the improvements, which is positive. At the last inspection the security of one of the ground floor bedrooms was compromised, as there were no window locks fitted to the windows. Since then, the registered person acted upon this failing to make the Khaya Project a safer place to live. Other residents spoken to, confirmed their satisfaction with their personal spaces. The laundry facilities were designed to promote the residents’ independence as far as possible. It was also designed to ensure that they could develop their skills in this area. An infection control policy is in place and residents and staff are encouraged to work within this e.g. hand-washing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The layout of the home is such that foul linen is well away from food preparation and so the risk of the spread of infection is minimised. The services and facilities do comply with the Water Supply Regulations 1999. It must be noted that the feedback received residents and from external professionals was quite positive about the cleanliness and quality of the environment. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 21 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally staffing levels do reflect their needs. Recruitment practices are robust, which means that residents are protected from coming into contact with individuals not suited to work with them. EVIDENCE: At the time of the visit, there remained a core of staff that had been working in the home for sometime. They appeared committed to the cause and most have achieved an NVQ Level 3 in Care with some completing a certificate in Mental Health (Level 3). Throughout the course of the site visit staff demonstrated their ability to positively engage and interact with residents. It is fair to say that even at times when a resident became anxious, staffing interventions were generally appropriate. From the records viewed, staff were able to make appropriate referrals to external professionals e.g. the GP, and were generally able to take appropriate action when emergencies occur. They also have a good understanding of the aims of the service and their role in achieving those aims. One of the strengths of the service provided at the Khaya Project is the fact that staff are given training that is specific to the work they do. They are also Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 22 well supported and directed by the registered manager, and are in receipt of a structured induction – one that is in line within current guidance. They also have a good understanding of the General Social Care Council’s Code of conduct, which underpins their knowledge and understanding once they have completed both their NVQ and specialist mental health training. Residents and external professionals hold the staff team at the Khaya Project in high regard – in relation to the complex and challenging work they do. Most residents maintain long and stable periods, once placed at the home. The recruitment file of the most recently recruited staff was examined and there was evidence that the practices adopted were robust and in line with current guidance. All checks required by regulation were undertaken prior to staff taking up duty at the home and the registered manager takes the main responsibility for this. One of the key checks made include – checking the prospective employee’s right to work in the UK. Residents can be therefore assured that all staff are thoroughly screened prior to engaging with them. They are therefore more protected from the risk of coming to harm, which is a positive outcome for them. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 23 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management systems are in place to provide a quality service at the Khaya Project. Good quality assurance systems are implemented to enhance this. Health and safety practices within the home generally protect residents, except in the area of food storage. Lines of accountability are now clearer in the home for the benefit of staff and residents. EVIDENCE: The registered manager has managed the service from inception and is suitably qualified to so do by virtue of his professional qualifications and training. It must be noted that he appointed a registered manager in 2007 to focus on expanding his business and during that period he played an effective role in carrying out monthly provider monitoring visits on the service. In essence he has kept himself close and in tune with the daily operations at the Khaya Project. He has the respect of most if not all, external professionals and the staff that he works with and the residents see him as a positive influence of the existence of the home. He has kept himself updated with various pieces Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 24 of training to include: diabetes, safeguarding adults, employment law and staff supervision. Residents are assured that the home would effectively managed and with their interests at the focal point. There was evidence of quality assurance systems being implemented as part of monitoring and developing the service. Residents’ views were gathered in December 2007 and it was reported that it was difficult to gather the views of each individual. The registered manager however, follows up issues and ideas raised from the regularly held residents meetings (weekly). Feedback on the service development is gathered on an individual basis in Care Programme Approach meetings held annually – on average. An annual development plan is in place and this partly derives from the views of residents, relatives where applicable and external sources working with the home. Mr Mafu also has the benefit of external monitoring via his financial backers and so the service benefit from having various systems in place to monitor and steer its growth. The health and safety file was assessed and all records on; appliance safety, fire safety and electrical safety were in order. There was evidence that staff have as part of their induction, appropriate training in health and safety. Safety signs were also appropriately displayed throughout the home and all areas of the home were safely accessible to the residents. Risk assessments were in place for all residents to ensure their safety and independence. There was one area that needed improvement, which was food storage. A number of dry foods were found inappropriately stored. This was discussed in detail with the registered manager and the staff on duty for improvement. It was also observed that fire exit signs were missing throughout some parts of the home. The registered manager informed that the local fire authority had approved the lack of fire signs, as it was a small home. At the time he received this advice the home was registered for four beds, but it is now registered for five residents. He agreed to pursue this for clarity and ensuring the safety of residents and staff. During the course of the last inspection, it was observed that a deputy manager was referred to on the roster. On further examination it was not clear as to the hours he worked and, the supervision and guidance he was having. Staff spoken to at the time, gave a description of his role somewhat different to what was given by the registered manager and so a requirement was made for the clarification of the deputy’s role. It is now the case that the role (deputy manager) no longer exists and that lines of accountability and responsibility for managing the service are now clearer for staff and residents. Khaya Project DS0000037133.V363182.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 2 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 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 4 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 x x 2 x Khaya Project DS0000037133.V363182.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 YA19 Regulation 12,13 Requirement Timescale for action 30/07/08 2. YA23 13 3. YA42 13 The registered manager must ensure that the recording in the home improves, so as to accurately evidence how the healthcare needs of residents are met. The registered manager must 15/08/08 ensure that: 1)refresher training in relation to safeguarding adults is provided for all staff that needs it including staff already identified and 2) Review the safeguarding procedure that it defines the various types of abuse. The registered manager must 30/07/08 ensure that appropriate arrangements are made for the safe storage of food in the home at all times. Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Khaya Project DS0000037133.V363182.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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