Archived: Khaya Project

At our last comprehensive inspection on 22 August 2017, the home was rated as ‘Requires Improvement’ as robust risk assessments were not in place for one person to ensure they were safe at all times. During this inspection we found improvements had been made and the home has now been rated ‘Good’.

The home had a manager, who was the provider and registered with the Care Quality Commission as a provider. Like registered managers, they are 'registered persons'. Registered persons have legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008 and the associated regulations on how the home is run.

Risks had been identified and assessed, which provided information to staff on how to mitigate risks to keep people safe. Staff had been trained in safeguarding adults and knew how to keep people safe.

Medicines were managed safely. We found that people’s Medicine Administration Records (MAR) had been completed accurately. Medicines was being administered as instructed on people’s MAR, or in accordance with the provider’s policy. Medicines were stored securely.

Systems were in place to reduce the risk and spread of infection. There was a daily cleaning schedule and people were encouraged to clean their own rooms.

There were sufficient staffing levels to support people and staff had time to provide person centred care. Pre-employment checks had been carried out to ensure staff were suitable to care for people. Premises safety checks had been carried out to ensure the premises was safe.

Staff had the knowledge, training and skills to care for people effectively. Staff felt supported to carry out their roles and received regular supervisions.

People had choices during meal times and were supported with cooking meals when required. People told us they enjoyed the food. People had access to healthcare services.

Staff were aware of the principles of the Mental Capacity Act 2005 and sought people’s consent before supporting them.

People told us that staff were friendly and caring. Our observations confirmed this. People were treated in a respectful and dignified manner by staff who understood the need to protect people's human rights. People had been involved with making decisions about their care.

People received care that was shaped around their individual needs, interests and preferences. Care plans were person centred and staff knew how to provide personalised care to people.

People were aware of how to make complaints if they wanted to and staff knew how to manage complaints.

People had an activities schedule, which included accessing the community. Group activities were organised and people were encouraged to participate in these activities.

Staff felt well supported by the management team. People were complimentary about the management of the home. Quality assurance and monitoring systems were in place to make continuous improvements.

At our last comprehensive inspection on 22 April 2015, the home was rated as Good. During this inspection we changed the rating to Requires Improvement.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008 and the associated regulations on how the home is run.

Risks were not always robustly managed. We saw that some people had risk assessments in place. However, one person had not been risk assessed, which placed them at greater risk of harm.

Quality assurance systems were in place but were not always effective. For example, the audits had not identified the shortfalls we found during the inspection with risk assessments.

Staff were aware of how to identify abuse and knew who to report abuse to within the organisation and outside the organisation.

Premises safety checks had been carried out by qualified professionals. These checks did not highlight concerns.

Medicines were managed safely. People received their medicines as prescribed. Medicine records were completed accurately and were stored securely. Staff had been trained with medicines and competency assessed to check their understanding of medicines.

Pre-employment checks had been carried out to ensure staff were fit and suitable to provide care and support to people safely.

There were appropriate staffing levels. Staff told us they had time to provide person centred care and had enough staff to support people.

Staff had received training required to perform their roles effectively. People were being cared for by staff who felt supported.

Staff had been trained on the Mental Capacity Act 2005 and knew the principles of the act. People had capacity to make their own choices and were independent.

People had the level of support needed to eat and drink enough and were supported with cooking healthy meals.

People had access to a range of health care professionals, which included services that supported people with drug and alcohol problems.

People had a positive relationship with staff. We observed staff were caring.

People’s privacy and dignity were respected by staff.

People were able to participate in activities if they wanted to. There was a weekly activities timetable for each person.

Care plans were person centred and detailed people’s preferences, interests and support needs. People were involved with making decisions on their care.

Staff told us the culture within the home was like being part a family and told us the home was well-led. People’s feedback was sought from resident meetings and key worker meetings.

We identified a breach of regulation relating to risk assessments. You can see what action we have asked the provider to take at the back of the full version of this report.

People's privacy, dignity and independence were respected. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

People experienced care, treatment and support that met their needs and protected their rights. Staff encouraged and supported people to be as independent as possible and to access their local community.

There were effective systems in place for managing medication.

There was also an effective complaints system available.

Two out of the three current residents told us that they were happy with the services provided by the home. The third felt he had outgrown the service and was in the process to move on to a less supported environment.

People's potential for living in the community is assessed over a long period due to their complex mental health needs.

Residents are encouraged to access services in the community and to be part of the community.

People told us that the staff were always available to help them with any aspect of their needs. Residents received personalized care and support which reflected to their lifestyle choice.