Archived: Khaya Project 2

At our last inspection of this service on 16 June 2016 the service was rated Good. At this inspection we found two breaches of the fundamental standards and regulations. The provider had not ensured there were risk assessment and management plans for people identified with a health condition and behaviour that challenged. The provider’s quality assurance systems were not effective.

You can see what action we told the provider to take at the back of the full version of the report.

There was a system in place to manage accidents and incidents to reduce the possibility of reoccurrence. There were systems and processes in place to protect people from the risk of abuse.

The service had enough staff to support people. The service carried out satisfactory background checks of staff before they started working. Staff supported people so they took their medicine safely, however one member of staff’s competency to administer medicines had not been assessed. The service had arrangements in place to deal with emergencies and staff were aware of the provider’s infection control procedures.

Staff carried out an initial assessment of the needs of each person to ensure they could be met before they started to use the service. The service provided induction and training to staff to help them undertake their role. The service supported staff through supervision and annual appraisals.

People’s consent was sought before care was provided. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and the policies and systems in the service support this practice.

Staff supported people to eat and drink sufficient amounts to meet their needs. Staff supported people to access healthcare services they required.

Staff considered people’s personal choices, general wellbeing and activities. Staff supported people to make day to day life choices and maintain relationships with their family. Staff supported people in a way which was kind, caring and respectful. Staff protected people’s privacy and dignity.

The service had a clear policy and procedure about managing complaints. People knew how to complain. The provider had systems and processes in place to support people with end of life care in line with their wishes. However, at the time of the inspection no one required end of life care support from the provider.

The provider had notified us of notifiable events. The service sought the views of people using the service. Staff felt supported by the manager. The service worked effectively in partnership with health and social care professionals and commissioners.

The last inspection rating of the service was displayed correctly on their website.

Khaya project 2 is a service registered to provide personal care for up to four people with mental health needs who live together in a supported living house in Woolwich. There were four people using the service at the time of the inspection.

There was a registered manager in place at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that staff provided person centred support for people living in the house and were committed to promoting a positive culture. They actively promoted independence and supported people to maximise their potential in all aspects of their lives.

The deputy manager and staff were aware of what constitutes abuse and the action they should take if such an incident occurred. They received regular safeguarding training and policies and procedures were in place for them to follow.

There were enough staff to support people safely and to meet their individual needs.

Assessments were undertaken to assess any risks to people using the service and steps were taken to minimise potential risks and to safeguard people from harm.

Safe recruitment procedures were used that ensured staff were suitable to work with people as staff had undergone the required checks before working at the service.

Staff completed an induction programme and mandatory training in areas such as, safeguarding, mental health awareness, first aid, health and safety and safe handling of medicines.

Staff had a good understanding of the principles of the Mental Capacity Act. They always presumed that people were able to make decisions about their support and if they felt someone may lack capacity to make a decision they would always discuss this with the appropriate health or social care professional. This was in order for the best interest process to be followed.

Records showed that staff had received regular one to one supervision and this was seen by staff as useful and supportive. There was also evidence of regular annual appraisals.

Equality and diversity was an integral part of peoples care plans and staff were aware of how to ensure peoples differences were respected, valued and upheld.

Staff were aware of how to protect privacy and dignity. They always knocked on people's doors and waited for a response before entering their rooms. They promoted independence and maximised people’s ability by encouraging people to do as much as possible for themselves and offered support where needed.

Staff knew how to support people to make a formal complaint. There were effective systems in place to manage complaints as well as mechanisms to ensure learning from complaints was shared across the service.

Audits and quality monitoring checks took place regularly and annual service user satisfaction surveys were undertaken to ensure the service was delivering a high quality, person centred service.

We found that people using the service were involved in the assessment, planning and delivery of their care to meet their individual needs. The provider had systems in place to ensure the safe management of medicines and people received medicines at the times they needed them. There were sufficient staff with the right qualifications, skills and experience in place to provide people with appropriate support. We also found that complaints procedures were made available to people using the service and any complaints made were listened to and acted on by the provider.

We found that the people who used the service were involved in their care planning and received personalised care and support which was based on an assessment of their needs. Appropriate checks were carried out to ensure only suitable people were employed and staff received suitable support and supervision. Care records were stored safely and were up-to-date.