Archived: Kadima Support UK Limited No 7a

Updated 19 October 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 25 and 27 August 2015. The inspection was unannounced on the first day and we informed the service that we would be returning on the second day.

The inspection team consisted of an inspector and a specialist professional advisor (SPA). The SPA had a background in mental health nursing.

Prior to the inspection we reviewed information we held about the home, which included notifications of significant incidents reported to the Care Quality Commission.

We spoke with two people who used the service, two members of the support staff, the deputy manager and the registered manager. We spoke with the relative of one person after the inspection. We observed the support and care provided to people in the communal areas and looked around the premises.

We reviewed two care plans and the accompanying risk assessments. We also looked at a range of documents including four staff records, the complaints log, the safeguarding policy and procedure, medicine administration record (MAR) sheets, health and safety records, and quality assurance audits.

We contacted health and social care professionals with knowledge of this service in order to find out their views about the quality of the service. We received feedback from three professionals.

Updated 19 October 2015

The inspection took place on the 25 and 27 August 2015. This was the first inspection of the service since it registered with the Care Quality Commission on 17 October 2014, having been previously owned and managed by a different provider. Kadima Support UK Limited No.7 is registered to provide care and accommodation for up to five people with mental health problems. The service was at full occupancy at the time of our inspection and all of the people using the service were male.

There are four single occupancy bedrooms. There is a communal sitting room, kitchen, bathrooms and toilets. The rear garden and courtyard is shared with Kadima Support UK Limited No.7a, which is registered to provide care and accommodation for up to four people with mental health problems. People can use the conservatory at No.7, which is used as an indoor smoking area.

There was a registered manager in post, who managed both No.7 and No.7a. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives told us they were happy with the service. They said it was a safe environment with caring staff.

There were systems in place to identify and mitigate any risks to people’s safety and wellbeing, although the service needed to develop the crisis management plans.

Sufficient staff were deployed to meet people’s needs. Staff recruitment had been carried out by the previous provider and did not demonstrate rigorous systems to ensure references were authentic. The provider was aware of their responsibilities with the recruitment of new staff.

Staff received formal supervision and an annual appraisal. Staff told us they were enjoying the recently introduced programme of training, which focused upon how to meet the needs of people with mental health problems. However, we found that staff knowledge needed to be developed in regards to how to support people with their recovery.

Medicines were safely stored and protocols had been established to make sure medicines were safely administered.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report upon our findings. DoLS are in place to protect people where they do not have capacity to make decisions and where it is regarded as necessary to restrict their freedom in some way, to protect themselves or others. We found that staff understood how to protect people’s rights and no person was subject to a DoLS authorisation.

People’s needs had been assessed, and support plans had been developed in consultation with people. The support plans were well written but contained insufficient information about how to support people with their recovery.

People took part in some food preparation and cooking. However, we did not find sufficient evidence during our observations, and discussion with people and staff, that people were being supported to get involved in more activities of daily living. For example, food shopping and household chores.

Complaints and comments from people using the service and their relatives were properly investigated. Information about how to make a complaint was prominently displayed. People had been provided with verbal information about advocacy services to support them to express their views and comment upon services they received.

People told us the service was well managed. There were systems in place to audit support plans, staff training and support records, and health and safety checks. The registered manager was supported by other registered managers within the organisation, but there was no clear system for the provider to carry out detailed and meaningful audits and support the registered manager to improve the quality of the service.

We have made four recommendations. These are in regards to staff receiving training about the recovery model, for people and their representatives to be provided with comprehensive written information about advocacy services, and for support plans to demonstrate how people are being supported with achieving more independence with daily living activities. The final recommendation is for the provider to carry out detailed monitoring visits, which provide professional support for the registered manager.