Inspection on 08/10/09 for Kay Court

This is the latest available inspection report for this service, carried out on 8th October 2009.

CQC found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kay Court 17/10/06

Kay Court 22/02/06

Kay Court 20/09/05

Kay Court 18/11/04

Kay Court 15/06/04

Kay Court 02/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Kay Court 368 Finchley Road London NW3 7AJ Lead Inspector Pearlet Storrod Key Unannounced Inspection 8/10/09 12:00 09 DS0000010337.V378197.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kay Court Address 368 Finchley Road London NW3 7AJ 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) 020 7435 8214 0207 794 8146 MOforikoree@jcare.org www.jewishcare.org Jewish Care Margaret Ofori-Koree Care Home 54 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (54) of places Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only:Care Home Only - Code PC to service users of the following gender: Either whose primary care need on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia, over 65 years of age - Code DE(E) (maximum number of places:17) The maximum number of service users who can be accommodated is: 54 7th August 2007 2. Date of last inspection Brief Description of the Service: Kay Court is a registered Residential Care Home owned by Jewish Care with its main office at 211 Golders Green Road, London. NW11. It is a Voluntary Organisation and a Registered Charity that runs a number of specialist services for different age ranges and care needs for the Jewish people. Kay Court provides fifty-six (56) rooms for Residential Care for the elderly. The accommodation provides for fifty-one (51) Permanent Residents, 18 of whom can have dementia and five (5) Respite Care Residents. The home is divided into two parts: The main Kay Court building and the Annexe building, but the management remains as a whole. The level of fees will be recorded in the final report. The two-part building is divided into two units. The main unit is for residents with medium-dependency and the annexe unit for residents who require higher levels of care and support. This annexe provides a Dementia Care Unit All floors are accessible from the ground floor via a shaft lift in each unit. The home is able to accommodate people with physical disabilities and is wheelchair accessible. There is a large terraced communal and well-maintained garden. The lounge looks out onto a patio with tables and seating. Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 5 The home provides 24-hour care over three shifts, including waking night staff. The registered manager and deputy supervise four team leaders, who in turn supervise the care staff. Domestic, laundry and catering staff are subcontracted. Jewish Care employs a full-time maintenance operative. The property is situated in North West London between two underground stations, Finchley Road and Golders Green. The over ground at Finchley Station is close by as well as several bus routes. Parking is limited. Kay Court DS0000010337.V378197.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 3 stars. This means that the people who use this service experience excellent quality outcomes. The inspection took place over two half days and it took eight and a half hours to complete. One inspector carried it out. Prior to the site visit all information held at our office had been reviewed. This included reports that had been sent to us on a monthly basis including those relating to incidents or changes that had occurred since the last visit. The manager had completed and Annual Quality Assurance Assessment (AQAA), which gave us information about the people living and working in the home as well as the home’s compliance with key standards. Information outlined in the AQAA, also referred to as a self-assessment document, and was crossreferenced with the information and records at the home. Based on the above, we developed an inspection plan, which was used to conduct the inspection. Questionnaires had been sent to the home prior to the visit for people who live there and for staff. Feedback from the surveys is included in this report. Kay Court has an active “Friends of Kay Court” Volunteer Group who have formed a formal committee to ensure the well being of residents and who organise fund raising for the benefit of residents, amongst other activities in the interests of residents. During the visit I spoke to people living in the home, and examined four case files in depth. A small sample audit of medication was carried out and I went around the home speaking to four people using the service and three staff members. The findings were discussed with the manager during and after the inspection. What the service does well: The home responded swiftly to the recommendations. There is evidence of consultation with relatives, people using the service and volunteers. Comments from people using the service were: “They keep you together”. Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 7 “I am happy”. “The home is well organised” and “all is well”. “The home does everything it can; Jewish Care does a great job”. “It is good enough here”. The home provides good quality training for the staff they employ. This inspection showed that individual people are able to make choices and decisions for themselves and where appropriate, the home involves their relatives. As reflected in the report the home is faith specific and as such, the cultural and religious needs of people using the service are continuously met. The manager is continues to strive to improve standards within the home and a consistently good service is applied here, to an extent that no recommendation or requirements were made for the previous two key inspections. What has improved since the last inspection? As mentioned above no requirements or recommendations emanated from the previous two inspections. The Annual Service Review report highlighted that there were mixed views about the meals prepared previously due to the level of salt for example. This inspection demonstrated an improvement in this regard and there were no concerns aired at this inspection. The AQAA indicated that the care plans have been improved to reflect a more person centred approach. This was noted from the files that were inspected. More relatives were now involved in one to one activity programmes with their family member, in which the memory boxes of individual people using the service is used. All the beds of people using the service were now fitted with ski sheets to make it easier to evacuate in the event of a fire or other emergency situation. A falls pathway register is in place to enable staff to monitor and put any necessary action in place for individuals using the service. Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 8 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kay Court DS0000010337.V378197.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6 - People using 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. People using the service can be confident that their needs and aspirations will be met. EVIDENCE: It was noted from the (AQAA) Annual Quality Assurance Assessment that prospective people who use services and their families are given the opportunity to familiarise themselves with the home’s environment prior to having an assessment of their needs being carried out. This is reflected in the home’s statement of purpose and service user’s guide. Surveys were sent out to establish the views of people using the service and Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 11 13 were returned, which reflected mixed views as follows: Two people said that they did not receive enough information to decide whether to live at the home before moving in. One of these two people asserted that they were given no written information about the home’s terms and conditions, referred to as a contract. Four people did not know whether they were given a written contract and one other person had not received enough information prior to moving in and affirmed that they had not been given a written contract. Six people confirmed that they had received enough information before moving in; these six people also received written terms and conditions. I saw evidence of contracts in the files that I examined. Four care records were examined and these showed pre-admission assessments. The manager explained that such assessments are carried out in the person’s own environment, usually in their home if it is possible to do so. The prospective person who use services is offered the opportunity to spend a day at the home as a guest to allow them to familiarise themselves with life in the home. People referred by Social Service Departments, had copies of assessments and care plans under the care management process in their files. All admissions are based on the home’s ability to meet the person centred and holistic needs of the person using the service. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - People using 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. There were arrangements in place to meet the health care needs of the people living in the home. People using the service are protected by the home’s approach to medication management. EVIDENCE: Individual people who use the service had a comprehensive person centred care plan to meet their health, personal and social care needs, and reviews were noted to occur regularly. Where necessary relatives input were recorded. All care plans evidenced were found to be up to date and reflected the needs and wishes of each individual person. The care plans also revealed additional assessments in relation to manual handling, nutrition and pressure sore risks. Risk of falls are also taken into account. From observation and Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 13 discussions with people using the service it was apparent that service delivery matched the care plans. Records indicated that referrals were made to the Community Nursing Team and or to individuals’ General Practitioner (GP) as appropriate, where changes in condition or behaviour had been noted. The home has a General Practitioner who visits weekly though individual people who use the service can register with a GP of their choice. Individual people are given the opportunity of being responsible for administration of their own medication, if they wished, following an assessment of their capacity. A brief check was carried out in respect to the handling and control of medication. This was judged to be managed well. There was a robust policy and procedure for the ordering, receipt, storage, administration and disposal of medication in place. This is known to designated staff responsible for the administration of medication and underpins their practice; backed up by regular training in-house and annually as the need arise. Observation at the inspection, discussion with three staff, the examination of care records and feedback from people using the service with whom I spoke, confirmed that staff respect the privacy and dignity of the people they look after. Comments received were positive and an example of some points made were: “ They listen to us, keep our clothes clean”. “I’m happy”. “They take good care of me”. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - People using 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. The home meets the cultural and religious needs of the people who live there. People who use the service are supported to live the life they choose respecting their choices and individuality. EVIDENCE: This faith specific home and as such the home embraces the cultural and religious needs of all Jewish residents. The home runs two Shabbat services per month to accommodate everyone living at the home. This was confirmed by the people using the service with whom I spoke and is reflected in the self assessment document. All Jewish festivals are celebrated and a Jewish atmosphere was predominantly noted on two visits made to the home. An activities programme was observed on the notice boards around the home and a member of staff had been deployed with responsibility as dedicated Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 15 activities officer. It should also be said that all staff are trained to learn, understand and observe the Jewish culture. With this in mind, staff are also instrumental in ensuring that people who use the service are able to follow their own faith and fulture. People living at the home benefit from various trips and outings and other places of interests. People are required to register their interests if they wished to go on any of the planned events. I saw some individuals using the Wii console, purchased by the home to encourage individuals to participate in different kinds of activities and competitive sporting events using the Wii. I noted an individual participating in a bowling activity and they seemed to be having fun and enjoyment. Comment from two people using the service outlined in their individual surveys were, “would like to go out somewhere to watch Arsenal Football Club”; “would like to go out more” and “would like more entertainment”; “would like to do more exercise”. The social activities programme is planned around the Jewish Calendar. I saw evidence of entertainment in the home and the activities officer is being supported by the manager to develop and make this area more creative. The care home makes visitors and relatives feel welcome as well as maintains a good level of communication with families. People using the service, families and friends are notified of how to contact external agencies, such as advocates to act on their behalf. There is a weekly musical entertainment provided by “Friends of Kay Court”, which consists of various artists ranging from violinists to pantoloons. I had the benefit of enjoying an entertainment session where music was being played and I also danced with a person using the service, to my surprised at being asked. There is regular input from the relatives as discussed with the manager, and I was able to meet an individual who also fund raise for the service. She explained that help and support from relatives enables her to improve the quality of the service. Her specialist training in dementia care mapping allows her to ensure that people with dementia are properly supported, which may require input from the (DoL) Deprivation of Liberty. There is a restraint policy in place as confirmed by a staff member and reflected in the AQAA. This is used in unison with the consent of individual people using the service and their relatives where appropriate, for such things as use of “seat belt in wheel chair” for short periods. As stated previously, there is evidence of (Dols) input. Generally, the people with whom I spoke felt that they had control over their lives and there was praise for staff in supporting people to be as independent as possible, according to their individual capabilities. Feedback from staff as outlined in the surveys returned to us, suggested ideas that may potentially enhance the independence of some individuals. I had the benefit of attending a house meeting which was very well attended. The meeting was chaired by an individual person using the service who volunteered to do so. The agenda was devized by staff in consultation with Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 16 people using the service. The agenda was hand written and circulated to those in attendance as the photcopier was out of use. It was interesting and clearly noted that the meeting was controlled by the people using the service themselves. A planned trip out of the home and the celebration of Hanukkah were also on the agenda. An individual congratulated the laundry staff for providing a good service, this was re-echoed by others in attendance. The individual went on to say, “you do a good job but one of my sock was missing”. I observed at the house meeting held for people using the service, that an individual who only speaks Italian were appropriately supported by a staff member who was specifically recruited for that purpose. This enabled the person using the service to take part in the discussions at hand. This is commended. The homes catering services follow all the Jewish Kashrut dietary laws and the majority of the food offered are cooked on site. Daily menus are displayed on each dinning table with a main dish and optional choice. People who use the service were offered three course Kosher meals a day with approximately five hours interval between meals as reflected in the self assessment document. ”. People using the service also praised the cook in regards to the improvement in the food served. Those in attendance also voted to have a bowl of fresh fruits on the dining tables as opposed to being served tinned fruits. From observation and discussion with people using the service and staff, there was an improvement in the food served since the last key inspection, when there were mixed views. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - People using 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. People living in the home are fully protected by the approach to complaints, incidents and allegations. EVIDENCE: The home had a comprehensive complaint’s policy and procedure. The procedure is available to people living in the home and their relatives. Complaints, incidents and accidents are being recorded. These records were cross-referenced with the care records. Four of the people who returned surveys confirmed that they did not know how to make a formal complaint. One person said they did not know who to speak to informally if they were not happy. The other eight surveys indicated that these people knew who to complain to if they were unhappy as well as knowing how to make a formal complaint. The manager should perhaps liaise with the activities officer to have complaints as an agenda item and also ensure that key-workers discuss this issue with their clients. One person said in the survey returned to us, “up to the time of filling in this form, I have no complaints”; “they do the best they can”; “I am very settled here”. Ten complaints were made to the home since the previous inspection, the majority Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 18 of which related to complaint about the food. All complaints were addressed within the timescale. A copy of the complaints process was on notice boards and in the rooms of people using the service. No recommendation is made as a result. The accident reports were compared with the Regulation 37 notifications sent by the service since the last inspection. The service has a robust policy and procedure on adult protection, which is linked to local authority guidance. Staff had received training on adult protection and showed that they understood their role and responsibilities in this area for the safety and protection of people using the service. There were no safeguarding referrals made since the last inspection. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 - People using 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. People who reside in the home live in comfortable, homely and clean surroundings. EVIDENCE: People who use the service had the opportunity to personalise their private space. The reception area was decorated since the last key inspection and the area has an attractive appearance. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 20 A CCTV in a fixed position externally is used to protect the home, which provides security for people living and working there. The names and pictures of individual people are sited on the door to the rooms in the dementia care unit in accordance with those who consented. The home provides a safe environment for people who live there and they have access to an attractive garden with sensory beds. Feedback outlined in all thirteen surveys returned reflected that the home is at all times, fresh and clean. The home is in a reasonable condition and a handyman is noted to be employed. An area observed for improvement is the communal areas including the corridors. The manager acknowledged that these areas had been identified for redecoration and that a timescale would be sought from the provider and forwarded to the Commission. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - People using 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. The service places emphasis on recruiting appropriate staff that in turn is provided with the necessary training to meet the needs of people using the service. EVIDENCE: Staff were described by people living in the care home as “they listen to us, keep our clothes clean”; “very good;” “they are ok”. Feedback from the staff showed that they found working in the home a very positive experience and were proud of the care they provided. Some comments received from staff were, “the home provides up-to-date training and seminars for the staff. “The home welcomes complaints from service users, their families, representatives and the general public”; “all staff received training on safeguarding adults”. Suggestions with regard to improve the independence of people using the service were also made as follows: “staff could encourage service users to maintain the independency such as helping in giving teas or settling tables”; the home could have more comfortable chairs for the lounge and dining room”, and “encourage service users to help out in setting tables, for example folding serviettes”. There was evidence that the home attempts to match the gender Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 22 of staff to the gender of individual people using the service according to individuals’ choice and wishes. The provider had a robust recruitment and selection process. This was tested and the finding was that a number of Criminal Records Bureau (CRB) forms had not been refreshed. This was immediately attended to by the manager of the home and a follow up visit demonstrated that the staff concerned had completed the necessary forms and reapplied for their existing CRBs to be updated, no recommendation was made as a result of the proactive approach by the manager and Responsible Individual. Staff confirmed that the induction process covered what they needed to know about their role and responsibilities. Each staff member has a training profile and refresher training in health and safety, first aid and such like is on-going. Essentially, training in respect to the Jewish cultural and religious festivals and activities are also included as part of the induction process. In discussion with the manager, she stated that approximately all care staff had now completed and achieved NVQ levels 2 and 3 and that team leaders were now doing NVQ level 4. This is re-echoed in the self-assessment document, which reflected that 98 of staff had undertaken NVQ levels 2 and 3 training, that two team leaders have completed NVQ level 4 with four others going through the training process. The manager confirmed that she often visited the home unannounced, which enables her to carry out training and where necessary, supervision with staff working on the night shifts. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 - People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being managed in the best interests of the people living there. EVIDENCE: The manager had completed an Annual Quality Assurance Assessment (AQAA) also referred to as a self- assessment document, prior to this inspection. The information within the AQAA and further discussions with the manager during the site visits demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. There are clear lines of accountability and communication within the service. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 24 The manager holds the qualifications of a Registered General Nurse, the Registered Managers’ Award, and Diploma in Management from the Institute of Leadership and Management and is undertaking a Masters in Dementia. She is aptly registered with the Commission and a welcoming, open and transparent style of management was portrayed at the service. People using the service are protected by the policies and procedures. The quality assurance systems were effective and the manager is proactive in addressing quality issues within the home. All incidents and concerns are reported fully to the Commission and the manager demonstrated competence in dealing with untoward situations as noted on site visits, when two different situations arose. Comments from people using the service were: “They keep you together”. “I am happy”. “The home is well organised” and “all is well”. “The home does everything it can; Jewish Care does a great job”. “It is good enough here”. People are generally encouraged to manage their own finances, where this is not possible because of lack of capacity; I saw evidence of support sought from a relative and legal representative. Samples of health and safety records were looked at. These confirmed that the home is being managed in a responsible and effective way. Inspection of fire fighting equipments, fire alarm tests and testing of small electrical appliances were undertaken. Risk management plans were noted to be satisfactorily undertaken. There were evidence of monthly monitoring visits to the home and reports regarding such visits. The RI visited the home on my second site visit; the manager also asserted that she conducted additional unannounced visits to the home during the evening and early mornings on occasion. The purpose as mentioned earlier, is to provide training, supervision and support to night care workers. The preceding sections of this report have contributed to the judgment in this outcome area. It also took into account that no recommendations were made at the previous inspection and on this occasion. Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 25 Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 x 3 4 x 3 Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Kay Court DS0000010337.V378197.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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