Inspection on 13/11/07 for Kahala Court

This inspection was carried out on 13th November 2007.

CSCI 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

Kahala Court 25/05/06

Kahala Court 16/09/05

Kahala Court 13/04/05

Kahala Court 28/09/04

Kahala Court 20/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kahala Court Embankment Road Kingsbridge Devon TQ7 1JN Lead Inspector Margaret Crowley Unannounced Inspection 13th November 2007 10:00 X10015.doc Version 1.40 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 Kahala Court DS0000003726.V350510.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 Older People. 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. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kahala Court Address Embankment Road Kingsbridge Devon TQ7 1JN 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) 01548 852520 P/F01548 852520 Quay Court Care Centre Limited Mrs Sheena Jane Ford Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 Brief Description of the Service: Kahala Court is a large, detached house situated overlooking the creek, less than half a mile from Kingsbridge town centre. There is an accessible, level garden area and an adjoining car parking area, and access to the home is via a steep drive off the main road. There is a large lounge and dining area and a secondary sun lounge, which is light and airy. There are twenty-two single rooms and three double en-suite rooms although all are currently being used for single occupancy. All bedrooms have en suite facilities. The homes environment is maintained to a high standard throughout. Current fees range from £380 to £500 perweek. Written information regarding the home and the services provided is available in the reception and is given to prospective residents. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The inspection was unannounced and took place over 6 hours on 13th November 2007. Sheena Ford, the Registered Manager was on duty and available throughout the inspection and Sally Brazier the Responsible Individual was available for discussion at the end of the inspection. Prior to the inspection the management provided detailed information about how they maintain a safe environment, train and support staff and how they ensure that the views of the people who live at the home are used to improve the quality of care provided. There were fifteen people resident in the home at the time of the inspection. Many were spoken with, including four in more depth, regarding the lifestyle in the home and the care services they receive. Surveys were received prior to the inspection from eleven people living in the home. Two relatives were spoken with during the inspection and surveys were received from four relatives. Staff on duty were observed and spoken with in the course of their daily duties. Surveys were received from seven staff and two health professionals. A tour of the premises was made and records were inspected including care, medication and staff records. What the service does well: People who live at Kahala Court gave high praise for the support and services provided. People said: “I thank God daily for the opportunity of living here”; “Kahala is excellent and managed very thoroughly” and “Its as near to perfect as a home can be”. Relatives said “People are treated as individuals and catered for accordingly”; “ my mother is treated with great kindness and respect” and “they do a very good job of looking after my mother”. Kahala Court provides care of an excellent standard. Care is well planned and recorded to ensure that individuals’ personal, healthcare and social needs are met in a consistent way. The home is attractive, comfortable, very clean and well maintained. Many people previously lived locally and are encouraged to maintain contact with family and friends. Relatives commented on the friendly, welcoming atmosphere. People are encouraged to pursue their interests both individually and in group activities. They participate in local community events, which also take place in the home. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 6 Meals are of a very good standard and provide a wholesome, varied and balanced diet. People praised the cook and said they received “excellent meals in quality and quantity” which are “always well cooked”. There was a very positive atmosphere in the home, which was evident in speaking to people who live there, the staff and the management. People have confidence in the registered manager and the staff and said “Sheena and the staff make it such a happy community”. The registered manager and the staff take pride in their work and this is reflected in the manner in which they work together as a team to promote the wellbeing of people living in the home. People are treated respectfully, and personal support is provided in a manner that upholds their dignity and privacy. Staff said how much they enjoyed working at Kahala Court, comments made included “the best job I have ever had” “there’s good team spirit and “it’s a great service”. The staff team are experienced, well trained and supported to do their job effectively. Staff turnover is low which provides continuity of care. The registered manager takes a very active and personal involvement in all aspects of life in the home. She demonstrates excellent knowledge and understanding of the needs of the people who live in the home, and of the staffs’ abilities to meet them and any training needs to be met. There are efficient administrative practices in place and good quality monitoring systems, which ensure people’s views are sought and acted upon. What has improved since the last inspection? What they could do better: The management has strived to ensure that the minimum standards are fully met and endeavours to work to surpass them. No requirements or recommendations have been issued as a result of this inspection. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 7 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. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 8 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 Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3,.Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive information to assist them in choosing to live at Kahala Court and admission procedures ensure that their needs can be met. EVIDENCE: Two people who had come to stay at the home recently were spoken with. They said that staff were very kind and welcoming at the time they moved in. One person said a relative had visited the home on her behalf while she was in hospital, but she had felt involved and consulted in the process. She said she was receiving the level of assistance that she needed. Written information is provided for people considering moving to the home and is also available in the home’s reception. A relative said that she had found the information helpful and that they had chosen Kahala Court following recommendations from people locally. The registered manager completes the pre admission assessment. She visits the person whenever possible, in their own home or hospital initially to assess Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 10 their needs. A person living in the home confirmed “the manager visited me at home to have a chat and transported me to the home to see the general setup”. The manager is clear regarding the needs that the home is able to meet. Records inspected of people admitted recently showed evidence of detailed assessments undertaken, which also included information obtained from health professionals. Kahala Court does not provide intermediate care. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7.8.9.10. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living at Kahala Court receive care that is well planned and documented, so that staff have good information to ensure that their personal, healthcare and social needs are met. EVIDENCE: People living at Kahala Court said “staff are all very helpful and look after us well”, “they encourage me to keep mobile” and “help comes with a smile”. Relatives said staff “look after people’s physical and mental welfare” and “perform care tasks that are sometimes unpleasant calmly”. People are “treated as individuals, not patients”. All responses received were very positive about the care given and praised staff for their kindness and attention to people’s needs. They said that staff provided care sensitively and always respected people’s privacy. This was also observed during the inspection. Staff knocked on people’s bedroom doors before entering and referred to them by their preferred name. Support at lunch time was provided in a discrete and thoughtful manner. People were well dressed and said that their clothes were always returned well laundered and ironed. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 12 Four plans of care were looked at in some detail. A new care planning format and a co-ordinated recording system has been implemented since the last inspection. Those inspected were of a commendable standard. The new care plans is more person –centred than that previously in use and identifies personal, health care and social needs. It includes the person’s likes, dislikes, background and interests. The care plans gives clear and concise information and instruction to staff to enable them to provide care and support in a consistent way. Daily records showed that peoples’ care is monitored and concerns are recorded and dealt with. Dietary preferences and needs were noted in the care plans. People’s weight is monitored on a monthly basis. The care records contained risk assessments and showed evidence of a system of regular reviews of the plan of care to enable changing needs to be addressed. A relative commented, “Close monitoring by staff means that there is continual adjustment to mothers needs”. The home’s system for the administration of medicines was inspected. Medication administration records were completed satisfactorily and medicines were stored securely. The system for the storage and administration of controlled drugs was in order. People who wish to administer their own medicines are assessed as competent to self medicate and this is reviewed on a regular basis. They are provided with lockable storage to keep their medicines safe. All staff who administer medication have received training. The home has good liaison with local general practitioners and district nursing service. Positive comments were received regarding the quality of the care provided. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People enjoy a varied life at Kahala Court and visitors and local community links are encouraged and maintained. EVIDENCE: People said they liked the friendly, relaxed atmosphere at Kahala Court. They were seen making choices in their daily lives, including at what time they got up and whether they spent time in their own room or in one of the lounges. Several said they liked to visit Kingsbridge either with friends or family, or by themselves. People are actively encouraged to maintain their independence as far as they are able, with some coming and going quite independently. Good links are kept with the local community. A fund raising event for a local charity had taken place in the home in the week prior to the inspection and many people living in the home had participated in this. An impressive range of Christmas events had been organised which people could choose to attend and the information was displayed on the notice board. People living in the home, relatives and visitors confirmed that visitors are always made very welcome. A relative said “it’s a happy, friendly place to visit”. Relatives and friends are invited to attend social functions and meals. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 14 Staff undertake activities with people on a daily basis, both individually and in groups. Several people were seen to enjoy playing cards, scrabble and board games. Staff made efforts to ensure that newer people were enabled to participate in the activities. Staff were also observed to spend time talking informally with people who chose not to take part. Meals seen provided were of a very good standard. People praised the standard of cooking and the quality of the meals. All people spoken with said that they enjoyed the meals, which were described as “excellent”. The day’s menu was displayed in the dining room and it was confirmed that a choice is always available. Special dietary requirements are catered for, and the information is available for those preparing and serving meals. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Kahala Court can be confident that there are satisfactory arrangements for responding to their concerns and protecting them from abuse. EVIDENCE: The home has a written complaints procedure, which was on display. It is also contained in the service users’ guide. People living in the home and their relatives said they would make any complaint to the manager or senior staff , but have not needed to do so. The manager said that no complaints have been received in the home since the last inspection. Any issues are dealt with at the time to prevent them developing into more serious problems. The Commission for Social Care Inspection has not received any complaints since the last inspection. There is an adult protection policy and procedure which is accessible to staff Two levels of training in protecting vulnerable adults have now been introduced to raise staff’s awareness of protection issues. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a home that is very comfortable, clean, safe and well maintained. . EVIDENCE: A tour of the premises was made and most rooms were seen. People praised the quality of their rooms and their pleasant surroundings. Bedrooms are personalised to people’s taste. All have en suite facilities or a designated toilet. Kahala Court is very well maintained and furnished to a very good standard. There is an ongoing programme of redecoration and renewal to ensure that the premises remain attractive and safe. Since the last inspection the main lounge, dining room, and some bedrooms have been refurbished. New furnishings have been provided in the conservatory. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 17 The garden area has been landscaped and more seating areas have been provided. The responsible individual said that the company planned to extend the garden and to extend the premises to provide additional rooms. The premises were very clean, hygienic and free from unpleasant odours throughout. There are procedures in place to control the spread of infection. During the visit staff were seen to observe routine health and safety procedures, such as using gloves and washing hands which helps prevent any unnecessary cross infection within the home. The laundry is situated in the basement. There was some damage to the wall of the basement staircase, which the manager said was due to be repaired. . Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living at Kahala Court can feel assured that the staff working in the home are well trained, skilled and supported, and employed in sufficient numbers to meet their needs. EVIDENCE: People living in the home and their relatives said that staff were very kind, helpful and accessible without delays. Communication seen during the inspection between staff and people living in the home was warm, friendly and appropriate. Staff spoken with and feedback from staff questionnaires showed that they are very positive about their work. Staff turnover is low and morale good. Staff said there was “good team spirit” and new staff felt that they had been welcomed into the team. Staff spoke highly of the manager and said she provides “good support daily”. They value their access to training to develop their knowledge and skills in caring for people. There is a good range of experience and training within the staff group. The management demonstrate good commitment to staff training, including a systematic approach to training in mandatory training in safe working practices. Additional training provided since the last inspection has included communication skills, pressure area care, dementia care and death and bereavement. Training is provided in house by the Court Group training officer Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 19 and via external courses. Eight of the thirteen care staff hold the National Vocational Qualification in Care at level 2 or above and other staff are currently undertaking the training. New staff receive the Skills For Care induction training and all staff have regular supervision sessions . Staff rotas were inspected and the registered manager and the responsible individual said that staffing levels are maintained at an appropriate level. These are kept under review dependent on people’s needs and the registered manager has discretion to increase staff time if required. Staff records inspected provided satisfactory evidence of the recruitment processes including written references. Criminal Record Bureau disclosures are applied for centrally in the Court Group headquarters and the registered manager informed of the outcome. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Kahala Court is well managed by the registered manager who provides sound leadership and ensures that people live in a safe environment where their needs can be met. EVIDENCE: Sheena Ford, the registered manager has many years experience in working in the care of older people including several as a manager of this home. She holds the Registered Managers Award. Kahala Court is managed efficiently and there are clear systems in place. The registered manager and the responsible individual work together well and ensure that high standards are maintained. There is a very positive atmosphere in the home, which inspired by the registered manager. She takes a personal and daily interest in the wellbeing in Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 21 of the people who live in the home. The registered manager and staff team continue to provide a very homely and open environment. There are sound quality auditing systems in place. The responsible individual undertakes a monthly review of the service and produces a report, which is available in the home. People’s views are sought via surveys and at residents meetings, the results of which were displayed in the home. People are also invited to comment on their experience of going to live at Kahala Court. An annual development plan is produced and was also available. Records were kept of incoming and outgoing payments of any money held in safekeeping for people living in the home. A sample of the records was inspected and were in order. The amount of monies held is limited. People living in the home or their representative manager their financial affairs. The registered manager confirmed that health and safety matters continue to be well managed within the home and records inspected supported this. The home has a fire risk assessment and records were maintained or fire safety tests and drills. Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 23 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 Kahala Court DS0000003726.V350510.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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