CARE HOMES FOR OLDER PEOPLE
Kahala Court Embankment Road Kingsbridge Devon TQ7 1JN Lead Inspector
Judy Cooper Unannounced 16 September 2005 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 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 D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Kahala Court Address Embankment Road, Kingsbridge, Devon, TQ7 1JN Telephone number Fax number Email 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 01548 852520 Quay Court Care Centre Limited Mrs Sheena Jane Ford Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 13/04/05 Brief Description of the Service: Kahala Court is a large, detached house attractively 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. There is a large lounge and dining area and a secondary sun lounge, which is light and airy. There are currently nineteen single rooms and three double en-suite rooms although all are currently being used for single occupancy. All bedrooms have en suite facilities. The home’s environment is maintained to a high standard throughout the home. The home currently provides accommodation for up to twenty five residents who, in the main, remain mostly independent and able to take advantage of the nearby local community facilities. Since the last inspection further upgrading works has resulted in the creation of three new single en-suite bedrooms from accomodation that was previously unregistered. This will have the effect of increasing the homes registration from 25 to 28 once the completion of works have been formally agreed by this Commission. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on a Friday morning/afternoon. Opportunity was taken to tour the premises, which incorporated an inspection of the newly created three single bedrooms, examine some records and policies and talk with the manager, some residents and staff as well as a visitor to the home. Staff on duty were also observed, whilst in the course of undertaking their daily duties. All required core standards were inspected at the last inspection in April 2005. Those inspected on this occasion concentrated on resident welfare on a day to day basis as well as some general environmental standards. What the service does well:
Kahala Court continues to provide a comfortable, secure, well maintained environment, where residents’ individuality is encouraged and upheld. Basic residents’ rights, such as dignity, respect and privacy are also upheld and this was confirmed by the residents themselves The residents continue to receive excellent meals, visitors continue to be welcomed and encouraged, various daily informal activities continue to be made available and the local community invited to visit the home when appropriate/desired. The home views itself as part of the local community of Kingsbridge and the residents support several local charities and worthy causes within the town. The staff team continues to be well trained and therefore able to meet the needs of the residents, with the provision of appropriate training being ongoing. One of the homes real strengths remains the manager’s awareness of the need to ensure that the individual members of the resident group remain compatible with each other, and to this end the manager continues to take great care regarding the admission process to the home, taking into account the needs of both the current residents, as well as those of any proposed new resident. The residents spoken to again confirmed that their opinions are sought and that they felt very comfortable and well cared for within the home. The
Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 6 standard of care remains good with many of the staff members having been at the home for several years. The home, overall, continues to have a comfortable, welcoming atmosphere, where residents are able to choose how they spend their time. What has improved since the last inspection? What they could do better:
All hot radiators and pipe work in the house to which residents have access must continue to be guarded, to ensure that residents are protected form the risk of sustaining a burn.
Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 7 All hot water, provided to residents’ facilities within the home, must continue to be regulated to a safe temperature, to ensure that residents are protected form the risk of sustaining a scald. Locks should be provided to resident’s bedroom doors to ensure that residents’ rights to privacy are further enhanced. 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. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this occasion. EVIDENCE: Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Residents are looked after well in respect of their health and personal care needs. Residents are treated with dignity and respect and their individuality and independence maintained. EVIDENCE: During this inspection care plans were seen for one resident whose needs have increased considerably and for one resident who has recently moved into the home. Both were spoken with and the resident whose needs have increased was able to confirm that they were being very well looked after and were very comfortable within the home’s environment. It was also noted that support services were visiting the home and during the inspection the resident’s G.P visited and stated that all appropriate care was being given and the resident was being made as comfortable as possible. A MacMillan nurse was also noted visiting the resident and passing information to the manager and vice versa. The recently admitted resident was able to state that they had been able to have a short stay prior to choosing to live at the home and that all support had been made available at all times by the manager and staff.
Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 11 Other residents spoken to all confirmed that they were always treated with respect by the manager and staff and felt confident that both would help them with any area of their life that they needed assistance with. Residents’ privacy will be further enhanced with the planned provision, by March 2006, of door locks to individual residents’ doors. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 Residents continue to enjoy a peaceful, pleasant yet varied life at the home, with visitors encouraged and links encouraged and maintained at all times with the local community. EVIDENCE: Residents were noted as choosing how they spent their time with some spending time in their own rooms, others in the welcoming communal areas of the home whilst those able to, took themselves off for a walk or trip out with relatives etc. It was also noted that during the time of the inspection several visitors came and went and one relative spoken with, who confirmed that their relative was very well cared for and that she was always made welcome at the home when visiting. A particularly positive occurrence within the home, involved the fact that a relative had recently opened her house and garden to entertain the residents for a cream tea afternoon that had been enjoyed by all those that had attended. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Residents know how to complain and would be confident to do so if necessary. EVIDENCE: Residents confirmed that they would be confident in speaking to the home’s manager about any concern they may have and that they felt the manager would deal with the issue appropriately. The home’s complaint procedure was prominently displayed and included this Commission’s local contact details. There have been no complaints received by this Commission or the home itself since the last inspection. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this occasion. EVIDENCE: Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents’ needs are well met by an experienced and well trained staff group. Staffing levels are such that residents’ needs are well met. EVIDENCE: Residents stated that staff are always available to help them as necessary. They also stated that the staff group are kind and caring and this was confirmed on the day of inspection by observing staff undertaking their duties. They appeared confident, professional and approachable in the way they dealt with residents. The staff rota was observed and discussed with the manager and it was agreed that the current staff allocation is sufficient to meet the residents’ needs. When the resident numbers increase, due to the three extra rooms becoming available, the manager stated that staffing levels will also be adjusted and increased accordingly. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The manager aims to provide a safe environment through adhering to required health and safety checks. However, to ensure that residents are fully protected from the risk of sustaining a burn from hot surfaces, the programme already in place to cover all such surfaces that residents have access to, needs to be completed. Hot water, provided to residents’ facilities, should be regulated to a safe temperature to protect residents from the risk of scalding. EVIDENCE: The manager confirmed that health and safety issues continue to be well managed within the home. The home’s hot water supply is regulated where there are full bathing facilities. Although risk assessments are in place for any other areas i.e. hand wash basins these areas will now be regulated by December 2005.
Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 17 Not all hot surfaces, accessed by residents, are yet protected although there are risk assessments in place, and radiators within communal areas are now guarded and it is the owner’s intention to cover the remaining radiators/hot surfaces in residents’ rooms, on a priority basis by October 2005. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 19 YES Are there any outstanding requirements from the last inspection? 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. 1. Standard 38 Regulation 13 Requirement The registered person must continue to ensure that all pipe work and radiators to which service users have access are risk assessed and guarded or have low temperature services.(Previous timescale of 213/10/05 not yet expired). The registered provider must continue to ensure that all water outlets, including hand basins within the home, are risk assessed and the hot water regulated to 43 degrees Centigrade as required Timescale for action 13/10/05 2. 38 13 16/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 24 Good Practice Recommendations The registered provider should provide suitable door locks to individual residents bedrooms to ensure their rights to privacy are enhanced. Kahala Court D54-D07 S3726 Kahala Court V248447 160905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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