Inspection on 25/05/06 for Kahala Court

This inspection was carried out on 25th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 13/11/07

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 Judy Cooper Unannounced Inspection 23rd May 2006 10:15 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.V292187.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.V292187.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 01548 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.V292187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th September 2005 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. Since the last inspection the creation of three single en-suite bedrooms, from existing accommodation that was previously unregistered, has been finalised. This has resulted in the homes registration increasing from twenty-five to twenty-eight. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place on Tuesday 23rd May between 10.15a.m and 6.00 p.m. Opportunity was taken to observe the general overall care given to residents. The care provided for five residents was also followed in specific detail, from the time they were admitted to the home, which involved checking that all elements of their identified care needs were being met appropriately. A tour of the premises, examination of some records and policies, discussions with the manager, residents, and staff, as well as two visiting District Nurses, a visiting chiropodist and several visitors to the home, all formed part of this inspection. Staff on duty were also observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of six completed questionnaires from residents, four from the staff at the home, one from a local G.P, one from another health care professional and two from residents’ relatives, has provided further feedback as to how the home performs, and this collated information has been used in the overall writing of this report. All required core standards were inspected during the course of this inspection process. What the service does well: Kahala Court continues to provide a comfortable, secure, excellently maintained environment, where residents’ individuality is encouraged and upheld. Basic residents’ rights, such as dignity, respect and privacy are also upheld and the residents and, in some instances, their advocates were able to confirm this. The residents continue to receive varied, nutrious meals prepared to a very good standard. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 6 Visitors continue to be welcomed and encouraged, various daily activities continue to be made available and the local community continue to be welcomed into the home when appropriate/desired. The home views itself as part of the local community of Kingsbridge and to this end the residents involve themselves as they wish with local events. The staff team remains stable and well trained and therefore able to meet the needs of the residents. One of the homes real strengths is the management of the home. The registered manager has been employed for many years as the manager of kahala Court, having worked previously in a senior care capacity. She has an excellent knowledge, and understanding, of both the residents’ needs and of the staffs’ abilities to meet them and what training needs may be required to ensure the quality of care provided is of the best possible. All spoken with during this inspection, including residents, staff, and relatives and other professionals praised her leadership skills as well as her knowledge of residents’ needs and all felt supported by her. She, herself, is supported in her role by an experienced and efficient deputy manager and an experienced senior care staff team. The residents spoken to again confirmed that their opinions are sought and acted upon and that they felt very comfortable and well cared for within the home. The home, overall, continues to have a very comfortable, welcoming atmosphere, where residents are able to choose how they spend their time. What has improved since the last inspection? The Responsible Person has ensured that water temperature regulation is in place within the home, which therefore protects residents from the risk of scalding. The Responsible Person has ensured that all hot surfaces, such as radiators, are covered and therefore this protects residents from the risk of sustaining a burn. The Responsible Person has further ensured the efficiency of the home’s window restrictors, which again protects residents. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 7 The Responsible Person has provided a new chair lift to three stairs, accessed from the main, level hallway to a lower level hallway, where an entrance to the dining room is sited. This has allowed easy access for any resident that may have mobility problems. The registration of three new rooms has been finalised (September 2005) and the new rooms created have been finished to a very high standard. All are occupied. General, on-going, routine maintenance work, within the home, continues to ensure that the physical environment of the building remains at a very high standard. There are further plans in hand to imminently upgrade the home’s car parking area and walkway into the home. This will provide a smooth surface and eliminate the need for any chippings and so again further protect residents’ and visitors’ safety as well as make the whole area more visually pleasing. There are also plans in hand to provide a privacy lock to each resident’s door by the end of August 2006. There has been some additional in house training topics provided by the senior Court Group management in addition to the comprehensive training already made available, using their own in-house trainer. New areas of training have included such sensitive topics as death and dying which helps ensure that staff are prepared for all needs. The fact that the staff provide a good standard of care was confirmed by all those spoken with during the inspection process who gave very positive feedback as to the overall care given. What they could do better: The management of this home has met all the previously required requirements and has strived to ensure that the minimum standards are now fully met. To this end no requirements or recommendations have been issued as a result of this inspection. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 8 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 DS0000003726.V292187.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 Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality in this outcome area is good. The admission process continues to be well managed and residents and/or their next of kin/advocate are given clear information regarding the service prior to admission so that they can make an informed decision. EVIDENCE: Since the last inspection the home has admitted several new residents including a respite resident. Two of the new residents were talked with, as well as the respite resident. In all three cases the admission documentation was fully inspected. In respect of the two permanent residents their relatives were also available to speak with. Verbal feedback from one relative included the following comment “I found the placement for my Mother and I have been absolutely delighted with the care given, we feel so lucky that she is at Kahala Court”. Following these discussions, and observing documentation in relation to the admission process, it was concluded that the admissions had been undertaken in such a manner as to allow the residents and/or their next of kin/ advocate Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 11 to be aware of what services the home could offer and, following on from a pre admission assessment undertaken by the manager, know that the home was able to subsequently meet their needs. The manager had visited the residents, whenever possible, prior to the admission and there was detailed evidence of in-depth pre admission assessments as well as liaisons with other professionals that had taken place at this point. In the instance regarding the respite resident, a pre-admission visit had not been possible due to the immediacy of the placement; however there was close communication with the resident’s immediate carer to ensure the placement was in order and these details had been documented. Random selected residents also gave written feedback indicating that they had been given sufficient details to enable them to make an informed choice and, if able, they had undertaken a visit to the home prior to admission whilst a visit to their address prior to admission had also been carried out by the manager when necessary i.e. if they were unable to visit the home. The prospective residents and/or their families had been given access to necessary information, including the home’s statement of purpose. Relevant contracts were in place for all of the residents, which also included up to date fees. In the case of the newly admitted respite resident, discussions had taken place with the local G.P and the resident’s family as well as Social Services regarding the placement but a formal contract had not been drawn up. The home does not provide an intermediate care service. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is excellent. All residents are looked after very well in respect of their health and personal care needs. Residents’ privacy and dignity is upheld and their life style choices fully respected. EVIDENCE: Care plans were seen in respect of the four permanent residents who were case tracked. The care plan for the respite resident was in the process of being drawn up as the admission had only recently taken place a few days prior to the inspection. The care plans examined were thorough and covered all required care needs as well as social and psychological needs. There were appropriate risk assessments in place including a moving and handling assessment, a pressure area risk assessment and a self medication assessment (where appropriate). One resident, who wanted to, had been fully involved in the drawing up of their care plan and continued to be involved in the regular monthly review process. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 13 For the others, the management of the home had taken on this role, which the residents had chosen as being the way they wished their plan of care to be reviewed, not wanting, themselves, to be involved regularly in this process. However it was pleasing to note that the residents and/or their next of kin/advocate were fully aware of their care needs and knew what steps were being made to meet these and what changes had been noted. An example of this involved the way the home’s staff were successfully managing to care for one resident’s newly presenting continence needs, involving both the resident and the resident’s next of kin, whilst still fully ensuring the resident’s dignity was upheld at all times. The resident’s next of kin had nothing but praise for the sensitive way this particular issue was being dealt with in relation to her relative. The residents’ health care needs were known and were noted as being appropriately provided for, including any specialist needs. Medications were well managed with any resident, who self medicated, being supported in this and their ability to continue to undertake this, being risk assessed regularly. The home’s medication cupboard was inspected and the home’s medication procedures were noted as being in order with medications stored and administered appropriately. The home receives regular visits and advise from its supplying pharmacist. Other professionals are also asked for advise as required. During the inspection two visiting District Nurses were spoken with and gave the following verbal feedback: “The manager and staff communicate well with the District Nurse services as well as the residents. The management and staff are always willing to take and act on any advice given. They are good at identifying any clinical needs i.e. if someone looks like they could be developing a pressure area. There is always someone around to give help and the staff are very willing”. Both District Nurses also stated that they felt the care given was excellent. A visiting chiropodist was spoken with and stated the following: “ Kahala Court is a good home and residents are well cared for”. She stated that when she spoke with them individually they always said how well they were looked after. The home’s accident book was inspected and all details were noted as being in order in relation to two recent accidents that had involved the residents being admitted to hospital. All residents’ individuality and dignity was noted as being upheld throughout the inspection and all the residents spoken to confirmed that this is always the case. One resident pointed out that “it wasn’t just for show, but that staff were always excellent”. An example of this involved the manager discreetly ensuring that a resident who has some social problems when eating is still able to have their meals within the homes communal dining room setting, but in such a way as to not cause embarrassment to themselves or discomfort to other residents but still is able to benefit from the social atmosphere of this communal time. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 14 Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 12,13,14,15 The quality in this outcome area is excellent. Residents continue to enjoy a peaceful, pleasant yet varied life at the home, with visitors encouraged and welcomed, whilst links are maintained with the local community. Various daily activities are made available. Nutritious, well planned and presented meals continue to be provided. EVIDENCE: All residents spoken with stated that they were happy at Kahala Court and enjoyed living there. Visitors are welcomed and come and go as they wish. Several were noted as visiting during the inspection. Residents are encouraged to be as independent as possible with help available if required. Individuality is upheld by the staff and it was noted that residents chose exactly how they spent their time, with some coming and going quite independently. The management of the home have recently asked all residents for ideas as to what activities they would like to see. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 16 Following on from this a new activities programme has been provided which is based on the residents in-put. Those that are less able are provided with activities that they are both able to benefit from and enjoy. On the day of inspection two frailer residents were enjoying a game of dominoes with a more able resident. The staff were supporting the more frail residents in a very discreet manner, thereby allowing all to enjoy the game, whilst still maintain their dignity. The Court Group have just introduced a three monthly quality auditing of the activities that are being made available, to ensure that they remain as residents want and allow for residents to have a say on what is put in place within their home. One resident is enabled to smoke, as although the home operates a “No Smoking” policy, a covered outdoor area is available and staff helps in this, as the resident is a little unsteady on her feet. One resident who has some mobility problems stated that she felt that staff allowed her the time to mobilise as she could, even though this took time. This helped her retain her independence, within the home, enabled her to independently choose how she spent her time, i.e. if she had stated that she would be walking to the dining room staff were alerted to this and made sure her lunch etc was kept warm etc. All visitors to the home confirmed that they were always made welcome and it was noted that they all received a warm and personal greeting. Meals provided remain good. All residents spoken with stated that they enjoyed their meals and that there was always choice available if they wanted to have something different. The meal on the day of the inspection was appetising, hot and well presented and was enjoyed by the residents. Those residents that required some additional support with feeding were provided with this help in a sensitive and gentle manner. Two feedback comments from residents included the following: “The food is good home cooking, simple but of good quality” “The meals are very well cooked and in plentiful supply”. The relative of a resident that was case tracked was able to confirm that the resident had put on weight since coming to live at the home due to the good food, something which had been viewed very positively by all concerned. The cook has been at the home for over several years and takes pride in the planning and serving of quality meals. The provision of a new cooker within the home’s kitchen has aided the cook with this. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality in this outcome area is good. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint policy remains communally displayed and is also contained within the home’s statement of purpose and other home’s documentation. Residents spoken with were clear as to how to complain and felt they could easily approach the manager or any staff member should they have any cause to. Returned questionnaires from some randomly selected residents indicated that they were aware of the home’s complaints policy and would feel confident to speak to the manager if necessary with such comments as “the manager repeatedly informs residents of whom to speak to if you are not happy”. All staff receive vulnerable adult training on a regular basis. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 19,26 The quality in this outcome area is excellent. Kahala Court is very comfortable, clean, well maintained and provides a safe standard of accommodation for the residents. EVIDENCE: The tour of the home confirmed that the Responsible Person maintains excellent environmental standards within the home. Routine general upgrading continues to take place, including re-decorating, refurbishment and re-carpeting etc. On the day of site visit the Court Group’s full time maintenance person was in the home, undertaking routine upgrading work. Since the last inspection in September 2005, several bedrooms have been refurbished, with the provision of some new updated ensuite facilities, whilst one room has been completely upgraded, including the raising of the room’s ceiling. The resident in the room was clearly delighted with the new works and was proud to show her room off. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 19 Level access has been provided to the home’s dining room with the provision of a chair lift to four steps, within a corridor, running parallel with the dining room and the opening up an old, previously not utilised, doorway to allow additional easy access to the lower part of the dining room. This is in addition to the existing entrance, through the home’s lounge area. The manager maintains the home’s fire precautions in line with the requirements of the local fire department. The home’s fire log book was inspected and found to be in order. During discussions with the residents it was evident that they were also aware of the need to maintain a safe environment and understood that there was a need to keep fire doors closed. Privacy locks to residents’ bedroom doors are in the process of being fitted. Each resident has had a room risk assessment undertaken which included details regarding the fact that water regulation and the covering of any hot surfaces (i.e. radiator) were now in place. The home presented as very clean and feedback given from various parties, during the visit, indicated that this was normal. There were no unpleasant odours what so ever throughout the home. The laundering needs of the residents are met appropriately with new improved laundry equipment having recently been provided which ensures that all residents’ laundry needs can be undertaken as effectively as possible. During the visit staff were noted as observing routine health and safety procedures, such as using gloves and washing hands which helps prevent any unnecessary cross infection within the home. New polices have been introduced where it is thought that this may help staff to ensure that the risk of cross infection is controlled, an example of this being the introduction of a blood spillage policy. Staff have also received cross infection training, with some further planned. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the residents’ needs at all times. EVIDENCE: All residents and visitors spoken with during the site visit confirmed that the staff cared for the residents well. Staff were also noted as being well presented and polite. A feedback comment stated that” independence is encouraged but help is always readily available”. The staffing rota was inspected and it was noted that there were sufficient staff rotered on duty to provide the necessary care. It was pleasing to note that the staffing hours are adjusted, as required, taking into account resident numbers. When the home has over twenty-five residents there is an increase to two waking night staff from the one waking and one sleeping when resident numbers are less than this. Training is provided regularly. Recent training provided has included updated statutory training provided for staff on the 9th May which included such areas as fire safety, moving and handling, health and safety, challenging behaviour, care of the confused and food hygiene. Running along side of this is the provision of NVQ level 2/3 training in care with 75 of the current staff being trained to these levels, whilst other staff Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 21 have been accepted to commence the training in September, including a currently employed overseas worker. The Court group, overall, is to introduce a newly amended induction training programme, which will have the benefit of involving the staff member involved in a more interactive training programme. This level of training ensures that staff are both appropriately trained and consequently able to provide suitable care for the residents at the home. Staff records for the three staff members, employed since the last inspection, were looked at in detail. The robust recruitment procedures within the home ensure that there are suitable staff working within the home and that residents are protected. Staff on duty were spoken with and it was evident that they took pride in their role and felt that ensuring residents had a good quality of life, irrespective of need or diversity, was the most important part of their role. All staff spoken to felt well supported by the manager and there were written records of the supervision that had been provided by the management to each staff member. There are also regular staff meetings held with minutes kept. Information that may be useful to staff, including the Court Group’s corporate strategies are made available to all staff, which allows them to have an awareness of all issues surrounding their roles and a pride in their role. The manager had recently also undertaken each staff member’s annual appraisal where their whole performance was assessed and discussions took place as to how best their strengths could be best used and any weaknesses built on. The home maintains a very stable staff group, which allows residents to feel secure and confident of the carers’ ability to care for them. All residents, and others spoken with, were very complimentary about the staffs’ abilities to provide good care. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality in this outcome area is excellent. The home is managed efficiently and well, with the manager being easily available and approachable. The registered manager undertakes her role very professionally and has an awareness of all residents’ needs and the staffs’ abilities to meet them. The home provides a safe, secure environment where residents’ safety and well being is maintained. EVIDENCE: The manager has achieved her Registered Manager’s Award. She has been in post for many years and is well acquainted with the day to day running of Kahala Court. She is well liked and respected both within the home by residents and staff, and by outside professionals and visitors to the home. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 23 All those spoken with stated how confident they were with her management of the home and how she led by example being always available, approachable and ensuring that residents’ needs are met on a daily basis, as well as planning for their long term needs/goals. The manager spends rotered some time working with residents on a daily basis providing personal care, as she was when this unannounced visit took place. From having this personal input with the residents she is very well acquainted with the residents’ individual needs. The manager also performs her management tasks efficiently and professionally maintaining all required records to an excellent standard. All records inspected were up to date, concise and detailed. The residents or the residents’ families/advocates deal with any financial matter. The manager does not deal with residents’ monies other than to hold small amounts as requested by residents or their families. There were detailed records in respect of these and the Court group senior management team undertake a monthly review of all monies held. This ensures residents’ monies are secure. A member of the Court group senior management team undertakes a formal monthly in-depth review of the service and provides both the manager and the Commission with a written record of this visit as required under regulation twenty-six. The manager holds three monthly residents’ meetings with the last one being held early in May this year. The Court Group Senior Management team are in the process of further improving their quality auditing approach to ensure that residents’ views are taken into account at all times. An example of this is the recently introduced auditing of the admission process for the residents, where newly admitted residents are invited to feed back on how they felt their admission went. These processes ensure that the home continues to be run in the best interests of the residents and continues to meet their needs at all times. The home’s annual development plan has also been made available and a copy for 2006-2007 was forwarded to the Commission for the home’s file following the visit. The manager confirmed that health and safety issues continue to be well managed within the home and records inspected supported this. The home’s hot water supply is now regulated throughout the home. All hot surfaces, accessed by residents, have now been covered. Both these measures help maintain residents’ safety at all times. Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 24 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 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 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 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 x x 3 Kahala Court DS0000003726.V292187.R01.S.doc Version 5.2 Page 25 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.V292187.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 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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