Inspection on 20/09/05 for Kay Court

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Kay Court 07/08/07

Kay Court 17/10/06

Kay Court 22/02/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kay Court 368 Finchley Road London NW3 7AJ Lead Inspector Ms Franki Solomon Unannounced Inspection 20th September 2005 10:30 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 Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 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. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 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 emoyo@jcare.org Jewish Care Miss Esther Moyo Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2004 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 Volunteer 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 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 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. 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. 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 overground at Finchley Station is close by as well as several bus routes. Parking is limited. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first annual inspection for the year 1st April 2005 to 31st March 2006. The inspection was unannounced. The inspection was over one day and took 10 hours. Time was spent in discussion with the manager and deputy manager, speaking with staff and service users. The remainder of the time was spent examining records, touring the premises and observing the interaction between staff and service users. The Commission sent out Comment Cards to service users and anyone involved with service users, including G.Ps and professionals from Healthcare. The residents appeared happy and confident. They interacted well with staff and staff were seen to be attentive and respectful to service users. The inspector found the staff willing, motivated and well informed about the needs of service users. The manager was keen to implement suggestions which would improve and raise standards for service users. The Registered Manager and the home have been complimented at previous inspections for the high standards achieved on various aspects. This has not changed. The standards in the home are still high and the manager and staff continue to maintain and improve on that. Conduct and Management of the home is exemplary. Two requirements and four recommendations have been made. The inspector would like to thank Management, staff and service users for their hospitality and assistance with the inspection. What the service does well: Staff’s performance is good and reflects on the satisfaction expressed by service users. Training to staff is given high priority to enable staff to be competent and deliver a professional service to service users. This is includes a programme of training on dementia for those service users who have lived at Kay Court for some time and whose needs are increasing. The manager has an inclusive style of management which enables staff to express, participate and share skills and experience to the benefit of service users. The manager leads by example and pitches in with general staff duties. This enables her to remain aware of staffs’ responsibilities first hand and keeps her in touch with service users on a daily face-to-face basis. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: 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. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 7 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.V250808.R02.S.doc Version 5.0 Page 8 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. (Standard 6 is not applicable. Service Users needs and preferences are appropriately considered in view of what the home can provide. This enables service users, relatives and interested person to be confident that Kay Court is a suitable home for them. EVIDENCE: The manager or appropriately trained staff undertake assessments of new service users to the home, together with the service user and their family or representative. A sample of assessments in service users’ care plans demonstrated that all procedures were in place and undertaken and reviewed. Service users confirmed they were involved in their assessments and signed off their care plans once they had been agreed, either by themselves or their relatives. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 9 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. There is a new comprehensive Care Planning format being implemented which requires some ‘fine tuning’ and when finalised should be easier for staff to use and read. The medication administration procedure is clear, but not adhered to. Service users are happy and feel respected and confident and their privacy is observed. EVIDENCE: The home is in the process of updating their Care Plans. More than 50 have been completed. The manager and deputy were working on a pre-planned format to personalise it to the home and to ensure the final Care Plan format was robust in order to ensure that individual service user’s each need (activities of daily living) was identified, that a plan of action was developed, how the service user’s plan of action would be implemented on an ongoing basis. The action plan will be dated with dates for future reviews. The inspector sat in on a handover of shifts with staff. Staff demonstrated good knowledge of service users. With the new format for the Care Plans, all staff should have a Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 10 clearer idea about the support and care required by particular service users. Arrangements were in place, and Service user records demonstrated that all relevant support services from health and local authority are accessed. Service users confirmed the home ensured they received appropriate services from external agencies as required or requested. Medication Policies and Procedures were in place. The manager had been at pains to ensure that named staff attend medication training covering a period of 12 days and which involved an exam at the end of the training. However, on inspection of a sample of the medication and administration charts, medication of one set did not tally. Also, the medication trolley was left unattended whilst the staff member in charge of the trolley was assisting a service user with their meal. Staff were seen to treat service users with care and attention and service users confirmed they felt respected and treated appropriately. A requirement has been made in terms of medication administration and auditing. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 11 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. Kay Court is a residential home for the Jewish people and as such provides specific support for the needs of Jewish people. The home welcomes relatives, visitors and friends at all times. Although the home has a good activities programme, some service users had a perception there could be more activities. The support to service users is caring, attentive and patient. The food is wholesome, nutritious and caters for individual diets as required. Meals are presented tastefully and in a pleasant atmosphere. EVIDENCE: Comment cards were sent to Health professionals. One returned said: “An excellent, well run home in my opinion”. Service users expressed their views freely. Some said they would prefer to be in their own homes, but knew they could not manage. Given another choice, they said they would choose Kay Court. Another said they did not like the food, and wanted the food to be “the way my mother cooked”. Another service user said “I think its wonderful here”, and another comment card from a relative noted: “We have been very satisfied with the care that has been given to *mother*. Thank you.” Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 12 Some residents said there were not enough activities. Generally everyone said they liked Kay Court and had no complaints. There seemed to be quite a few residents in the home on the day of inspection. The manager informed this was because the hairdresser visited on that day and service users remained at the home to have their hair done. In the morning there was a pianist with singalong songs and residents sang to old familiar songs. In the afternoon a second pianist came along and played different gentle tunes which the residents seem to enjoy very much. They asked him when he was coming back. The activities chart indicated various activities throughout the week, as well as visits to the theatre, and outings - a recent outing having been to Windsor Castle. Volunteers come in to do shows, as do students from Hampstead School. “Friends of Kay Court” Committee pay for additional activities and entertainment. The manager said that when outings or activities were on offer, not all service users wished to participate. One service user said he preferred to eat later; the manager advised that the service user had been offered to have their meal served at a later time, but they chose to have their meal when the rest of the service users ate. Menus were varied, and a menu card placed on each table with some floral decoration as in a restaurant. Linen tablecloths are used and the table laid in a smart manner. Different coloured tablecloths for the different meal servings are used. Food was served and presented in an appetising way. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 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 the following standard(s): 16 & 18 Complaints are dealt with quickly and resolved satisfactorily. Training is high on the list for staff and their knowledge on Protection of Vulnerable Adults (PoVa) is reflected in the staff’s service provision to service users. The home could find a way of reminding relatives of their complaints procedure. EVIDENCE: The inspector noted there were no complaints recorded since the last inspection. The manager advised this was because a) there were no complaints, and b) that any complaints received had been minor which were resolved immediately. A comment card received from one relative stated they were not satisfied with a certain item in the dining room. The issue was attended to satisfactorily. The manager should consider having some protocol for recording minor complaints, such as a ‘feedback’ book. A recommendation has been made. Arrangements were in place for the Protection of Service Users. The home has the Local Authority PoVa Guidelines, staff have received appropriate training and demonstrated their commitment and motivation to delivering a safe and supportive service. One comment card from a relative indicated they were not aware of the home’s Complaints Procedure although the inspector saw notices around the Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 14 home advertising the complaints procedure. A recommendation has been made. Service users said they felt safe and any complaint would be treated seriously. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 15 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 standard of the décor has improved since this inspector last inspected. The environment is well maintained and the home is, in the main part, pleasant and a homely place to live. The home is clean, pleasant and generally free from odour. There may be a level of staffing shortage in the catering side of the service. EVIDENCE: Except for one communal room which is used by three service users with high dependency needs, the home is comfortable and homely. The room mentioned is a through-room to an office, and used as the waiting room when the G.P. visits and is not homely or pleasant in appearance. This was discussed with the manager who anticipates having a refurbishment programme for the room. Throughout, the home was clean and hygienic except for a small area outside a toilet opposite the manager’s office where there was some unpleasant odour. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 16 A comment card received from a relative advised they had had reason to complain to Kay Court about the lack of cleanliness of a trolley and the dining room. In discussion with management, the matter had been attended to immediately. However, this could be a reflection on staffing numbers in the kitchen. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 17 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. Service Users benefit from a well balanced staff team who are appropriately trained, experienced and who are competent in meeting their day to day needs. The home ensures service users’ safety. EVIDENCE: The home is staffed 7 days /24 hours over three shifts. On the morning shift there are 2 Team Leaders and 7 Support Workers. The afternoon shift has 2 Team Leaders and 6 Support Workers. The Night Shift is covered by 1 Team Leader and 3 Support Workers. This does not include the Manager and Deputy Manager. The Manager has the required Manager’s NVQ – Level 4 Certificate and the Deputy is in the process of undertaking the required NVQ training. Jewish Care also has a maintenance operative who undertakes the on-going maintenance of the building. Contracted staff are responsible for all other services required: • 4 Domestic Staff (including 1 part-time evenings) • 2 Laundry Staff • 4 Catering Staff – Hotel Services Manager, 2 Chefs and 2 General Assistants. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 18 The sample of staff files confirmed that Jewish Care had undertaken all necessary checks to vet staff before employment to ensure the safety of service users. Arrangements were in place for the Protection of Vulnerable Adults (PoVa) in terms of Policies and Procedures, and staff confirmed their training in PoVA. The training profile was seen. All arrangements for training were in place. Almost all Kay Court’s staff (over 50 ) have appropriate National Vocational Qualification (NVQ) certificates and since some of the residents are confused, staff have received “Introduction to Dementia” training and further training on dementia is in the pipeline. The manager had introduced a more inclusive and sharing forum for the handover procedure of shifts. The inspector sat in on the handover. All staff contributed, and demonstrated good team working. Staff demonstrated motivation and commitment and expressed their appreciation of the training received. Staff satisfaction should have positive effects for service users. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 19 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): 31,32,x 33, 35 & 38 The Manager and Deputy are skilled, well qualified and have an open and inclusive approach to staff management. Regular supervision, as well as the encouragement from the manager for staff training enhance staff skills and knowledge. Staff morale continually progresses and consequently they share their knowledge and skills to the benefit of service users. Service Users’ financial interests are protected and the staff are committed and motivated to ensure the safety and welfare of service users. Kay Court ensures the safety of their service users and staff. EVIDENCE: The Manager and Deputy Manager are both Registered General Nurses. The Manager has the required Manager’s NVQ – Level 4 Certificate and the Deputy is in the process of undertaking the required NVQ training. During the shift handover the open and inclusive management approach was demonstrated by Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 20 staff’s participation and contribution of information on service users. The sharing and open discussion was in the interest and benefit of service users. Records demonstrated regular and consistent supervision and was confirmed by staff. A check of a random sample of residents’ finances proved accurate. All Health & Safety, Policies and Procedures and Service documents were in place and current. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 21 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 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 x 3 x x 3 Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 22 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. 1 Standard 9 Regulation CH13 Requirement Timescale for action 29/10/05 2 26 OP26 The Registered Person must ensure that staff adhere to Administration of Medication Policies and Procedures, and implement a frequent and regular audit of Medication Administration. The medication trolley must not be left unattended when unsecured. The Registered Person must explore more secure means of holding medication which was at the time of inspection in an open cardboard box. The Registered Person must 01/11/05 ensure the home is kept free from odours. The inspector acknowledges the odour was mild and in a small area. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Kay Court Refer to Good Practice Recommendations DS0000010337.V250808.R02.S.doc Version 5.0 Page 23 1 2 3 Standard 16 18 19 4 26 The Registered Person may consider having a notification of the Complaints Procedure in Service Users’ room. The Registered Person may consider introducing protocols for communication from staff and recording minor complaints such as a “feedback” book. The Registered Person could review the layout of the communal room adjacent to the rear office. The revised layout could also take account of the safe storage of equipment. The Registered Person could evaluate the staffing levels of the kitchen staff. Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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. Extracts may not be used or reproduced without the express permission of CSCI Kay Court DS0000010337.V250808.R02.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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