CARE HOMES FOR OLDER PEOPLE
Kay Court 368 Finchley Road London NW3 7AJ Lead Inspector
Ms Franki Solomon Unannounced Inspection 22nd February 2006 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.V283257.R01.S.doc Version 5.1 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.V283257.R01.S.doc Version 5.1 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.V283257.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th September 2005. 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 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.V283257.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory inspection for the year April 2005 – March 2006. The inspection was unannounced and was over a period of 3-1/2 hours. Since all of the key standards had been assessed at the last inspection, this inspection was to check on requirements made, to do a brief tour round the building, to observe staff and their interaction with residents. Kay Court has an active “Friends of Kay Court” Volunteer Group who have formed a formal committee to ensure the well being of residents and who organise fund raising for the benefit of residents, amongst other activities in the interests of residents. In recognition of the home’s care of a service user who had been resident at Kay Court, his son has made a substantial donation to the home which has been used to convert four bedrooms into three smart refurbished bedrooms with en-suite facilities. What the service does well:
Residents appear to be happy and feel confident to express their views freely. The home responds swiftly to requirements and also to recommendations. The home identified that one of the lifts needed constant repairs and upon evaluation decided to have a completely new lift installed so that residents may feel safe and secure. The home is in the process of redecoration in parts to give the home a face lift so that residents may enjoy pleasant surroundings. The “Friends of Kay Court” Volunteer Group has on their agenda to raise funds to obtain a 10-person mini-bus so that residents may have more outings. When the home received a substantial donation from Dr Lawson, they used it to convert four bedrooms into three bedrooms to include en suite facilities. The findings on this inspection was that the registered manager has undertaken a comprehensive audit of the home’s environment, management procedures and staffing competencies. Subsequently she has developed an action plan to make the home as smart and homely as possible for residents and to introduce reviewed systems in terms of risk assessments, recording, monitoring and auditing systems to ensure the safety and well being of the residents. Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 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.V283257.R01.S.doc Version 5.1 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.V283257.R01.S.doc Version 5.1 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): The key standards were assessed at the last inspection. EVIDENCE: Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 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): 8 & 9. Some residents needs are increasing which may not be met at the home and the registered manager involves appropriate professionals and consults with those residents and their relatives to ensure the safety of all residents. The key standards were assessed at the last inspection. Since then safe and secure methods are in place to ensure the health and safety of residents. EVIDENCE: The needs of some residents who have been at Kay Court for a long time are increasing. The registered manager is aware that Kay Court may no longer be appropriate. However, the suggestion to relatives that their elderly parent/relative may have to move on is met with resistance and concern. Relatives are not willing for their elderly parent/relative to move on from a familiar home. The registered manager ensures that the G.P. monitors their health and well being constantly. The registered manager has introduced an auditing system in terms of administration of medication so that residents’ safety is ensured. Medication is kept locked and the trolley is secured. In addition an order has been placed for a larger medication trolley.
Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 10 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): The key standards were assessed at the last inspection. EVIDENCE: Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 11 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. The key standards were assessed at the last inspection. Following a recommendation, the home’s complaints policy and procedure is easily accessible to residents. EVIDENCE: Residents have the home’s complaints procedure in their rooms available, so they and their relatives may know how to make a complaint. Before the last residents’ meeting, the deputy went round to the residents to enquire what items they wanted placed on their agenda. They were forthcoming and raised items about outings. The registered manager has raised this as a quality assurance item and the “Friends of Kay Court” Volunteer Group has become involved in fund raising for Kay Court to have a mini-bus so that all residents, including those who are frail, can have the type of outings they have identified. Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 12 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): 26. The home is free from unpleasant odours. EVIDENCE: The domestic staff clean the carpets daily to ensure there are no unpleasant odours in the home. Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 13 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. The home’s staffing ratios are adequate and their skills mix are appropriate. Following any incident, the registered manager responds quickly and appropriately to any deficiencies discovered in staff’s performance. EVIDENCE: Following an incident concerning some staff who had not followed the home’s policies and procedures, the registered manager immediately ensured appropriate action was undertaken, including internal investigation, disciplinary, as well as internal assessment and evaluation of all staff’s understanding, observance and follow-through of the home’s policies and procedures according to Social Care Code of Practice. The action from the registered manager was to ensure that the outcome would ensure the health, well-being and safety of residents. Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 14 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): The key standards were assessed at the last inspection. EVIDENCE: Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 15 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 x x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kay Court DS0000010337.V283257.R01.S.doc Version 5.1 Page 17 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
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