Inspection on 07/08/07 for Kay Court

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 17/10/06

Kay Court 22/02/06

Kay Court 20/09/05

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 Pippa Canter Unannounced Inspection 7th August 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kay Court DS0000010337.V333594.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. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 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 Margaret Ofori-Koree Care Home 56 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (56) of places Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2007 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, 18 of whom can have dementia 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 level of fees will be recorded in the final report. 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. This annexe provides a Dementia Care Unit 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 over ground at Finchley Station is close by as well as several bus routes. Parking is limited. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day, which lasted from mid-morning until mid-afternoon, about six and a half hours in total. The manager was available and assisted the inspector along with additional input from staff on duty, visitors and people living in the care home. Records such as care plans, assessments and menus were examined. The care plans were also cross-referenced with other records, such as complaints and accident and incident reports. A partial tour of the building was made. Four service users were asked for their views of the running of the service and talked about their experiences of being in the home, though some were unable to give them due to their level of disability. Staff were observed fulfilling their roles and responsibilities and were involved in general discussion with the inspector. Service users and staff were spoken to during both, and lunch was observed being served during one of the unaccompanied tours. Some staff were asked about aspects of care, and of their experience of working at the home. Staff recruitment, supervision, and training records were examined. Prior to the inspection we looked at all the information we had about the home, including notifications of accidents or serious incidents and previous inspection reports. The manager had returned an Annual Quality Assurance Assessment, which confirmed some useful information about the service. Comments cards for service users and relatives were left for collection in the home. Sic residents and two relatives returned surveys. Other surveys were sent out to Care Managers and a GP surgery and Commissioning agents but to date these have not been returned. Any feedback received is reflected in this summary as well as the main body of the report. We reviewed all the evidence and it has allowed us to form a judgement about the outcomes for people living in the home. At the end of the inspection, general feedback was given to the manager. A feedback form will be sent along with the draft report so the manager can let us know how she felt about the inspection process. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements were set at this inspection. The manager clearly demonstrated that she knew the areas in which to make more improvements These were clearly outlined in the annual quality assurance assessment. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their needs will be fully assessed and their needs and aspirations will be recognised and met. EVIDENCE: A total of four care records were examined. The people had been admitted since the last inspection. People were asked about their experiences during the admission process. All four care records examined contained pre-admission assessments. Those referred by Social Service Departments, had copies of assessments and care plans under the care management process but the home had also completed a pre-admission documentation that was detailed enough to ensure all needs would be addressed on entering the home. All the surveys returned confirmed that there had been sufficient information available about the Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 10 service before admission. Discussions with service users in the home confirmed that they had been supported and not overwhelmed by the admission process. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is continuous assessment, care planning and review which makes sure that the personal and healthcare needs of the people living in the home are met EVIDENCE: A sample of four care plans were examined, which included looking at the daily recording for the previous three weeks. The care records included medical conditions, recent admissions and people with cognitive impairment. In each case we met with the person concerned but could not discuss their care with them in all cases. Relatives were also asked for their feedback. A comparison was made between the care recorded in the records and the care being received by each resident. A sample audit was taken of the medication administration systems. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 12 All care plans were found to be up-to-date and reflected the needs and wishes of each individual service user. The care records were comprehensive and important health and personal care needs were clearly identified. Where additional assessments were indicated, such as manual handling, risk of pressures sores and nutritional risks, these had been carried out and were reflected in the care plans. From observation and discussion with people using the service is was clear that service delivery matched the care plans. As from previous inspections the care records clearly show referrals to and the involvement of other health care professionals. The records show that referrals are made to the Community Nursing Team and where staff have identified changes in condition or behaviour referrals have been made to the General Practitioner (GP). All service users are registered with a local GP. Entries in care records show clear evidence of collaborative care with interventions from Occupational Therapist, Physiotherapist, Chiropodist, Dietician and a Tissue Viability Nurse. Dental and Optical needs are also addressed. A sample audit only was taken paying particular attention to the medication administration records of the people being case tracked. The audit identified that the staff are accurately recording of the receipt, administration and disposal of medication. Observation on the day of the site visit, discussion with staff, feedback from people using the service and the examination of the care records confirmed that staff respect the privacy and dignity of the people they look after. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Kay Court continues to meet the cultural and religious needs of the people who live there. Arrangements are in place to make sure the health care needs of the residents are taken care of. EVIDENCE: This is a faith specific home. The home continues to welcome people whatever their level of religious observance. As a Jewish home, a Jewish atmosphere is encouraged and Shabbat and all festivals are marked in the traditional way with service held in the home. Service users confirmed that no one is obliged to attend services. With a multi cultural staff, the manager encourages an exchange of cultures and understanding. Staff attend training in order to learn about the Jewish culture and are instrumental in ensuring that service users are able to follow their own faith and culture. Although a synagogue is available on the premises, transport is arranged for them to attend a place of worship in the community. As a Jewish faith and culture is based on hope, the staff recognise that they need to approach the end of life decisions with sensitivity. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 14 The four care plans seen were comprehensive and included wishes and preferences. Work is in progress to gather all relevant information about people living in the service with cognitive impairment. The manager is working with relatives to obtain this background information. The care home makes visitors and relatives feel welcome as well as maintains a good level of communication with families. A comment received was “We have regular meetings for the relatives of residents with managers and staff.” A programme of activities is available and an activities organiser is in post. During the inspection, there were activities taking place. People living in the care home confirmed that they had a choice to join in the programme or not. One person commented, “Not interested.” The inspector continues to receive mixed comments from residents about the food served in the home. The “food committee” is still in existence. This is made up of people living in the home. Their role has been to develop new menus and to assess the quality of food and make recommendations for improvement. Of the six people who returned surveys, two made negative comments such as “Not very tasty. Could be better if made more carefully” and “Fried fish too crispy, dried up; chips cold and hard; soup is salty, peppery and watery; meat sometimes tough.” Feedback during the inspection was more positive and most people recognised that the subject food is very subjective and not everyone will be satisfied all the time. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints, incidents and accidents are being recorded. These records were cross-referenced with the care records of the people being case tracked. The accident reports were compared with the Regulation 37 notifications sent by the service since the last inspection. The home has a comprehensive complaint’s policy and procedure. The procedure is available to people living in the home and their relatives. All those who returned surveys confirmed that they knew who to speak to if they were unhappy. A complaint has been made and the manager is working with commissioners of the service to set up a meeting to resolve the matter. The service has a robust policy and procedure on adult protection, which is linked to local authority guidance. Staff have received training on adult protection and showed that they understood their role and responsibilities in this area for the safety and protection of the service users. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who reside in the home live in comfortable, homely and clean surroundings EVIDENCE: The environment of this home has always been judged as being good at previous inspections. A partial tour of the home found the home to be in good decorative order, well furnished and maintained. The home provides a safe environment for people who live there and they have access to a mature well laid out garden with sensory beds. On the day of the inspection, a number of people were able to enjoy the good weather by sitting on the patio area. A comment from a relative was, “At the moment I cannot see how they can improve. Lately they have been doing a lot to make the lives of residents comfortable.” Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 17 The home is CCTV protected, which provides security for people living and working in the home. The front door is locked but a receptionist is available during the busy times of the day to let visitors in. Improvements were noted since the last inspection and this includes appropriate signage in the Dementia Care unit and resident’s names and pictures mounted on the bedroom doors, where agreement has been reached. Overall the home was found to be clean and tidy. The home has an infection control policy. Clinical waste is stored in suitable containers and collected on a regular basis through contractual arrangements by a reputable collection agency. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service places great emphasis on recruiting appropriate staff who are in turn are provided with the training in order to meet the needs of the people living in the home EVIDENCE: People living in the care home made positive comments about the staff describing them as “very caring”, “always willing”, and “good at what they do.” We observed staff working with people, and generally they had warm and friendly relationships with those in their care. However the period of observation not only showed some good practice but also elements of poor interaction with residents on the part of staff. This has been discussed with the manager who will address staff performance. Training records showed that a training programme is in place and the manager has an ethos of creating a learning environment for staff. She plans to increase the level of in-house training to make sure that staff apply the knowledge and skills to their working environment. Recruitment records were looked at. All required documents were in place. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. The care home is being managed in the best interests of the people who reside there. EVIDENCE: The current manager has successfully completed the registration process. The manager has worked in the home before and has completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection. The information within the AQAA and further discussions with the manager during the site visit demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. There are clear lines of accountability and communication within the service. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 20 The judgements in preceding sections of this report have contributed to the judgement in this outcome area. The care home has a welcoming environment and promotes an open and transparent style of management. The company invests in the continuing developing of the staff team. People using the service are protected by the polices and procedures and the feedback feeds into any improvements to the service We discussed the arrangements for safeguarding of people’s personal finances. The conclusion was that the financial and accounting procedures are appropriately managed and monitored. A sample of health and safety records were looked at. These confirmed that the home is being managed responsibly with essential checks being made. The provider monitors health and safety in the home. There are robust procedures in place to monitor compliance. Equipment is serviced regularly and where required repaired or replaced. Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 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. 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.V333594.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kay Court DS0000010337.V333594.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!