Inspection on 16/01/06 for Kay-sera-sera

This inspection was carried out on 16th January 2006.

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-sera-sera 22/01/09

Kay-sera-sera 08/01/07

Kay-sera-sera 24/08/05

Kay-sera-sera 03/02/05

Kay-sera-sera 08/09/04

Kay-sera-sera 10/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kay-sera-sera 7 Willowbrook Derrington Stafford Staffordshire ST18 9NN Lead Inspector Mrs Wendy Grainger Unannounced Inspection 16th January 2006 09:30a 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-sera-sera DS0000005087.V276720.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-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kay-sera-sera Address 7 Willowbrook Derrington Stafford Staffordshire ST18 9NN 01785 244684 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) Mrs Jennifer Elizabeth Lucas Mr Michael Patrick Lucas Mrs Jennifer Elizabeth Lucas Care Home 4 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (4) of places Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2005 Brief Description of the Service: Located on the periphery of the town of Stafford and in the village of Derrington Kay Sera Sera can be accessed by a public transport route. The home was registered to provide accommodation for three older people, two of who have a mental frailty. Kay Sera Sera is located near to a shop and post office. And is the family home of the providers Mr & Mrs Lucas. The home was extremely comfortable, each of the service users were provided with exceptional personal space for their daily life style. There were two large lounges and an area at the head of the stairs that one of the service users prefers. Each of the service users were provided with a bathing facility off their bedroom or within the shower room on the ground floor. Access to the home was via a short flight of steps or via the ramp, which was fitted with a substantial hand rail. Mr & Mrs Lucas takes the time to provide the service users with a pretty patio area at the rear of the home. Since the previous inspection the home had increased its service users capacity to four. The extra bed will be offered for respite care only. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed with the providers and residents on the morning of the 16 January 2006. Comments from the residents including one resident who was receiving respite care were very favourable with “ we have good food here that why I look good” “ I keep returning because the home and care is excellent” “All my needs are met and “Jennie”& Mike” look after us so well”. Located in a quiet part of the village of Derrington the home was maintained to exceptional standards both in personal space, comfort and hygiene. Two of the three residents at the time of this inspection self-administer their medication, one person is not prescribed medication and the remaining person was administered one tablet by the providers. Accommodation is located on the first floor each of the present residents were able to manage the stairs. Each resident had access to personal bathing and shower facilities; this included the respite facility. Arrangements were in place for the continued health care of the residents including any respite person. The respite person confirmed that arrangements had been made for her to visit the local surgery later in the day. An assessment of an individuals needs would be carried out prior to an admission. Catering would be prepared from a menu based on home cooking; based on individuals likes, recognising dislikes. Having a small number to cater for the providers demonstrated a well balanced diet with items such as duck & trout. At the time of this inspection the providers were the main carers for the day, The staff team were employed on a part time basis to meet the resident’s needs. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 6 What the service does well: 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-sera-sera DS0000005087.V276720.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-sera-sera DS0000005087.V276720.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): 1,3,5 The appropriate information to make a placement was provided by the owners of the home. Appropriate arrangements were in place to comply with the admission process. EVIDENCE: The Statement of Purpose contained the appropriate information to ensure that a person could make an informed choice regarding a placement. Mr & Mrs Lucas had an admission process, which included pre admission assessments for respite care. The home provided a respite care service; this facility was well accessed by regular people from the Community. Kay-sera-sera DS0000005087.V276720.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): 7,8,9,10 Arrangements were in place for the residents to access professional care agencies when appropriate. The home had simplistic care plans with the required support recorded. The system for medication administration remained unchanged and satisfactory. EVIDENCE: Samples of the care plans were evidenced during the inspection. The providers maintained a simplistic format for the information where resident support was recognised and addressed. At the time of this inspection a general practitioner had recently seen one resident. The respite person was to attend surgery on the afternoon of the inspection. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 10 Medication was very limited at Kay Sera Sera, with only one person administered by the provider, the remaining residents including the respite person were not prescribed medication or self administered. The daily record was current and satisfactory. Personal care continued today, with two residents assisted with showers. There were no employed staff on duty today; the providers were the main carers. Each of the residents spoke highly of the providers to the inspector and their commitment to their life style. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 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 15 The chosen life style of the resident group continued while being supported by the providers. EVIDENCE: The residents at Kay Sera Sera were very individual in their social life style. One preferred only to leave the home with friends and chooses to remain in her room. One resident continued her life style as prior to being admitted to the home. She continued to meet friends and attend local clubs and church. The remaining resident went out with the providers, into Stafford or the local area. Visitors were welcome at the home at any time; the door often opened by a resident, this custom was part of the continued life style of residents. The menu for the week was recorded in the diary, records evidenced that the providers offered a balanced varied diet; home cooking was a priority. Residents had the option to experience trout and duck. Residents commented on the food and the excellence of it. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 12 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 Residents and visitors had full access to the home complaint process. The care practices and experience protected the residents. EVIDENCE: The Commission or providers had received no complaints since the final registration of the home approximately eight years ago. The residents and visitors were made aware of the complaints process verbally by the providers and via the written documents. Residents were protected by the care practices of the staff and providers via training and experience. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 13 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): 19,20, 23,24,25,26 Residents at Kay Sera Sera live in a safe, comfortable environment with quality fixtures and fittings. EVIDENCE: Located in a quiet area of the village of Derrington, the home offered care to older people. The home was in an exceptional condition both in decoration, and quality fixtures and fittings. Each of the residents had the option of personal daily space. Bedrooms were located on the first floor, with the exception of the respite ensuite room on the ground floor. Bathing and toilet facilities consisted of five separate toilets, two showers plus two bathrooms. The home was comfortable light, well ventilated and warm. The well fitted kitchen is off the entrance hall, located at the rear of the home was the utility room. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 14 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): 27,28,30 The providers were fully aware of the robust procedures required for employment of staff. Experience and training ensured that the residents were well cared for. EVIDENCE: At the time of this inspection no employed member of the staff were on duty, Mr & Mrs Lucas were the main carers for the day. The providers worked as part of the staff team to provide personal and social care. Mr & Mrs Lucas were aware that they needed to update their Moving & Handling training. This was being explored with another home in the area. This home was contacted they were waiting for a date and will contact Mr & Mrs Lucas. Other staff worked at other residential homes and continued with the obligatory training. Mrs Lucas would be informed when this had taken place, to update her records. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 15 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): 32,33,36,38 The home was operated in the best interest of all the residents. The providers ensured that each person was recognised as an individual, and respected their rights. EVIDENCE: The providers worked as a team and as part of the staff team to provide quality care. Each person was recognised as an individual. The rights and life style of residents was encouraged. Verbal feedback and cards sent by grateful clients and families were part of the quality assurance process. The records in the event of fire, room temperatures, water and smoke alarms were recorded weekly and evidenced in the records. Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 16 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 3 X X X 3 3 Kay-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 17 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-sera-sera DS0000005087.V276720.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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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