Inspection on 24/08/05 for Kay-sera-sera

This inspection was carried out on 24th August 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-sera-sera 22/01/09

Kay-sera-sera 08/01/07

Kay-sera-sera 16/01/06

Kay-sera-sera 03/02/05

Kay-sera-sera 08/09/04

Kay-sera-sera 10/03/04

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Maple Lodge

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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 Wendy Grainger Announced 24 August 2005 9:00 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 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 E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 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 Lucas Mrs Jennifer Elizabeth Lucas CRH 4 Category(ies) of DE(E) 2 registration, with number OP 4 of places Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3 February 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 E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was completed on the 24 August 2005 the report was compiled from information provided in the pre inspection questionnaire, discussions with residents, staff and providers. The providers provided documents, records and reports. Four comment cards had been received, three from relatives one from a resident. One relative made no additional comments and was satisfied with the home and the care provided. other additional comments included “ Mrs O is well looked after the staff never grumble and she is well fed” “ my friend is extremely happy and comfortable, she really enjoys her food and loving care” the resident made no additional comment but was satisfied with all aspects of the home. Located in a quiet road in Derrington, Kay Sera Sera provides an exceptional environment, atmosphere and life style for three elderly people. At the time of the inspection the respite room was occupied, this person returns on a regular basis because of the care and support provided. Permanent resident accommodation is located on the first floor, the respite accommodation is off one of the lounges and is en-suite. The home maintained exceptionally high standards of hygiene, fixtures and fittings. A number of changes had been made since the previous inspection. Each one had taste and quality. No person would be admitted to the home unless Mrs Lucas had made a full assessment of his or her needs. She was fully aware of the homes category and the abilities of her staff; also consideration was given as to the compatibility with the other residents. Where necessary arrangements were in place to provide additional care from other professional agencies. The medication system remained unchanged; the system ensured that medication was secured in a locked cupboard and recorded when administered. Self administration was encouraged where possible. Mrs Lucas was aware of the need for a risk assessment. Catering was based on the likes and dislikes of the residents being a family extended home the menu can be more personalised. Home cooking was prepared wherever possible. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 6 The staff team works with Mr & Mrs Lucas by hours agreed to meet the needs of the residents. The staff team work at other establishments and received the mandatory training required. There were plans for Mr & Mrs Lucas to take Moving & Handling training. 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 E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 standard(s) 1 3 5 Standard six is not applicable to this home. Information provided by the providers ensured that prospective residents were aware of the facilities provided. The assessment process ensured that the home could meet the needs of individuals. EVIDENCE: The Statement of Purpose and Service Users remained unchanged. Both documents were available to any person visiting the home. No resident would be admitted to the home unless a full assessment of his or her needs had been carried out. Mrs Lucas would continue this philosophy for any respite enquiries. Any person enquiring about a respite stay was invited to the home to meet other residents and to view the home, meet the staff and providers. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 standard(s) 7.8.9.10. The home had contacts with the appropriate professional agency for continued care when necessary. The individual care plans identified personal needs to be addressed. The system used for the administration of medicines was satisfactory. EVIDENCE: Two care plans were seen today, one had been reviewed and evaluated further following an illness and slight change of needs. The respite care plan identified that the person was very self caring. Arrangements were in place for any of residents to receive assistance from any other professional agency. One person required contact with the continence advisor. Mr Lucas had fitted a new locked cabinet to contain the limited amount of medication prescribed. One resident plus the respite person self medicates, one is prescribed no medication and the remaining resident had one tablet daily. Records were current and accurate. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 10 Staff during the inspection promoted two residents mental agility by playing cards; one resident prefers to spend time watching television. The respite person had come to the home with her small battery scooter maintaining her social contact with the village. The staff had a warm, respectful manner assisting when necessary. They were very aware of the individual needs of residents. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 standard(s) 12 13 14 15 When entering the home there was a relaxed comfortable atmosphere where residents’ rights and life style was respected and encouraged. EVIDENCE: A person’s life style was promoted from their personal choice, one of the permanent residents had a very full social life, and this was enhanced with the providers providing transport when appropriate. Residents confirmed that they had a good life style and the respite person told the inspector that she would not go to any other home. The home is a family extended home and outside entertainment was not provided. The family of the providers visit and spend time with the residents. Families were welcome at any time. It was obvious from the evidence seen and demonstrated by the staff that residents were provided with quality care and support. The menus were printed and provided for the inspector, having a smaller client group the menus can vary from the printed menu. Food was based on the likes and dislikes of individuals and can be adjusted if necessary. The providers also enjoy the daily menu prepared. The fridge and freezer temperatures were recorded daily. Residents confirmed that the food was excellent and that they enjoyed their meals. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 standard(s) 1 6 17 18 The homes complaint process was made available to any person, the information provided was accurate; the procedure was easy to follow. EVIDENCE: The Commission had not received a complaint since the home was registered. Residents, families, visitors, staff had the applicable information to raise a concern with the providers or Commission. The residents confirmed that they were aware of whom to approach if they had a complaint. The inspector was provided with numerous letter/cards of compliments following the care provided at the home. Residents make a personal choice for election purposes. Staff and providers promote the awareness of any form of abuse via training and experience in the caring profession. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 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 standard(s) 19 20 21 23 24 25 Kay Sera Sera provided an exceptionally comfortable environment, contained in a homely setting. The internal and external areas provided ensured that residents had an abundance of personal space. EVIDENCE: Located in the quiet village of Derrington, Kay Sera Sera was registered to offer accommodation to four elderly people. Near to the local shop, the home provided comfort and quality surroundings. Personal spaces for individuals were outstanding; with each resident having their own lounge and en-suite. The home had well tended gardens, with quality garden furniture and shade. The home has five separate toilets, two showers, two bathrooms, each within easy reach of the lounges. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 14 Bedrooms were personalised to suit the people’s choice. Each bedroom exceeded the required sizes for registration. All areas throughout the home had large windows allowing plenty of light and ventilation into the rooms. Staff and providers were aware of the need to monitor infection control. Residents’ washing would be done in separate washes in the domestic style utility area. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 The home had in place appropriate procedures when recruiting any new staff. The levels of staff at any one time were deemed satisfactory for the number and dependency levels of the residents. Staff demonstrated their commitment to the care of the residents. EVIDENCE: The providers were part of the staff working team, available at night as the sleep in staff. The entire staff provided a package of care including housekeeping and catering duties. Three of the staff had level II NVQ in Care, other mandatory training had been provided. Mr & Mrs Lucas were to update their Moving & Handling training. The residents were supported by staff that were experienced and trained in the care of the older person. New staff employed had been checked to comply with the appropriate requirements. Mrs Lucas was to complete the Criminal Record Bureau checks in retrospect for other employees. These employees were employed in other establishments and had a current Criminal Record Bureau checks. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 33 35 36 37 38 The providers ensured that the residents were safe and secure in a home that operated for the benefit of the residents. The homes audit would highlight any defects within or external to the home. Relatives’ comments provided constructive details in respect of the quality care provided. The systems in place recognised the confidentiality of the residents. EVIDENCE: Mrs Lucas has been in the caring profession for a number of years. She is part of the working team and leads by example. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 17 The numerous letters and cards provided high praise for the staff, provider and care provided. There was limited contact with District Nurses and general practitioners. Residents personally attend their practitioners. The providers did not have the responsibility of personal finances. General and formal supervision continued complying with the requirements. Records seen today demonstrated that the required weekly checks on equipment were completed. Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 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 4 4 4 x 4 4 4 4 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 Standard No 16 17 18 Score 3 3 3 3 4 3 3 N/A 3 3 3 Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? 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 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. 1. Refer to Standard Good Practice Recommendations Kay-sera-sera E51- E09 s. 5087 Kay Sera Sera v 240814 240805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Stafford - 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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