Inspection on 08/01/07 for Kay-sera-sera

This inspection was carried out on 8th January 2007.

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 16/01/06

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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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 Key Unannounced Inspection 8 January 2007 09:30 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-sera-sera DS0000005087.V325338.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-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kay-sera-sera Address 7 Willowbrook Derrington Stafford Staffordshire ST18 9NN 01785 244684 F/P kayserasera@sagainternet.co.uk 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.V325338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 January 2006 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 permanent 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, one lounge recently had been converted into a ground floor bedroom. An area at the head of the stairs was where one of the service users preferred. 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. From the information contained in the pre inspection questionnaire the current fees for Kay Sera Sera is £ 353 additional costs would be for personal items. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this inspection on the 8 January 2007. The providers were on duty and assisted the inspector, as did the residents, visitor and respite person with the information contained in the report. A tour of the home findings from the examination of records, reports and comments received will be included in the contents of the report. At the time of this visit no staff were on duty for the morning. What the service does well: What has improved since the last inspection? Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 6 Since the last inspection in 2006 the home has had a new resident, the ground floor lounge has been transformed into a bedroom to enable the present resident to live a normal life style with his visual impairment. The on going decoration and refurbishment continues. The main drive had had tarmac laid and a tasteful wall had been built since the previous 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. The summary of this inspection report can be made available in other formats on request. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 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.V325338.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 1,3 were reviewed. This judgement has been made using available evidence including a visit to this service. The providers made available the service users guide, there was a separate information for respite care that can be provided for one person. No person was admitted to the home without prior knowledge and an assessment of needs. EVIDENCE: All assessment were seen at previous inspections. Since the previous inspection the home had admitted a new resident, the resident had on occasions chosen to stay on respite care. Due to a visual impairment the resident had a room on the ground floor. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 9 The Statement of Purpose and Service Users Guide were examined. The service users guide and the statement of purpose would be available to any person. There was a recommendation to include a paragraph on the provision of day care. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. Standards reviewed were 7,8,9,10. This judgement has been made using available evidence including a visit to this service. The care plans while simplistic in design identified the required support provided. Residents health and personal needs were met by the dedicated staff team EVIDENCE: One of the three residents continued to self administer her medication, there had been an increase in the provision of medication for one resident . Medication was stored within a locked cupboard in the kitchen; temperatures were satisfactory and the prescribed medication was stored satisfactorily. There was a recommendation to review the system used when family took medication from the home. Medication cannot be signed for by the providers it can however be identified that they have passed this responsibility onto the family. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 11 This small establishment has a dedicated staff team who work as a team with the providers who are the main carers to provide excellent personal care. Arrangements were in place for the continued monitoring and intervention if necessary from other professionals. The care plans for two residents were sampled, they were simplistic in design and continued to identify needs changes and support. While the new resident had been at the home only a very short time his care plan needs to include all the relevant details following his assessment. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is excellent. Standards 12,13,15 were reviewed. This judgement has been made using available evidence including a visit to this service. Residents choice for a social experience was recognised and respected. Visitors were welcomed at any time; contact with friends was encouraged. A varied menu based on residents choice and home cooking was provided. EVIDENCE: Resident’s option to remain in their rooms was respected by the staff and providers. One resident had his room specially laid out to ensure his safety due to a visual impairment. This resident had numerous visitors on a daily basis. His life style was enhanced with equipment located to hand to enjoy either music or novels. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 13 One resident continued to enjoy a full social life, she maintained contact with the local church, clubs and friends who visit. This resident had an avid interest in craft, and was encouraged to continue her tapestry, knitting. During the inspection visitors came to see one residents he, had visitors daily sometimes more than one person arrived. Mrs Lucas was the catering person for the day, the meal being prepared was observed at the commencement of the inspection. The meal was a roast, accompanied by a selection of vegetables including fennel; this was to be followed by a hot pudding and custard. Each of the residents told the inspector that the food was excellent all home cooked and served to suit their preferences. Meal times for some days were more flexible to fit in with individuals’ social life style. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. Standards 16,18.were reviewed. This judgement has been made using available evidence including a visit to this service. Residents were provided with the appropriate information to exercise their option to raise concerns. The priority for the providers and staff was to protect the residents. EVIDENCE: The new resident confirmed that he had been informed about the complaints process and would speak to the providers if he had a concern. The complaints procedure was maintained in the Service Users Guide. The staff employed at the home worked in other residential establishments, they were fully aware of the need to protect and care for the vulnerable adults in their care from training programmes provided. Staff have stated at previous inspections that they had received training. The providers maintain a copy of the certificates provided following training. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Standards reviewed 19,20,21,23,24,25,26. This judgement has been made using available evidence including a visit to this service and including a tour of the home. Residents were provided with exceptional surroundings, quality furniture and fittings were well maintained. The home has exceptionally high standards of hygiene throughout. EVIDENCE: Each of the residents were provided with exceptional personal space, which included an en-suite and other ground floor shower/toilet facilities. The bedroom used for respite also included an en-suite bathroom. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 16 The providers had a continuous on going programme for the renewal and redecoration of the home. The home was maintained to an exemplary high standard. The large ground floor lounge had been transformed into a bedroom for the new resident. He had access to all the ground floor facilities. The home internally and externally was well maintained, since the previous inspection the external façade had been upgraded with a tarmac drive with a tastefully wall being built. The first floor landing had been set out as a lounge/dining room area for the resident who prefers to remain upstairs. High standards were maintained throughout the home. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards reviewed were 27 28,29,30. This judgement has been made using available evidence including a visit to this service. Staff were in numbers sufficient to meet the residents needs. The providers and staff were experienced in the care of the older person. EVIDENCE: Two recruitment files were examined. The providers had recruited two new staff members, the Criminal Records clearance was waiting to be received before commencement of duties. Mr & Mrs Lucas were the main full time carers, staff employed were on a part time basis. Each one maintained the skills and training to provide quality care. There was a recommendation to the providers to ensure that the one item to complete Schedule 2 was on the staff records i.e. a copy of a birth certificate. During the inspection the providers made arrangements to update their Moving & Handling training at a home locally .This was evidenced from information contained in the pre inspection questionnaire provided. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 18 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 good. Standards 31,33,35,38 were reviewed. This judgement has been made using available evidence including a visit to this service. The ethos of the home was relaxed, comfortable and operated in the best interest of the residents. EVIDENCE: Mr Lucas took the responsibility for the compliance of testing the systems for the fire, home temperature, water, surface temperatures of the radiators and call system. The testing was completed on a weekly basis and records evidenced this. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 19 Discussed with Mr Lucas the contents of the contingency plan in the event of an emergency. Mrs Lucas is the homes registered care manager. The providers have been in the caring profession for a number of years they operate as the main carers, providing exceptional care while recognising individuals life style, opinion and judgement. Residents’ comments during the inspection confirmed that they were very satisfied with the concept of living at Kay Sera Sera and the care provided. All the residents manager their own finances. Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 20 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 X 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 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 4 X 3 X N/A X X 3 Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? N/A 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. 1 2 3 Refer to Standard OP1 OP9 OP30 Good Practice Recommendations It was recommended that the statement of purpose contained a paragraph in respect of the day care provided It was recommended that the medication system for the medication taken out of the home was reviewed and made safe for all parties. It is a recommendation to ensure that the one part of Schedule 2 which was missing was updated i.e. copy of the births certificate Kay-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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-sera-sera DS0000005087.V325338.R01.S.doc Version 5.2 Page 23 - 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. 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