CARE HOME ADULTS 18-65
Kaydar Kaydar 7 Snows Green Road Shotley Bridge Durham DH8 0HN Lead Inspector
Gavin Purdon Unannounced Inspection 24th January 2006 3:00 Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 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 Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 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 Adults 18-65. 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. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Kaydar Address Kaydar 7 Snows Green Road Shotley Bridge Durham DH8 0HN 01207 580931 01207 590333 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) Mr Angus Lascelles Burns Mrs Noreen Helen Burns Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: Kaydar is a care home registered to provide care and accommodation for up to 8 people with a learning disability. It does not provide care for people who require nursing care. The home is a private business, owned and managed jointly by Mr Gus & Mrs Noreen Burns. Kaydar care home is a stone built end terrace house near the centre of Shotley Bridge. It is in a pleasant conservation area close to the local amenities. Facilities are provided across the 3 floors of the home and would not be suited to people with limited mobility. At the time of inspection 8 service users were living at Kaydar. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over the late afternoon and early evening. It was assisted by one of the home’s owner/managers, one of the home’s care staff, and two of the home’s residents, who showed the inspector some of the facilities and talked about life at the home. There was an opportunity to look around the home with one of the managers and to see a typical Kaydar teatime. This is a busy and important time for staff and residents and hopefully the inspection process was not too intrusive. Records relating to maintaining the health and safety of residents and staff in the working and living environment were seen. Generally, this was a very satisfactory inspection. What the service does well: What has improved since the last inspection?
Management and staff thought that the recent and ongoing care and management training has improved the standards of care and management in the home. These improvements included better risk assessment documents to make sure residents are safe and comfortable wherever they are in the home. There have been some improvements to residents’ bedrooms recently with personally chosen furnishings and décor. One of the residents showed the inspector their new three quarter bed and duvet, and said, “ I’m pleased with this. It’s great.” Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 6 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. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Residents live in a safe, comfortable and convenient home. Residents’ safety and comfort are protected by good standards of hygiene and cleanliness. EVIDENCE: Management and staff interviewed thought the home safe, comfortable, and convenient for residents. Staff thought they were well trained, well equipped, and well organized to support the safety and comfort of residents. The risk assessments of the building, records of health and safety training, cleaning rotas, and aprons and rubber gloves seen, supported this positive view. The inspection of the building and observation of residents using dining and lounge facilities gave a good impression of Kaydar as a safe comfortable and convenient place for people to live. Toilets, bathrooms, bedrooms, kitchen and laundry facilities were seen. These looked well kept and well equipped. One bathing facility was out of action due to its being used as a storeroom. There are plans to review the location and equipment of bathing facilities. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 14 The residents seen and spoken to, briefly, looked safe and comfortable in their surroundings. 2 residents talked about the bedroom and bathing facilities and said they were happy with these. Management and staff described how hygiene and cleanliness are maintained and understand its importance in protecting residents. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 33,34, & 35. Residents benefit from support provided by a well-qualified staff group. Staffing levels allow the care team to work quite effectively on behalf of residents. Residents are protected from unsuitable care staff job applicants by the home’s careful recruitment and selection practices. Staff have a programme of training and development that ensures residents’ needs are understood and met in a way that benefits residents. EVIDENCE: 21 out of 30 of the home’s staff group hold the NVQ2 or 3 qualifications in Care. Management and staff thought staffing levels allow the care team to work quite effectively on behalf of residents. Typically on weekdays there are 2 care staff on mornings until 8.00am and 1 care staff from 8.00am until 9.00am. When residents return there are 2 to 3 staff on late afternoons and evenings depending on what activities are planned Night staffing is 1 carer awake and 1on call off the premises. Generally, these
Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 16 standards reflect the lower dependency of most residents and the time residents spend away from the home. Discussion confirmed that proper criminal record checks, work histories, and references were required and provided by job applicants. The home’s programme and record of staff training and development was seen. This covered the necessary topics to ensure staff can help residents remain safe, comfortable, and as fulfilled as they can be. Management and care staff spoken to thought they worked well together for the good of their residents, and that their knowledge training and teamwork helped this happen. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, & 42. Kaydar has a well-established and well-experienced management team to oversee the running of the home, and this works well for the benefit of staff and residents. The home is interested in what residents, relatives, and staff, think about how care is provided and gathers information about this from various people to help decide whether their service is satisfactory or needs improving. The home’s management makes organized and formal checks to ensure the building is a safe and comfortable environment for residents to live in. EVIDENCE: Both owners of the home are involved in the day-to-day management of Kaydar. Both are experienced and hold relevant qualifications. One owner/manager is partway through the NVQ4 in Management to acquire a level of qualification equivalent to Standard 37(Management & Care). This has
Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 18 helped them to reflect on and develop their standard of management practice, for the benefit of the home. Survey questionnaires were seen for gathering information on how satisfied people are with the service Kaydar provides. Checklists were seen for ensuring that systematic checks are made throughout the home to confirm that the environment remains a safe and comfortable setting to live and work in. Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 4 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Kaydar Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 4 X X 3 X DS0000007482.V255936.R01.S.doc Version 5.0 Page 20 No 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. 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 YA37 Good Practice Recommendations Taking into account extensive experience and existing qualifications, the management of the home should complete those elements of NVQ4 necessary, to the equivalent of National Minimum Standard 37 (Care Homes for Adults (18-65). Information from the quality assurance satisfaction survey document should be used to draw up and publish a general picture of the strengths and weaknesses of the home from the point of view of residents, relatives, and staff, together with plans for any future improvements. 2 YA39 Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. Extracts may not be used or reproduced without the express permission of CSCI Kaydar DS0000007482.V255936.R01.S.doc Version 5.0 Page 22 - 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!