Archived: Kay Sera Sera

Updated 21 August 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 18 June 2015 and was unannounced. Two inspectors undertook the inspection.

We reviewed the information we held about the service. Providers are required to notify us about events and incidents that occur including unexpected deaths, injuries to people receiving care and safeguarding matters. We refer to these as notifications. We had not received any notifications from the provider for over 12 months. We reviewed additional information we had requested from the local authority safeguarding team and local commissioners of the service. Commissioners are people who work to find appropriate care and support services which are paid for by the local authority.

We observed how care was provided and carried out and observed how people were supported to eat and drink. This helped us understand people’s experiences of care.

We spoke with three people who used the service, one relative, two staff members, and the proprietors of the service.

We looked at three people’s care records to help us identify if people received planned care and reviewed records relating to the management of the service. These records helped us understand how the provider responded and acted on issues related to the care and welfare of people, and monitored the quality of the service.

Updated 21 August 2015

We inspected Kay Sera Sera on 18 June 2015. The service is registered to provide support and accommodation for up to four people living with dementia. At the time of our inspection, four people used the service. At the last inspection of the service on 2 April 2014, we asked the provider to make improvements in the following areas: How people’s medicines were managed, ensure adequate staffing levels and how the quality of the service provided was assessed and monitored to ensure that people received safe and good quality care. During this inspection, we found that improvements had been made in how people’s medicines were managed and in ensuring sufficient staffing levels; however further improvement was needed in the way the proprietors monitored the quality of the service.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The service was managed by the owners, whom we refer to as ‘the proprietors’ in this report.

People’s care records did not always reflect the care they received. People did not always have risk assessments and management plans in place to guide staff on how care should be provided. This meant that people were at risk of receiving inappropriate care that did not meet their needs.

The provider did not consistently follow the guidelines of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) to ensure that people were not being unlawfully restricted of their liberty. Staff did not always have a good understanding of the relevant requirements MCA and DoLS. The MCA and the DoLS set out the requirements that ensure where appropriate; decisions are made in people’s best interest when they are unable to do this for themselves. This meant that people’s liberties were at risk of being restricted.

Action had not been taken to ensure that improvements had been made against all the areas identified for improvement during the last inspection. Newly recruited staff did not have an induction. The provider did not always ensure that staff received relevant training to ensure that they carried out their roles effectively.

People told us they felt safe and protected from harm. Staff understood what constituted abuse and knew what actions to take if abuse was suspected. There were appropriate numbers of staff employed to meet people’s needs. People’s medicines were managed safely.

People were cared for by staff that knew them well and understood their care needs. Staff understood their roles and responsibilities and provided care in line with these.

People told us they liked the food and were supported to eat and drink adequate amounts. People were offered a choice during meals. People were supported to attend healthcare appointments and staff liaised with their GP and other healthcare professionals as required in order for people’s health and social care needs to be reviewed.

People told us and we observed that staff were kind and treated them with dignity and respect. People’s care was tailored to meet their individual needs. Care plans detailed how people wished to be cared for and supported. People were involved in the care planning process and in decisions about their care and treatment. People and their relatives told us that the provider responded to their concerns appropriately. There were systems in place to deal with complaints and concerns.

People who used the service, their relatives and the staff were very complimentary about the registered manager of the service. They told us the proprietors were always available and were approachable. We observed that the proprietors had a hands-on management style. People and their relatives told us they provided feedback and obtained information about services on a regular basis.

We identified that the provider was not meeting some of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 we inspect against and improvements were required. You can see what action we have told the provider to take at the back of the full version of the report.