Inspection on 11/04/05 for Ker Maria

This inspection was carried out on 11th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ker Maria 30/09/09

Ker Maria 07/04/09

Ker Maria 30/10/08

Ker Maria 17/04/08

Ker Maria 29/11/07

Ker Maria 29/06/07

Ker Maria 18/12/06

Ker Maria 25/05/06

Ker Maria 16/11/05

Ker Maria 18/12/04

Ker Maria 02/08/04

Ker Maria 10/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ker Maria The Retreat, Aylesbury Road Princes Risborough Aylesbury Buckinghamshire, HP17 0JW Lead Inspector Gill Wooldridge Unannounced 11 April 2005 10:00 a.m. 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. Ker Maria Version 1.10 Page 3 SERVICE INFORMATION Name of service Ker Maria Address The Retreat, Aylesbury Road, Princes Risborough, Aylesbury, Buckinghamshire, HP17 0JW 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) 01844 345474 The Augustinian Sisters Care Home 41 Category(ies) of Dementia (41), Old age, not falling within any registration, with number other category (41) of places Ker Maria Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 December 2004 Brief Description of the Service: Ker Maria is situated within walking distance of the market town of Princes Risborough which has many facilities including bus, train and road links. The home is purpose built on two floors and has well maintained gardens. The home provides nursing care for forty one residents, a significant number of whom are diagnosed with dementia. All residents have individual rooms with fifteen bedrooms having en-suite facilities. The proprietors for the home are the Augustine Sisters who delegate the day to day management of the home. Ker Maria Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on 22nd April with a follow up visit on 6th May 05. Overall the inspection took approximately ten hours. The inspection was carried out by two inspectors on both of the days. During the course of the inspection the requirements and recommendations from the last inspection were discussed and some evidence was found to show that these shortfalls had been met. The inspectors toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a further number from the corridor. Four care plans were studied and the care of these residents tracked. Staff personnel files, training records and Medication Administration Record (MAR) sheets were also studied. Several staff on duty were spoken to and time was spent with the acting manager, residents and their relatives. The inspectors observed two meal times at the first inspection and a further meal at the follow up visit and spent time in conversations with residents, their relatives and a visiting professional. The inspector also spent time in both lounges talking with residents and observing interactions between staff and residents. What the service does well: The acting manager was able to describe a number of areas in which she feels the home does well these include: The care of the residents including their personal care has a clear emphasis. The acting manager described an efficient staff team who are professional. The spiritual needs of residents including residents from a variety of different denominations are encouraged. Staff working toward and having completed their NVQ 3 have a positive impact on care plans. The home has a calm and relaxed atmosphere. The home is to continue to work with the Commission to address any problem areas identified. The acting manager and proprietor are developing systems to audit care. Residents’ relatives have been encouraged to support the home through regular meetings. The home is supported by a number of ancillary staff who are committed in their work to maintain the fabric of the building and support the care team. There appears to have been a clear commitment to staff training. Ker Maria Version 1.10 Page 6 What has improved since the last inspection? What they could do better: The proprietor and acting manager must ensure that residents’ needs are met at all times, this is of concern especially during the evenings and weekends when staffing numbers decrease. The acting manager must ensure that residents’ dependency levels are assessed appropriately and records maintained. The acting manager must ensure that future admissions are supported by a thorough assessment of need and that this is developed into a care plan for all newly admitted residents within 7 days. The proprietor and acting manager must ensure that all care plans are detailed and identify and reflect individual needs. Training and ongoing support for staff is necessary. The acting manager must ensure that staff personnel files are in good order and meet the standard. The proprietors must ensure that the acting manager receives regular supervision. Further recruitment of the home’s own staff, rather than deploying agency staff, will enable continuity of care for all residents. Recruitment of a permanent manager must be made a priority by the proprietor. The acting manager must receive formal supervision. The acting manager must inform the Commission of any event that effects the well being of residents as given in Regulation 37 of the Care Homes Regulations 2001. Ker Maria Version 1.10 Page 7 The acting manager must ensure that all agency staff and bank staff are competent to meet residents’ needs and they must have a comprehensive induction with records maintained for inspection purposes. The acting manager must ensure that the fire doors are not propped open by any device other than those advised by the fire officer. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ker Maria Version 1.10 Page 8 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 Ker Maria Version 1.10 Page 9 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) 3 There was a lack of written detail in the assessment/care plan relating to the last admission, this limited the information available to staff to enable them to satisfactorily meet this resident’s needs. EVIDENCE: From studying the most recent resident’s assessment it was evident that although there was some clear information, which was not dated or signed, much of the written information needed by staff to support this resident was lacking including a moving and handling assessment. This resident was admitted on the 14/4/05 and seen by the General Practitioner on the 20/4/05. There was no clear care plan, risk assessment, continence assessment or other recognised tool to support staff practice in meeting this resident’s needs. The acting manager confirmed that a care plan would be in place within 7 days. Issues relating to the care of this resident may be lost within a verbal handover and without supporting, written documentation there may be a danger that verbal information may get lost and so effect the service delivery. The acting manager must ensure that she audits all admission assessments. Ker Maria Version 1.10 Page 10 The proprietor must explain in writing to the Commission why this requirement has not been met from the previous inspection. Ker Maria Version 1.10 Page 11 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 Care plans studied lacked specific detail and did not always demonstrate that health needs were followed through. This may compromise continuity of care and meeting the health, personal and social care needs of residents. Some information relating to residents care plans is held on a computerised system which can be difficult to access depending on the equipment and competency of staff. This is unacceptable and does not facilitate the smooth evaluation of residents’ care. Risk assessments were not complete and lacked the information to support staff practice, this may place residents at risk. Medication procedures are in place however; further developments in the home’s policies and procedures are needed to protect residents. EVIDENCE: Care plans studied contained information relating to residents which was complete and informative. Care plans covered areas such as communication, eating and drinking, elimination, expressing sexuality, maintaining a safe environment, skin, sleeping, washing and dressing, working and playing. All Ker Maria Version 1.10 Page 12 the care plans identified a goal and actions, the actions were extremely detailed. However, in some care plans issues of concern were for example, a ‘break in a resident’s skin’ did not describe fully the wound and staffs’ role in ensuring further breakdown or any preventative measures such as high protein diet and pressure relieving equipment. During the follow up visit a trained nurse showed the inspectors a recent care plan relating to wound care. This document gave more detail including interrelation between diet, pressure relieving equipment and staffs’ responsibilities. Fluid charts were in place although there were some gaps of at least 12 hours noted at night. Staff are reminded to record their practice fully and the acting manager must audit these and maintain records for inspection purposes. It was evident that the care plans were not specific to the individual. One care plan referred to washing and dressing of a lady on six occasions, when in fact this was the care plan of a gentleman. Nutritional assessments carried out on 13/8/04 showed no evidence of review or follow up. This is of concern as this indicates that the care of this underweight lady is not being monitored or a referral made to the GP and dietician. Further to this a Waterlow assessment showed no sign of review since 12/1/2003. The score at this assessment was 27 which indicates high risk. A further Waterlow assessment was completed on the 29/1/05 with a score of 28 which again indicates a very high risk, a note was seen which stated ‘to be reviewed weekly’, these records were not evident. One resident’s care, relating to his nutritional assessment described one type of diabetes and in other documentation viewed this described a different type of diabetes, the above discrepancies are of concern. Regular review and clear documentation will ensure residents’ care is monitored and followed through as appropriate. The care of a number of residents was tracked and supporting documentation to support staffs’ described practice was not always evident. There were no fluid charts, turning charts or recognised information relating to staff checking residents and talking with them. It is acknowledged that fluid charts and other information relating to the care of residents was actioned during the inspection and staff verbally handed over this request to the next shift. One resident, whose care was tracked, was unshaven. This resident’s preferences should be recorded in the care plan. The residents’ preferred bedtime was not detailed in the care plan studied. Ker Maria Version 1.10 Page 13 All bar one of the care plans had review dates due recorded. However, it was not evident that reviews had been carried out. A review seen identified changing needs, however, there were no apparent changes to the care plan. Care records stored on computer were not always available to staff either because of their ability to use the computer or because the equipment failed to function. On the whole evaluations did not give a clear picture of the changed needs of residents and hence this was not reflected in care plans. Incontinence assessments were in place, to further good practice, it is recommended that the home develop a written toileting programme for each resident. Some time was spent with the continence assessor and it is hoped that the assessment of residents’ continence will continue, supported by training. Daily diary notes which were printed off showed that staff do themselves a disservice by recording the minimum of information which is not reflective of the actual care they provide. For example, ‘slept well, settled and comfortable, assisted with washing. remains sleeping in his room’. One entry stated ‘please observe’, followed by ‘settled afternoon’. One later entry did describe fully that fluids were taken. There needs to be consistency of recording throughout the staff team to ensure continuity of care. Moving and handling assessments viewed need to be completed fully with a regular review system in place to support residents’ needs. The inspector noted that staff showed good practice by encouraging one resident to walk and also encouraging residents to be self managing when rising from chairs. This detail needs to be recorded in care plans and moving and handling assessments ensuring residents’ independence is promoted and any potential risk is minimised. Staff spent time discussing one care plan with an inspector, this member of staff was completing her NVQ 3. It was clear that much thought had gone into this care plan and staff described being supported by a trained nurse. The resident’s care plan had involved relatives. Staff were able to describe their practice of describing personal care in detail. It is advised that this detail is recorded in all care plans. The acting manager described developments relating to the key worker system with care staff writing a weekly progress report. Staff working towards or having obtained their NVQ 3 were particularly good at this practice. Formal training and ongoing support for staff, perhaps a template for staff to refer to along with an audit system, will ensure the Standard is met. The proprietor must explain in writing to the Commission why the above requirement has not been met from the previous inspection. Ker Maria Version 1.10 Page 14 It is required that the acting manager develop protocols relating to residents’ needs which must include, diabetes, catheter, wound and stoma care, the taking of blood and anti coagulant therapy. The acting manager must develop a PRN medication management plan for each resident who requires this to ensure that staffs’ practice is supported by clear guidelines. It was noted that staff, when administering medicines, approached residents sensitively, encouraging interaction and for example, explaining to a resident who she, the staff member, was. It was pleasing to note that staff explained fully the process of administering medication covertly to a resident, further to which the home had gained permission from relatives, unfortunately this was not documented. A covert administration of medication procedure must be developed ensuring that relatives and/or representatives and the resident’s GP have given their permission for this to happen and records maintained for inspection purposes. On the whole recording on Medication Administration Record (MAR) sheets was much improved. It is recommended that where staff do not give prescribed medication and that they are reminded to use codes and an explanation at the bottom of the sheet to record the reason for omission. It was reported to the inspector that the proprietor types up the (MAR) sheets which may mean that there is opportunity for human error. It is strongly recommended that computerised charts or labels are obtained from the pharmacist and a copy of the Royal Pharmaceutical Society’s Guidelines are obtained. The acting manager is developing audit system which will continue the progress made so far. It is acknowledged that the proprietor has spent much time in supporting the acting manager in this area. It was noted that the home has a new stock control for Temazepam in place. The proprietor must explain in writing to the Commission why some parts of this requirement have not been met from the previous inspection. Ker Maria Version 1.10 Page 15 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. Recreational and social activities are not a core role of staff therefore the social and recreational needs of residents are not consistently met. Systems need to be developed to facilitate wider access to the community and recreational opportunities to ensure that all residents who wish to, have access to these. Meal times were better managed than previously noted however, the acting manager and chef are to continue to look at developments around meal times to enable residents to experience a relaxed, creative and supportive atmosphere which facilitates choice and meets residents’ needs. EVIDENCE: The acting manager confirmed that she is in the process of recruiting an activity organiser. Care staff should be encouraged to engage in this role to ensure residents’ social and recreational needs are met. Relatives confirmed that they have been encouraged to become involved in arranging activities for the resident group. The inspector spent some time upstairs with a group of residents, little staff interaction was noted and although sensitive toileting was observed staff were not seen to be available to support residents’ social and recreational needs. The senior nurse described a hand and neck massage for residents in the morning. It is acknowledged that residents may be unclear about what they would like to do but stimulus and support must be available to them all. The radio was playing in the upstairs lounge but it was noted that Ker Maria Version 1.10 Page 16 this may have been for the benefit of staff rather than residents. The numbers of agency staff used on the days of inspection are of concern as they had no apparent training in dementia care and therefore may not have the skills to meet residents’ needs. The acting manager must ensure that all agency staff have the appropriate mandatory training and that all agency staff are supported by dementia training before working in the home. This is not wholly the acting manager’s responsibility but also that of the agency. If the agency cannot provide staff who are appropriately trained, competent and experienced then the acting manager must consider using a different agency. The acting manager confirmed that she has contacted an advocacy agency to support residents as they wish, evidence was seen to support this. Relatives confirmed that they have regular meetings to support the home. It is considered that the proprietor should liaise fully with this forum to benefit residents. The breakfast, lunch and tea time meals were observed. One service user was fed breakfast of two Weetabix in her room which, according to her Nutritional assessment, was appropriate. The staff member assisting this resident was observed to provide a protective bib and was seated facing her. At lunchtime a number of residents downstairs were self-managing and staff were seen to verbally encourage other residents whilst feeding another. The inspector is still concerned that food for some residents may be cold as residents were taking a considerable amount of time to finish their meal. The lunchtime meals that were a soft diet were appropriately presented. The tea time meal was a choice of sandwiches, shepherds or cottage pie. On the whole the meal times were not as concerning as previously noted however, it is strongly recommended that the acting manager considers the deployment of additional staff to help at these time consuming and needy times of day. In some care plans sampled likes and dislikes relating to food and mealtimes were not always evident, this was further supported by relatives and observations of inappropriate meals offered to residents who clearly were not able to eat a meal left for them. The acting manager must maintain records that ensure that staff are aware of residents’ choices and dietary requirements relating to residents medical conditions and dietary needs. During the follow up visit it was disappointing to note that staff had to be asked to offer the resident an appropriate choice and to provide a further spoon for desert. Staff must not assume that visitors will feed their relative. Ker Maria Version 1.10 Page 17 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) 16 &18 Consultation with relatives indicates that complaints are appropriately actioned which should ensure that residents and relatives views both listened and responded to. Staff and the acting manager appeared aware of how abuse may manifest itself and are supported by the organisation’s policies and procedures. These measures should ensure residents are protected from abuse. Recruitment procedures do not meet the required standard and therefore have the potential to put residents at risk. EVIDENCE: The home advertises its complaints procedure in the entrance hall and it appears that residents and relatives are able to comment about the service freely. The relaxed, open style of the acting manager indicates that complaints are listened to, relatives supported this finding. It is strongly recommended that the acting manager clearly details how she responds to all verbal and written concerns outlining a clear action plan to ensure small concerns do not become larger issues. The proprietors are reminded that where relatives complain directly to them, it would be prudent to inform the Commission under Regulation 37. It is further advised that the proprietors encourage a two way dialogue with relatives who are using the new forum of a relatives meeting, to benefit residents and ensure that small issues do not become major concerns. Ker Maria Version 1.10 Page 18 Staff were able to describe the different types of abuse that might occur and how they would report any alleged, potential or actual abuse. Ongoing yearly training in adult protection is strongly recommended. Weaknesses in the recruitment processes have been discussed in Standard 35. Ker Maria Version 1.10 Page 19 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, 25 & 26 Risk assessments are in place regarding hot water temperature in the kitchen as a compromise to environmental health requirements and safeguarding residents from scalding. There is a marked improvement in the main lounge with new carpets and furnishings which have been re-arranged to create a homely feel for residents. The refurbishment and maintenance of the property must be maintained so that the environment meets residents’ needs. The acting manager must ensure that door wedges or any other item is not used to hold open any doors to ensure residents’ safety. EVIDENCE: It was noted that the furniture in the lounge had been re-arranged to encourage small group seating. There are some areas of the home that need decoration, the acting manager confirmed that this is planned for two further bedrooms in addition to those already done. It is strongly recommended that Ker Maria Version 1.10 Page 20 the proprietor and acting manager tour the building monthly setting time scales for works identified to be completed and maintaining records for inspection purposes. Shortfalls identified include the seal in the double glazed unit in the dinning room which appears not to be functioning this must be replaced, this appears to be the case in the first floor lounge also. The inspector did not tour all of the home but entered bedrooms with residents’ permission and viewed other bedrooms from the corridor. There was no apparent odour of incontinence however, the acting manager confirmed that there has been a reduction in house keeping staff and this will be monitored at future inspections to ensure that there is no impact on the environment. Housekeeping staff are to be commended for their hard work in maintaining the environment. It was noted that staff are wedging open doors with either a door wedge or chair, this practice must cease. The acting manager must ensure that doors are not wedged open by any device other than those approved by the fire authority. The acting manager is required to consult with the fire authority regarding an appropriate door holding device. It was concerning to note that during the follow up visit the office door and kitchenette door were propped open with a chair and fire extinguisher placing residents at risk. The proprietor and manager must write to the Commission outlining what actions they will take to safeguard residents and ensure staff do not continue with this practice. The inspector will return to the home to check that this Requirement is being complied with. Risk assessments are in place regarding hot water temperature in the kitchen as a compromise to environmental health requirements and safeguarding residents from scalding. Consultation with environmental health department regarding the home’s risk assessment may be prudent and may safeguard residents further. Ker Maria Version 1.10 Page 21 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 & 30 The procedures for the recruitment of staff are not robust and therefore do not provide the appropriate safeguards to residents. Training records showed that not all agency staff have undertaken mandatory training, which could potentially put residents at risk or result in failure to meet their needs. Not all staff have received dementia training by an accredited trainer and may therefore fail to support residents’ needs. The large numbers of agency staff being deployed in the home may not provide continuity of care or meet residents’ needs. EVIDENCE: Three staff files were studied. All had CRB disclosure however, it was concerning to note that only one reference was found on a bank staff member’s file. This shortfall must be actioned as should the organisation of the personnel files. It is a requirement of this report that the proprietor audits all staff recruitment files using a checklist to support this practice maintaining and records for inspection purposes. To ensure that the home has robust recruitment procedures in place to ensure the appropriate safeguards for residents. The proprietor must explain in writing to the Commission why this requirement has not been met relating to the previous inspection. Ker Maria Version 1.10 Page 22 Staff described recent training in a number of topics. It is strongly recommended that the acting manager, maintains a training schedule to include dementia training by a recognised, accredited trainer. Care planning training must also be completed for care staff and trained nurses to facilitate this process. This training must be completed within six months. Records of the training and staff certificates must be maintained for inspection purposes. All newly appointed staff should have planned mandatory training within six months of the commencement of their employment. Some relatives described being concerned about low staffing levels and this was supported by staff. The staffing levels on the afternoon of the first day of the inspection fell to three carers and one trained nurse on each floor. Three of these staff had been provided by an agency and the deployment of these staff on the first floor, where resident need is greatest, is of concern. Staff continue to work long days which is also of concern. During the follow up visit one member of staff left the building to go to the chemist and the trained nurse upstairs finished her duty at 6pm leaving residents potentially with unmet needs or at risk. During this shift agency staff were employed to meet residents’ needs, two being deployed downstairs and one upstairs. Information relating to agency staff was not well ordered and showed that not all agency staff had undertaken mandatory training or training in dementia care. The file of information relating to agency staff also needs to contain the information as discussed with the acting manager. All agency, bank and permanent staff must have a comprehensive induction with written records detailing meeting residents care needs as well as fire procedures and the home’s philosophy. Senior nurses left in charge of the home must have a detailed senior induction to cover areas such as complaints, fire safety, on call systems and any other emergency that may befall the home. Following a meeting with the proprietors in Jan 2005. The Commission for Social Care Inspection had decided, for a trial period, that staffing levels can be reduced in the morning to four carers on each floor with a trained nurse on each floor. This was reviewed at this inspection. Staffing levels were not sufficient to meet residents’ needs at this inspection and the previous unannounced inspection. It is a requirement that the proprietor recruits permanent staff to ensure that staffing levels do not fall below ten carers in the morning; ideally five carers on each floor, with a trained nurse in addition to the carers on each floor during the waking day which is from 8am to 8pm at all times. In the afternoons there will be eight carers, ideally four on each floor in addition a trained nurse on each floor from 8am to 8pm at all times. At night the home must never fall below four carers and one trained nurse. Ker Maria Version 1.10 Page 23 If residents’ needs change the proprietor and the acting manager must ensure that they increase staffing levels to reflect this. In the interim to allow the proprietor time to recruit staff. The staffing levels must not fall below four care staff in the morning and afternoon. Trained nurses on duty must cover the whole of the waking day from 8am to 8pm. The acting manager must ensure that if for any reason staffing does fall below these levels the acting manager must inform the Commission. All agency staff must undergo a thorough induction as detailed earlier to ensure residents needs are met. The acting manager must inform the Commission under Regulation 37 should staffing levels fall below these numbers explaining what measures she has taken to remedy the situation. Ker Maria Version 1.10 Page 24 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) 38 Some audit systems fail to include resident’ views indicating that the home may not be consulting residents or their representative regarding their experience of service delivery. Accident recording must be followed up by clear actions and where appropriate risk assessments need to be developed and supported by a clear in- house review to ensure immediate action is taken to protect residents. Supervision for the acting manager and staff team must be in place to support the service delivery. The proprietors must appoint a new manager within six months to ensure the smooth running of the home. Ker Maria Version 1.10 Page 25 EVIDENCE: Accident records viewed need to be clearly documented with follow up actions to prevent any further actions, risk assessments may need to support the process and it is recommended that the acting manager audits the accidents to ensure that if there is a pattern to falls or an environmental issue this can be addressed immediately. It is acknowledged that audit of these records is done centrally by the proprietor. It was unclear that there is formal supervision for all staff. The acting manager must ensure that all staff receive formal supervision at least six times a year. The acting manager will need to be supernumerary and not work on the roster to facilitate the process of supervision for staff. The proprietors will need to ensure that the acting manager receives formal supervision at least every month, as well as their obligations under Regulation 26. The lack of clear management is not a reflection on the acting manager but the lack of time she can give to the role when she is providing care on the roster. The acting manager is reminded that under Regulation 37 she is obliged to inform the Commission of any event that effects the well being of a residents. Audit systems relating to medication and care plans need to be developed to ensure service delivery meets residents’ needs and that residents are consulted in the process. These audits must be maintained for inspection purposes. Ker Maria Version 1.10 Page 26 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 1 x x 1 Ker Maria Version 1.10 Page 27 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 3 Regulation 14 (1)10 (1) (a) Requirement The acting manager must ensure that future admissions are supported by a thorough assessment of need and this assessment is developed into a care plan for all new residents within seven days. The process must be supported by an audit system. (Previous timescale of 31/4/05 not met). The proprietor must explain in writing to the Commission why this requirement has not been met. The acting manager must ensure that all care plans are detailed and reflect identified needs and clear actions. Social and recreational needs will be identified and met as will preferances relating to residents dietary needs. The manager must ensure that care planning training continues until the care plans have achieved the minimum standard. The manager must ensure that an audit system is in place to support the content of the care plans. (Previous timescale of 31/3/05 not met). The proprietor must explain in writing to the Version 1.10 Timescale for action 31/12/05 2. 7 12 & 15 12 (1) (b) 31/12/05 Ker Maria Page 28 3. 7 12 (1) (b) 4. 7 13 (4) 5. 9 13 (2) Commission why this requirement has been met. All Staff must be trianed and 31/8/05 competent in using the computerised system and records maintained for inspection purposes. The proprietor must ensure that all the computer equipment works and there is a back-up sysytem provided incase of a power failure. Risk assessments must be 31/8/05 developed to detail maintaning residents independence and indentifying any potential risk. The acting manager must ensure 31/12/05 that there are safe medication practices at the home through the following. The acting manager will need to develop PRN management plans for each service user who is prescribed medication PRN. The manager must develop a protocol to support the covert administration of medication ensuring that the General Practitioner has been consulted and families permission is gained and recorded. The acting manager must ensure that all trained nurses working in the home are regularly assessed for their level of competency relating to the administration of medication. The acting manager must ensure that the above is underpinned by a quality audit system and maintain records for inspection purposes. Protocols for taking blood, catheter care, diabetes, stoma care and anticoagulant therapy must be developed. (Previous timescale of 31/4/05 not met). The proprietor must explain in writing to the commission why parts of this requirement have Version 1.10 Page 29 Ker Maria not been met. 6. 19 23 (1) (a) The refurbishment and maintenance of the property must be maintained so that the environment meets residents needs, for detail of the shortfalls refer to the Standard. The acting manager must ensure that chairs, fire extinguishers or any other objects, unless approved by the fire department, must not be used to prop open any door. The proprietor and acting manager must ensure that service users needs are met at all times. Service users’ dependency levels will need to be assessed regularly and staff deployed appropriately at all times. The proprietor must recruite permanent staff to meet residents needs and ensure that all agency staff have a clear recorded induction that they are trained and provide continuity of care. The proprietor and manager must adjust staffing levels to ensure there is a minimum of 10 carers in the morning, ideally five carers on each floor with a trained member of staff additional to the carers on each floor during the waking day 8am to 8pm at all times. In the afternoons there will be eight carers, ideally four on each floor in addition to include a trained nurse on each floor from 8am to 8pm at all times. At night the home must never fall below four carers and one trained staff. If residents needs increase the manager must ensure that she increases staffing levels to reflect this. Any shortfalls must be reported to the Commisssion. Version 1.10 31/08/05 7. 19 13 (4) 6/5/05 and ongoing 8. 27 18 (1) (a)10 (1) (a) 31/10/05 9. 27) 18 (1) (a) 31/10/05 Ker Maria Page 30 10. 29 19 Schedule 2 11. 30 18 (10 (a) 12. 13. 31 33 8 37 14. 36 18 (1) (a) Untill this requirremnt is met the staffing levels will remain as four staff on each floor am and pm and a trained nurse on each floor during the waking day from 8am to 8pm. The proprietor must ensure that all the recruitment files have the detail as outlined in Schedule 2 Regulation 19 and all information will be kept on the premises. (Previous timescale of 31/3/05 not met). The proprietor must explain in writing to the Commission why this requirement has been met. The proprietor and acting manager must ensure that staff are trained by a recognised trainer to provide dementia training for all care and nursing staff. The proprietor must recruit a permanent manager for the home. The acting manager must ensure that she informs the Commission of any event that effects the well being of residents. The proprietor and manager must ensure that all staff including the acting manager receive formal supervision as described in the Standard. 31/10/05 31/10/05 31/10/05 30/6/05 31/7/05 15. 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 7 Good Practice Recommendations It is strongly recommended that staff record residents preferd bedtimes and night routine. Version 1.10 Page 31 Ker Maria 2. 7 3. 4. 5. 6. 7. 9 18 18 119 & 38 It is strongly recommended that the acting manager introduce and record a clear toileting programme, fluid and turning charts for all rsidents and audits theses new initiatives. It is strongly recommnded that the acting manager obtains computerised charts or labels from the pharmacist. It is strongly recommended that the acting manager and proprietor record all verbal and written concerns and send a resume of any concerns to the Commission. It is strongly recommended that the proprietor encourages a two way dialogue with the newly established residents relartives group. It is stongly recommended that the manager consults with environmental health department to seek advice relating to the hot water risk assessment. Ker Maria Version 1.10 Page 32 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close Aylesbury Bucks, HP19 8JR 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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