Inspection on 16/11/05 for Ker Maria

This inspection was carried out on 16th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 11/04/05

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 Announced Inspection 16th November 2005 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 Ker Maria DS0000019236.V252559.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 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 DS0000019236.V252559.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ker Maria Address The Retreat Aylesbury Road Princes Risborough Aylesbury Buckinghamshire HP17 0JW 01844 345474 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) 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 DS0000019236.V252559.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Elderly Physically Frail Elderly Mentally Impaired Date of last inspection 11th April 2005 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 DS0000019236.V252559.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place on 16th November 2005. Overall the inspection took approximately ten hours. The inspection was carried out by two inspectors on both of the days. The inspectors toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a number from the corridor. 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, residents, their relatives staff and the manager. The inspectors observed the teatime meal. The inspectors also spent time in both lounges talking with residents and observing interactions between staff and residents. During the course of the inspection the requirements and recommendations from the last inspection were discussed not all requirements have been fully complied with although it is acknowledged that progress is being made in some areas. The proprietor and new manager must produce evidence to the Commission to ensure full compliance with the previously set requirements. Non compliance may result in the Commission consulting its legal department with a view to consider enforcement. Since the inspection the manager has written to the Commission outlining his response to the requirements and progress so far. What the service does well: The care of the residents including their personal care has an emphasis on detail however, this detail is often generalised. The spiritual needs of residents from a variety of different denominations are encouraged. The manager confirmed that staff working towards or 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. 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. The new manager appears to have high expectations of the staff team and the service. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? There is a relaxed feel to the home and staff appear to be focusing more on meeting residents’ needs. The proprietor has recruited a permanent manager. The newly appointed manager is developing systems to support the care of residents. The proprietors have been visiting the home regularly to support the new manager and care of residents. The manager described receiving support from the proprietors. The manager has ensured that admissions are supported by an assessment of need and that this is developed into a detailed care plan for all newly admitted residents within 7 days. There are two activity organisers in post ,their work appears to have a positive effect on the residents and they are supported by a message therapist who supports the hands on care of residents. Staffing levels have increased which should ensure that residents needs are fully met. The staff personnel files examined showed a marked improvement than those seen previously. The manager and senior nurses have been informing the Commission of any event that effects the well being of residents as given in Regulation 37 of the Care Homes Regulations 2001. The manager has introduced an induction for agency staff and a quick reference guide for agency staff to refer to regarding residents’ care. A significant number of relatives have been involved in the care planning process. However before the inspection several relatives reported that they were still awaiting copies of care plans. The proprietor and manager have developed a monitoring systems ensuring MAR sheets and care plans are audited. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 7 What they could do better: The proprietor and manager must ensure that residents’ needs are met at all times, this is of concern especially during the evenings and nights when staffing numbers decrease. The manager must ensure that residents’ dependency levels, continue to be assessed appropriately and records maintained for inspection purposes. The proprietor and manager must ensure that all care plans are detailed and identify and reflect individuals’ needs. Training and ongoing support for staff is necessary. Further recruitment of the home’s own staff, rather than deploying agency staff must be made a priority. It is acknowledged that some work has been done in this area. The proprietors must send to the Commission Regulation 26 visit reports each month. This visit must be unannounced and the report must be detailed. The quick reference guide in the care plan for use by agency staff must be more detailed and contain essential information regarding the care of each resident. Medication practice must be robust as detailed in the standard. Care plans must be supported by accredited training and ongoing support for all staff. All documentation regarding residents care must be used appropriately. Risk assessments must be in place and reflect the residents present situation. Ensuring residents health and safety and maintaining their independence. The proprietor and new manager must produce evidence to the commission to ensure full compliance with the previously set requirements. Non compliance may result in the Commission consulting its legal department with a view to consider enforcement. Further welfare visits may be carried out to assess the progress on all areas identified above. It is acknowledged that the manager has sent to the Commission his update outlining the progress being made since his appointment on outstanding requirements. These comments have been included in the report. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 8 The manager has also sent an action plan, detailing how the requirements given at the feedback, stating many of the requirements described as being actioned with immediate effect with supporting audit systems. 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. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 9 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 Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 3 There was some clear information in the assessment relating to the last admission, this information is available to staff which if referred to should enable them to meet residents needs. EVIDENCE: From studying the two recent residents’ assessment it was evident that there was some clear information, which was generally dated or signed. There were care plans in place however, these documents were lacking, moving and handling risk assessments. Other recognised assessments were in place for example Waterlow however, it was apparent that not all Waterlow assessments led to a detailed care plan and guidance for staff to use these tools was not available. The manager must ensure that he audits all admission assessments and that all identified needs are followed through into the care plan for example ,Parkinsons disease. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 & 10 Care plans studied lacked specific detail and did not always demonstrate that health and care 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 competency or confidence of staff. This is unacceptable and does not facilitate the smooth inclusion of information regarding residents’ care. The printed format of the care plans has improved which should aid the process and service delivery. Risk assessments were not available in residents files, this has the potential to place residents at risk. Medication procedures are in place however; further developments in the home’s policies and procedures are needed to protect residents from harm. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 12 EVIDENCE: The care of seven residents was studied this included tracking the care of some residents. The supporting documentation to support staffs’ described practice was not always evident. Some 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. It is acknowledged that during the process of inspection the care plans of the agreed care plans were not only studied . This is inevitable when tracking residents care. All the care plans identified a goal and actions, the actions were extremely detailed for example ‘when Mrs X exhibits challenging behaviour its best to leave her for a few minutes to calm down then return to her and she usually will respond in a happy manner’. The care plans are computerised but hard copies are available in an easy to follow format which is presented well, although only one risk assessment was seen as a hard copy. In some care plans issues of concern were noted for example,’ Found blisters on Mrs Y left hip, nurse in charge informed and pressure area care carried out throughout the day’. This record on an accident incident sheet did not correlate with a specific care plan or instructions for staff to ensure this area had healed, which the nurse described as having healed. It was evident from touring the home that residents nursed in bed were supported by completed fluid charts. Turning charts must also be completed as indicated in the care plans. Relatives confirmed that a number of fluid charts had been removed before the inspection. It is necessary that any resident who is being nursed in bed has a fluid and turning chart. This recorded practice is essential to support staff’s practice. Care plans indicating fragile skin were not detailed regarding the care of residents skin. Care plans did not interrelate for example, that appropriate pressure relieving equipment was in place, an increase in proteins and fats regarding diet and the care of the residents skin with a clear description of any wound or red area. Trained nurses described that they would seek advice from the tissue viability nurse if wounds were seen as a grade 2 or not improving. This information must form part of any care plan where residents skin is at risk of damage. In one care plan staff described both weekly and monthly assessments of Waterlow scores, this is confusing and unclear instructions regarding any new nurse caring for this resident. Waterlows for resident at a high risk should be re assessed weekly as a good practice. It is acknowledged that the care of residents being nursed in bed was observed as more than satisfactory on the Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 13 day of the inspection. One care plan stated ‘enhance her dietary and fluid intake’ this instruction is not clear. The manager and trained nurses spoken with confirmed that the home was not nursing any resident with a pressure sore. It is acknowledged that al residents being nursed in bed looked very comfortable nightdresses were clean and rooms were fresh and tidy. Staff are reminded to record their practice fully and the manager must audit care plans and maintain records for inspection purposes. It was evident that the care plans were not specific to the individual. One care plan referred to her on more than one occasion when the care plan was for a gentleman. Nutritional assessments carried out were not always reviewed or followed through for example, weights were not always being recorded in the appropriate place in the care plan. One nurse confirmed that residents had been weighed and the information was in a weight book. The use of the weight book, bath chart and bowel chart are institutional and it is strongly recommended that the records are maintained in their care plans maintaining residents confidentiality. Following the inspection the manager confirmed that he had actioned the above. The Residents’ vital signs were also not been consistently recorded. Regular review and clear documentation will ensure residents’ care is monitored and followed through as appropriate. In most care plans residents’ preferred bedtime was not detailed in their care plan. Generally care plans had review dates recorded. It was evident that reviews of care plans had been carried out. Relatives confirmed that they had been involved in the development of care plans although some relatives said that they had only recently received a copy of the document. Care records stored on computer were available to staff but it was evident that some staff lack confidence in using the technology. Incontinence assessments were not seen at this inspection however they were seen previously. It is recommended that the home develop a written toileting programme for each resident. Information described by staff indicating that areas of pressure had healed were not always recorded in care plans. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 14 Daily diary notes seen on the computer screen indicated 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, slept well, assisted with washing, ate well. Only one risk assessments was seen as a hard copy this is of concern and has the potential to place residents at risk. The risk assessment completed indicted that the resident was independent however, it was recorded ‘ needs assistance from 1 carer, or 2, use of hoist’. It was apparent that the person writing this information was unaware that two staff should support residents when using a hoist. Weaknesses identified at the previous inspection were a requirement of the previous report. The manager has eight weeks from the receipt of this report to ensure that each resident has a comprehensive moving and handling assessment on file. One resident’s file indicated that she had a number of falls. There was no documentation to indicate a re assessment of this lady’s moving and handling assessment. One incident form indicated the lady had a bruise on her forearm from perusing the five days daily logs previous to this event it was evident that this was not recorded in the daily log. Records must interrelate and support staffs observations. Other incident accident sheets were hand written. It is strongly recommended that the manager purchase an accident book and reviews and monitors all accidents which should include reviews of risk assessments. The care of residents was discussed with nurses and the manger and the detail regarding a resident dialysis was not completely reflected in this residents care plan. The good practice described must be recorded and available for all staff to refer to. Care plans for both husband and wife must refer to each other and information to support their relationship. 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. Formal accredited training and ongoing support for staff, perhaps a template for staff to refer to along with an audit system, will ensure that Standard 7 is met. The 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 by an acredited trainer continues until the Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 15 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). Timescale at this inspection not exceeded. It is acknowledged that introducing a new care plan system together with staff training does take time. However, a previous time scale of 31/3/05 was not met and only limited progress made at the time of this inspection. As a consequence it is highly unlikely the new timescale of 31/12/05 agreed with the proprietor earlier this year will be met. The new manager is now in post and with the support of the proprietors progress with the care plan process is expected and a further visit will be carried out in early January 06 to assess this. The proprietor and manager must explain in writing to the Commission what measures they are going to introduce to ensure that the requirement set at the previous inspections is fully met by the ageed timescale. This must include acredited training in care planning for staff. Computer training for staff and ongoing support for staff. Failure of this evidene to be produced to the Commisison may result in the Commission consulting its legal department with a view to consider enforcement. Since the inspection the manager has confirmed in writing that staff have made progress regarding the care plans. ‘ Work has been done and is ongoing internal training staff in care planning to meet the needs identified. Training continues with new external initiatives being planned for 2006. A revised protocol is in place to deal with pre admission assessments, this has bee designed to meet the needs expressed. An audit system is now in place. Computer training and computer back up system. ‘Some training has been conducted internally. Hard copies of care plans in place’ External training is being sought to further improve staff computer skills. A new system is currently installed to overcome some of the problems that existed, Jan 2006. It is required that the 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 manager must develop a PRN medication management plan for each resident who requires this to ensure that staffs’ practice is supported by clear guidelines. A covert administration of medication procedure needs to be developed further ensuring that relatives and/or representatives have given their permission for Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 16 this to happen and records maintained for inspection purposes. This process must be reviewed regularly. On the whole recording on Medication Administration Record (MAR) sheets showed some concerns as they were new sheets there were a number of errors noted. It is recommended that where staff do not give prescribed medication that they are reminded to use codes and an explanation at the bottom of the sheet to record the reason for omission. For example one lady is administered Digoxin and it is unclear why there were omissions as staff were not using codes. 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 are obtained from the pharmacist. Medication stored as a controlled drug were checked and these tallied with the records seen. Staff were ticking entries for creams this is not acceptable. The manager must develop an audit system which will ensure that the recording of medication is consistent with the homes policy. The manager must ensure that issues of poor practice are addressed and that records are maintained for inspection purposes. It is acknowledged that the manager has issued staff with information from the NMC and has reminded staff of their accountability. The manager must ensure that there are safe medication practices at the home through the following. The manager will need to develop PRN management plans for each resident who is prescribed medication PRN. The manager must develop further the homes protocol to support the covert administration of medication ensuring that families permission is gained and recorded. The 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 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 anti- coagulant therapy must be developed. (Previous timescale of 30/4/05 not met). Timescale at this inspection not exceeded. The proprietor must explain in writing to the Commission what measures they are going to introduce to ensure that this requirement is fully met by the ageed timescale. This must include audit systems records to address poor practice and reinforcing trained nurses accountability. Staff competency checks must take place and records maintained for inspection purposes and retraining offered where appropraite. It is acknowledged that introducing a new medication system, together with staff training and support takes time. However, a previous time scale of 31/4/05 was not met and only limited Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 17 progress made at the time of this inspection. As a consequence it is highly unlikely the new timescale of 31/12/05 agreed with the proprietor earlier this year will be met. A new manager is now in post and with the support of the proprietors progress with the medication administration process is expected and a further visit will be carried out in early January 06 to assess this. Since the inspection the manager has confirmed in writing that staff have made progress regarding medication administration.’ In addition to the work already done new initiatives are being introduced to better meet the needs identified. Audit system is now in place.’ ‘ A monitored dosage system is currently being examined. This will remove that risk of transcription error, provide additional training for staff and provide an independent periodic system of audit. This is scheduled to take place Jan 09, 2005. Protocols for vena puncture , diabetes, stoma care and anti coagulant therapy. ‘Some protocols already developed. Other protocols being developed.’ Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 18 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 the following standard(s): 12, 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 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 choices this must correlate with residents preferences in care plans. EVIDENCE: The manager confirmed that the organisation had previously recruited two activity organisers. They are supported by a massage therapist who provides hands on care for residents. Care staff should be encouraged to engage in this role to ensure residents’ social and recreational needs are met throughout the day. Activities upstairs were appropriate and staff joined in the process adding to the overall enjoyment. An appropriate video was playing downstairs in the lounge and portions of fruit were available for residents to enjoy. During the inspection residents were seen to be offered a number of drinks. The Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 19 seating was rearranged and residents were noted not to be in their wheelchairs relatives confirmed that this practice was not always the norm. The numbers of agency staff used on the day of inspection and as identified on the rota are off concern as they had no apparent training in dementia care, adult protection training and other mandatory training and therefore may not have the skills to meet residents’ needs. The 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 manager’s responsibility but also that of the agency. If the agency cannot provide staff who are appropriately trained, competent and experienced then the manager must consider using a different agency. The tea time meal was observed. Staff were seen to support residents sensitively. Staff were seen to feed residents sensitively and at the residents level. Information from the dietician was separate in the care plan and must correlate with other areas of the document. In some care plans sampled, likes and dislikes relating to food and mealtimes were not always evident and residents weights not always recorded in an appropriate place. Staff were seen mixing up one residents soft diet this did not look appetising and this practice was not a detail of the residents care plan. the manager confirmed that following training all soft diets will be reviewed and systems put in place to ensure meals are presented attractively. The manager must maintain records that ensure that staff are aware of residents’ choices and dietary requirements relating to residents’ medical conditions and dietary needs. Residents and relatives confirmed that the food had improved and the meals seen were generally presented attractively. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 20 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 the following standard(s): 16 & 18 Consultation with relatives indicates that complaints are appropriately actioned which should ensure that residents and relatives views are both listened and responded to. Staff and the 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 did meet the required standard and therefore should protect residents. 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 new manager indicates that complaints are listened to, relatives supported this finding. The recent concerns raised by relatives have been forwarded to the Commission and handled satisfactorily. There are however, a number of concerns, which it is believed have been raised by relatives which have come to the attention of the Commission since the inspection which may not have been responded to in the appropriate time scale. The home advertises its complaints procedure in the entrance hall and it is evident that residents and relatives are able to comment about the service freely. The relaxed, open style of the manager indicates that complaints are listened to, relatives supported this finding It is strongly recommended that the manager clearly details how he responds to all verbal and written concerns outlining a clear action plan to ensure small concerns do not become larger Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 21 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. 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. There is an outstanding adult protection issue which apparently the manager is not fully aware of, the proprietors must liase with relatives to keep them informed regarding this matter and bring the manager up to speed regarding this important issue. The manager was reminded to ensure that all staff need to undertake adult protection training and that this should be an agenda item for all staff meetings where whistle blowing and how abuse may manifest itself is discussed. It is strongly recommended that the manager requests that social services review all residents as part of ensuring all residents assessed needs are met as discussed at a strategy meeting. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 22 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 the following standard(s): 19 & 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. The refurbishment and maintenance of the property must be continued to be maintained so that the environment meets residents’ needs. Requesting information from the fire officer in writing will support the manager’s risk assessment regarding bedroom doors being left open at night. EVIDENCE: It was noted that the furniture in the lounge had been re-arranged to encourage small group seating. Residents were sat in chairs watching an appropriate video. Relatives described that this was not the norm. Fruit and drinks were available. The manager confirmed that three bedrooms had been re-decorated and there are plans in place to achieve a number of refurbishments before the end of the financial year. It is strongly recommended that the proprietor and manager tour the building monthly Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 23 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. Curtains in bedrooms 22,, 23, 33 & 36 must be re-hung. Bedroom 29 must be redecorated The fan in the kitchenette must be cleaned. In bedroom 24 the wall paper needs re sticking, Bathroom paintwork needs touching up Swing top bins must be replaced by foot pedal bins These issues must be addressed before the end of this financial year. It is evident that residents sat in the lounge do not have access to a call bell or system to support them. This is a requirement of this report The manager and proprietor explore different types of call bells and ensure systems are in place to support all residents in accessing care and nursing staff. It is acknowledged that the kitchenette on the first floor has been redecorated and cupboards have been fitted. A tour of parts of the building took place however, not all bedrooms with viewed, residents’ permission was gained and other bedrooms were viewed from the corridor. There was an odour of incontinence in room 19 a this may be due to the reduction of housekeeping staff. The cleaning schedule for this room must be increased and if this does not remedy this issue the carpet must be replaced. Housekeeping staff are to be commended for their hard work in maintaining the rest of the environment. It was noted that staff were not wedging open doors as has been the practice noted at previous inspections. The manager is required to consult with the fire authority and request that they put in writing their described instructions for staff to be able to leave open bedrooms door at night. A risk assessment was 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. The manager confirmed that he has developed an induction for night staff which includes the security of the building this document was seen. The implementation of this system should ensure residents and staff safety. Since the inspection the manager has confirmed in writing that the progress made since the last inspection. Refurbishment and Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 24 maintenance of the property. Bedrooms are refurbishment when they become vacant or if the resident can be moved to another room that is empty temporarily. ‘This is ongoing three bedrooms refurbished between September and November 2005. A fourth bedroom is being refurbished at present’. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The procedures for the recruitment of staff appear robust and therefore should 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. All staff have not received all mandatory training which has the potential to place residents at risk. 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 does not always provide continuity of care or meet residents’ needs. EVIDENCE: Five staff files were studied. All had CRB disclosures and 2 references. However it was not clear from the documentation received by the home from the Nursing Homes Association that they had carried out a POVA First check The manager must confirm with the Nursing Homes Association that this is the case and write to the Commission when he has received a response. It is acknowledged as part of the CRB process the POVA check may have been completed. The organisation of the files makes them difficult to follow and the manager has agreed that this should take place. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 26 The agency staff file was also studied again this folder must be organised. The manager has confirmed that the administrators work load is being adjusted to enable this process to commence by Jan 2006. It was evident from studying the contents that staff training of agency staff is of concern and the dates of training were often out of date or no date given by the agency. The home uses three agencies and the information regarding CRB and reference was generally satisfactory. Staff described recent training in a number of topics. It is strongly recommended that the manager, maintains a training schedule to include dementia training by a recognised and accredited trainer. Care planning training by an accredited trainer must also be completed for care staff and trained nurses to facilitate this process. 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. Staff training records indicated some mandatory training however the manager confirmed that recent training booked for staff to attend was not attended by any staff. This is unacceptable and the manager needs to put measures in place to ensure that staff attend training. This was discussed fully during the inspection. The manager stated that the organisation has agreed to appoint a training co-ordinator which should facilitate the further training plans to support residents needs. The manager stated that he is accessing external training to support the service delivery. Since the inspection the manager has confirmed in writing that the progress made since the last inspection regarding dementia training. ‘ongoing ‘Sr Miriam delivered training on dementia August 2005, two members of staff attended training with Bucks county council. Six more staffs scheduled to attend between December 2005 and Feb 2006. November 2005 a psychologist conducted one session on challenging behaviour. Further sessions to be conducted in 2006.’ Staffing levels on the day of the inspection were satisfactory, in fact they exceeded the numbers agreed at the last inspection. Staff described the smooth running of the shift and time spent with residents. The manager explained that agency staff had been booked and then forgotten to be cancelled leading to the high numbers of staff on duty. During the inspection one staff member went to the pharmacist this has happened at previous inspections and is of concern if this happens in the afternoon when staffing numbers are lower. The home must have a contingency plan in place if this occurs. Relatives and staff raised concerns regarding the number and use of agency staff on some days. The issues raised include resentment by staff, the lack of continuity and the quality of the service this was discussed fully with the Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 27 manager. It is acknowledged that until the proprietors recruit more staff, this is perhaps inevitable. The manager described his ideas in trying to solve this problem which included the following an increase some staff hours and looked at the redeployment of some staff which has had some positive impact on the service delivery. Following the inspection the manager confirmed that he had fifteen application forms to shortlist. Since the inspection the manager has confirmed in writing that the progress made since the last inspection regarding staff recruitment a new manager has been recruited. Recruitment for other staff is in progress. ‘A proposal for recruitment from Europe is currently being examined based on experience of the same approach at St Georges. The manager confirmed that staffing levels will be monitored by the home manager. The manager must develop a more comprehensive introduction to residents care to enable agency staff to work effectively with residents. The supervision and direction for staff is still of concern and this must be addressed to reassure relatives regarding the level of service delivery. The rotas indicated that staffing levels had generally been five carers in the morning for a number of weeks. The level of need of residents would indicate that in the afternoon staffing should not fall to four staff and night staffing will also need to be reviewed. Staff continue to work long days which is also of concern The manager must also ensure that there is a trained first aider identified on the rota every day. It is acknowledged that there is a system in place. The manager described all agency, bank and permanent staff as having a satisfactory induction with written records detailing meeting residents care needs as well as fire procedures. This information must be more detailed as described earlier in the report. The manager confirmed that he has made some progress in developing training for staff including staff attending challenging behaviour this will be supported by in house training. 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. The progress of this issue was not discussed at this inspection, the manager should write to the commission outlining the progress. Security for the home at night was discussed and the manager has developed a check list for staff to complete, which should ensure residents are safe at night. The manager has confirmed that Night checks are in place and the manager is on site and does these checks at random. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 28 The proprietor must explain in writing the progress and plans for recruitment of new staff to the home. It is acknowledged that since the inspection the manager stated that he has fifteen application forms which should ensure that he can recruit a number of staff. The manager is reminded that staffing levels must 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 2pm 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 2pm to 8pm. At night the home must never fall below four carers and one trained nurse. These staffing levels will be reviewed again at the next inspection as discussed earlier in this report. If residents’ needs change the proprietor and the manager must ensure that they increase staffing levels to reflect this. The manager must ensure that if for any reason staffing does fall below these levels they must inform the Commission. The manager is aware of his responsibility to inform the Commission under Regulation 37 should staffing levels fall below these numbers explaining what measures he has taken to remedy the situation. The manager confirmed that he had explained to trained nurses their responsibilities in informing the commission regarding regulation 37. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 29 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38. Some audit systems fail to include residents’ 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 and include more detailed information and be supported by a clear in- house review to ensure immediate action is taken to protect residents. Supervision for all staff must be in place to support the service delivery. EVIDENCE: The new manager has been in position for a number of weeks and their has been some progress regarding a number of requirements however, the proprietors must write to the commission outlining their progress. The manager must apply to the Commission to be registered. Since the inspection the manager has been sent an application form. The manager confirmed that Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 30 the home has a number of issues and these include communication with families, and changing the ‘culture’ of the staff team. The manager has a number of ideas which it is hoped will encourage the changes needed to support the process of change. It is acknowledged that the manager has registered on a Registered Managers Award. Accident records viewed need to contain more detail with follow up actions to prevent any further incidents, risk assessments may need to support the process and the manager is required to audit to ensure that if there is a pattern to falls or an environmental issue this can be addressed immediately. Some documentation was not recorded on the appropriate forms. Accidents and incidents recorded did not always correlate with other areas of the care plan for example the daily log did not interrelate. For example a bruise noted on a residents forearm and detailed on an incident sheet did not correlate in any daily log covering a five day period. It is strongly recommended that the manager purchase an appropriate accident book and that staff training includes staff being aware of the difference between accidents and incidents. It is acknowledged that audit of these records is done centrally by the proprietor. It is not evident that staff or trained nurses receive formal supervision. The manager must ensure that all staff receive formal supervision at least six times a year. The manager will need to develop a culture of supervision. The proprietors will need to continue to support the manager through formal supervision at least every month, as well as their obligations under Regulation 26. It is apparent that the proprietors are not sending regularly to the Commission a copy of their Regulation 26 reports. This is a requirement of this report. Quality audits and systems to support the care of residents involving the residents, as individuals will need to be developed to support the service delivery. Generally health and safety records viewed were in order. However, these records are not held on the premises and risk assessments must be reviewed and updated regularly. It was noted that objects were not being used to hold open doors during the inspection. This was a requirement at previous inspections. The manager is required to ensure that all health and safety records must be available for any inspection and held in the home. It is strongly recommended that wheel chairs are checked monthly and emergency lighting is checked monthly. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 31 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 X X 2 X X N/A 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 2 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 1 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 1 X 1 Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 32 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 12 (1) (b) Requirement Timescale for action 31/12/05 2 OP7 12 (1) (b) The 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 by an acredited trainer 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 fully met). Timescale at this inspection not exceeded. Time scale agreed with the new manager 30/06/05 All staff must be trianed and 30/06/06 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. Previous timescale of 31/ DS0000019236.V252559.R01.S.doc Version 5.0 Ker Maria Page 33 3 OP38OP7 13 (4) 4 OP9 13 (2) 08/05 not fully met. The new timescale has been agreed agreed with the new manager. Risk assessments must be developed to detail maintaning residents independence and indentifying any potential risk and available for inspection purposes. Generic risk assesments must be reviewed regularly. Previous timescale of 31/ 08/05 not met. Timescale at this inspection exceeded. The new time scale has been agreed agreed with the new manager. The manager must ensure that there are safe medication practices at the home through the following. The manager will need to develop PRN management plans for each service user who is prescribed medication PRN. The manager must develop further the homes protocol to support the covert administration of medication ensuring that families permission is gained and recorded. The 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 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 fully met). Timescale at this inspection not exceeded. The new time scale has been agreed agreed with the new manager DS0000019236.V252559.R01.S.doc 30/06/06 30/06/06 Ker Maria Version 5.0 Page 34 6 OP36OP30 OP27 18 (1) (a) 7 OP36 18 (1) (a) 8 9 OP38 OP38 13 (4) 13 (4) 30/06/06. The proprietor and manager must ensure that staff are trained by a recognised trainer to provide dementia training for all care and nursing staff. The proprietor and manager must develop a programme of planned supervision for all nursing and care staff. The manager must ensure that accident records accurately reflect the given situation. The manager must have evidence that he has consulted the fire department and environmental health officer regarding risk assessments. 30/06/06 31/03/06 31/01/06 31/01/06 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 OP38 Good Practice Recommendations It is strongly recommended that wheel chairs are checked monthly and emergency lighting is checked monthly. Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 35 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury 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. Extracts may not be used or reproduced without the express permission of CSCI Ker Maria DS0000019236.V252559.R01.S.doc Version 5.0 Page 36 - 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. 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