Inspection on 29/06/07 for Ker Maria

This inspection was carried out on 29th June 2007.

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 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 18/12/06

Ker Maria 25/05/06

Ker Maria 16/11/05

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 HP27 0JG Lead Inspector Julie Willis Unannounced Inspection 29th & 30th June 2007 09:35 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.V337539.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ker Maria Address The Retreat Aylesbury Road Princes Risborough Aylesbury Buckinghamshire HP27 0JG 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) swhitcombe@anh.org.uk 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.V337539.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Elderly Physically Frail Elderly Mentally Impaired Date of last inspection 18th December 2006 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 to the registered manager. Information to support potential Service Users and their families to make a decision for admission to the home is provided in the homes Statement of Purpose and the Service Users Guide. Both of these documents are provided to potential Service Users, with additional copies held in the home. The fees charged are presently between £525.00 and £625.00. Additional costs exist for such things as hairdressing, newspapers and personal toiletries. Information pertaining to the current fees was received from the Home on the 17th November 2006. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspection took place on Thursday 28th & Friday 29th June over a 14-hour period and covered all the standards for older people. Prior to the visit a questionnaire was sent to the Manager along with survey and comment cards for residents, relatives and visiting professionals such as doctors and nurses. Any replies were used to help form judgements about the service. Consideration has also been given to other information that has been provided to the Commission since the last inspection. The inspector toured the building, examined records and met most of the residents and five relatives that were visiting at the time of the inspection. The inspector also spent time talking to staff and observing how care was being delivered to the residents. The inspector gave feedback about her findings to the homes Manager at the end of inspection. There were 4 outstanding requirements from previous inspections that had been partially met at this inspection. These requirements are therefore repeated with an additional time scale to provide the home with extra time for completion. The home will also be required to complete an Improvement plan to say how it will meet the requirements and improve its service to residents. There has been no information about any complaints reported to the CSCI since the last inspection. What the service does well: Since the last inspection in December 2006 there has been a change of Manager at the home. The new Manager has been in post since March 2007 and is working hard to improve the standard of care provided to the residents. Residents and relatives speak highly of the new manager and confirm that he is “caring, kind and approachable”. The home is comfortable, clean and attractively decorated and furnished throughout. Residents are encouraged to personalise their own rooms and these are decorated and furnished to a good standard. There is enough staff on duty at all times to meet the needs of residents effectively. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 6 The home offers residents a range of leisure activities including games, crafts and quizzes as well as the opportunity to see outside entertainers and to join in parties and themed events. At the time of inspection residents in the ground floor lounge were enjoying, watching and participating in flower arranging. One resident said, “ I like doing the flowers, it gives me something to do. They are so pretty, I helped to cut them from our beautiful garden”. Food provided by the home offers residents variety and choice and is well presented in pleasant comfortable surroundings. What has improved since the last inspection? What they could do better: Although there has been improvement in the records since the last inspection, there is a need to ensure that care plans are kept up-to-date and accurately reflect the needs of residents. All care plans should be underpinned by effective risk assessment and risk management measures. Guidelines to staff on how to reduce identified risks should be clear, unambiguous and concise. There is a need to consider how records can be accurately maintained in the event of a computer system failure. Paper records should be kept as a back up. New and agency staff should be able to know what the needs of each resident are as soon as they come on duty it may be of benefit to provide them with a synopsis or pen picture of each resident. There are still gaps on the medication charts. All medication records should be kept accurate and up-to-date failure to do so could pose a risk to residents. There is a need for agency nurses to be reminded of their professional responsibilities in relation to medication. It would be of benefit if a double check system could be introduced. The staff team should receive refresher training in ‘Safeguarding Adults’, ‘Equality & Diversity’ and ‘Customer Care’ to ensure that the values that underpin the care to older people are fully understood and so that residents care can be provided in a manner which maintains their right to privacy, dignity and independence. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 7 The staff recruitment procedures should be improved to ensure that all necessary checks are undertaken to ensure the safety of the residents. The temporary Manager should register with the CSCI as soon as possible. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. Prospective residents are fully assessed prior to admission to ensure their needs can be effectively by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the pre-admission assessment documentation for 3 residents evidenced that all necessary information about the resident’s health and personal care needs are sought prior to admission. The use of clinical tools to assess the residents dietary needs, communication needs, mobility needs, risk of falls, continence and mental state are well developed. Residents spoken with during inspection confirmed that they had been visited by the homes staff pre-admission and had been provided with sufficient information about the home to enable them to make an informed decision as to whether to live there or not. They said that they had been given the opportunity to visit the home informally prior to admission and one of the Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 10 residents said that their relatives had visited the home on their behalf to meet staff and to observe the homes routines and to assess its general ambience. The majority of the current residents have been referred through the Care Management system. In each case the home obtains a summary of the Care Management assessment and copy of the referral form prior to admission. At the time of inspection two new referrals were made to the home. The Senior Nursing Sister carried out the pre-admission assessment of the prospective residents in nearby hospitals. The completed documentation was of a good standard and provided the essential information needed to provide the basis of the residents care plan. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is poor. The care plans have been improved since the last inspection but still do not accurately reflect the needs of the residents. Risk assessments lack clarity and do not provide staff with sufficient information on how to protect residents from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector viewed care plans that were being stored on line. They were minimal in content and did not always provide staff with enough information. It is not clear how someone coming on duty for the first time would provide care to the residents without trawling through all the records stored this way. Risk assessments were likewise minimal in content and did not always provide a safe system of work. Staff told the inspector the computer system ‘crashed’ repeatedly throughout the day and this was evidenced during inspection. It is not clear what staff would do in the event of a complete system failure or power-cut. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 12 Medication records were examined. Although the permanent qualified staff have significantly improved their own performance in relation to the administration of drugs, it was evident that agency staff have not administered medication with the same efficiency. Examination of the administration of medication for the evening before inspection evidenced gaps in the recording of medication given. An agency nurse had given the evening medication. There is a need to ensure that all nurses including agency workers are reminded about their professional responsibilities in relation to the safe administration of medication. Throughout the inspection period, staff were observed to provide care in a manner, which maintained residents privacy and dignity, however, a number of residents and relatives made comments to the inspector about the attitude of individual members of staff. These issues were raised at the time of inspection with the Manager who undertook to investigate the concerns raised. As part of the inspection the inspector had the opportunity to sit in on the morning to afternoon shift handover. The information provided to staff by the nurses was found to be entirely resident focused and appropriate. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is good. A range of activities is offered that provide opportunity for mental and physical stimulation. Residents are encouraged to maintain contact with their family and friends and are able to have visitors at any time. The home provides a varied and nutritious menu designed to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the management, staff and residents it was clear that people living at the home are offered the opportunity to participate in a range of activities suited to their needs. The home employs two activity organisers that provide a range of activities, quizzes and games. Discussion with one of the Organisers confirmed that they also offer one to one activities to residents on the dementia floor, as they are enthusiastic and keen to engage with all of the residents including those with complex needs. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 14 The home had recently held its summer fete to raise funds for outings and other social entertainments and residents confirmed its success. The home has an integral Chapel where residents may participate in church services. A number of the residents are retired Sisters and are visited frequently by the local Catholic priest and friends from their Order. Residents confirmed that their visitors are made most welcome at any time and are offered appropriate hospitality during their visits. A number of social events are held throughout the year which promotes community involvement and which provide residents families with the opportunity to engage with the staff and residents on an informal and regular basis. The food is considered by the residents and their relatives to be of “good quality”. Residents are encouraged to take meals in the dining rooms to aid socialisation but a number choose to eat in their rooms. The residents were eating lunch of home made cauliflower soup, chicken in thyme and white wine sauce with courgettes, leeks and Swede or vegetable pizza followed by home made trifle. Tea was fish fingers with mushy peas followed by rice pudding. There are vegetarian alternatives to the main course each day and these are displayed on a menu board in the dining room. Special diets can be catered for including soft diets, diabetic and vegetarian meals. Discussion with the chef and with residents evidenced that each suppertime residents may have milky drinks and snacks, toast or sandwiches, which are served by staff from the satellite kitchens. There is a choice of breakfast, which can be ‘full English’ toast, cereals porridge and fresh fruit. The Chef makes cakes each day and party cakes for special occasions such as birthdays and anniversaries. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is poor. The home has an accessible complaints procedure and residents and relatives feel confident that their complaints will be listened to and acted upon. However, issues relating to ‘Safeguarding adults’ are not always referred to the ‘Safeguarding Adults’ Co-ordinator appropriately, which puts residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an accessible complaints procedure and residents and their relatives confirm that they are confident that their complaints will be listened to and acted upon. Most of the residents said that they had never had to make a complaint, as they were “happy with the care provided”, however, they knew what to do if they wished to make a complaint. There have been a number of incidents reported to the home that should have been referred on to the ‘Safeguarding Adults’ Co-ordinator at the Local Authority for their advice and support. Several residents and relatives commented to the inspector about the “poor” attitudes of individual members of staff and episodes of unexplained bruising. These issues were discussed at length with the Manager who undertook to report one issue retrospectively to the Vulnerable Adults Co-ordinator at the Local Authority before the inspection ended. There is an urgent need for all staff to be retrained in the ‘Safeguarding of Adults’, ‘Equality and Diversity’ and ‘Customer Care’ to ensure all staff are Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 16 clear about what is expected of them and to reinforce the values that underpin their work with service users. There were serious deficiencies in recruitment that could pose a risk to residents. There was no evidence on several staff files that staff had been POVA (Protection of Vulnerable Adult) checked or had CRB (Criminal Records Bureau) checks. Nurse’s pin numbers had not been checked or recorded to ensure that they were qualified and competent to practice. The Manager undertook to check nurse’s registration at the time of inspection. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. The home is maintained as a safe and risk free environment for the residents. The home is comfortable, clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents were complimentary about the quality of décor and furnishings in the home. They said that the home was always clean, comfortable and hygienic. They said that the domestic staff always kept the toilets and bathrooms clean and fresh and vacuumed and dusted their rooms regularly. Communal areas were spacious bright and airy and comfortably furnished. Residents spend much of their time in one of the homes two lounges, which are currently the focus of the homes activities. One resident said that they particularly liked the room on the ground floor because they were able “to meet their friends and do activities with them”. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 18 Residents also told the inspector that they were able to bring with them small items of furniture and pictures and ornaments to personalise their own bedrooms. All staff have received training in infection control however, several staff were observed to be wearing gloves inappropriately from one resident to another and whilst transporting residents in wheelchairs. The Manager addressed the issue with those concerned at the time of inspection therefore this issue is not subject to requirement. From discussion it was clear that all domestic staff understand the need to use appropriate cleaning products and chemicals safely and have had health & safety and COSHH (control of substances hazardous to health) training. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards b27, 28, 29, 30 Quality in this outcome area is poor. The recruitment practices at this home are inadequate and do not protect residents from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection there were no recruitment files on site. From discussion with the Human Resources department it was clear that staff files had been removed from the home to input data onto the computer system. The inspector was told that this process had just started at Head Office and in future the records will be viewed on line. All original documentation will be scanned into the system so that these documents may be open to inspection. At the request of the inspector 10 staff files were faxed to the home for inspection. Of the files examined it was evident that not all necessary checks had been carried out on staff to ensure that they possess the necessary attributes to care effectively for users. In several cases there had been no POVA or CRB check undertaken before a new employee took up position and not all of the nurses registration details had been checked to ensure that they were competent and qualified to care for the residents. There was some evidence that staff have been inducted to Skills for Care Standard but the documents had not been signed off to evidence completion. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 20 Most staff had received training in core skills such as fire safety; first aid, manual handling, food hygiene, health & safety, COSHH and infection control but some of the training required a refresher. Not all staff had received training in POVA (protection of vulnerable adults). A number of the care staff have either achieved or are working towards a National Vocational Qualification at level 2 or 3 but this is not consistent. There were sufficient numbers of staff on duty at the time of inspection to effectively meet the needs of residents. There were 2 nurses and 10 carers on duty in the morning and 2 nurses and 8 carers on duty in the afternoon and evening. At night there is 1 nurse and 4 carers on duty in the home. A large number of agency workers are currently working at the home to cover gaps in the roster. Most residents felt that the staff in general were “kind, caring and helpful” but there was a level of dissatisfaction with the attitude of some individual members of staff. The issues were discussed with the Manager at the time of inspection that undertook to investigate the concerns raised. The inspector interviewed 5 of the permanent staff. The majority confirmed that they liked working at the home and felt supported and included in the way the home is run. They said that they attend staff handovers at the beginning of each shift and have regular staff meetings. They confirmed that they do not have formal one-to-one supervision sessions at the moment but that the Manager had informed them that these sessions are set to start in the near future. The inspector discussed supervision with the Manager who undertook to start supervision sessions as soon as the nursing staff were trained in how to complete the necessary documentation. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 38 Quality in this outcome area is poor. There is evidence that resident’s health welfare and safety is satisfactorily maintained. Management are qualified, competent and experienced to run the home for the benefit of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current Manager - Stewart Whitcombe, has been in post since March 2007. He is an experienced RGN & RMN. The Manager was recruited from an agency and is on a temporary contract. He is set to remain at the home until December 31st 2007. Over the last few months the Manager has been working hard to improve the standards in the home and to meet the outstanding requirements. A team of Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 22 senior nurses that are well motivated and aspire to providing good quality care supports him in the day-to-day running of the home. There have been significant staff shortages in the home over recent months. This has led to an over reliance on agency staff to cover gaps in the roster. This in turn has put an added burden on permanent staff and management who are constantly trying to train new staff. As a result staff and residents say that staff do not always work together well as a team and there has been a lack of continuity for residents. The home has recently introduced monthly resident and relatives meetings as part of the quality assurance process. One relative said he thought the meetings “were beneficial and helped to iron out misunderstandings”. Additionally a consultant has been employed to carry out the Proprietors representative visits on a monthly basis where quality of service provision is also monitored. Monies belonging to residents were found in named envelopes in the safe but no records were kept of the amount deposited and no receipts had been kept of any monies spent on behalf of individual residents. The lack of a safe cash handling system put residents at significant risk of financial abuse. On the advice of the inspector the Manager and Administrator carried out an audit of the monies held and entered the sums deposited in a ledger. The manager intends to return all monies held to the resident and/or relatives and no monies will be held on behalf of residents in the future. There is a need to improve the support and guidance to staff as there was evidence that staff do not feel properly valued for the work they do. There is a need to introduce a programme of supervision and appraisal to the home, which offers staff more opportunity to express their views on how the home is run, to discuss areas of practice and to identify their own personal development needs. Examination of a sample of health & safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals in general to maintain the home as a safe and risk free environment for users. Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 23 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 1 x 3 Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 24 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 13(4) Requirement The registered manager must ensure all individual service user risk assessments are completed in full and kept under review. Strategies must be put in place when a risk is assessed as high to reduce the likelihood of harm. That all service users have an appropriate moving and handling plan in place. This is a repeated requirement - original timescale of 31/07/06 and 15/03/07 not met. 2. OP7 15 The registered manager must continue to address the recurrent deficiencies in service users care planning to ensure care plans are written in a person centred manner, reflecting service users preferences and wishes. contain sufficient information as to how actions are to be achieved in relation to assessed needs. Care plans are updated when DS0000019236.V337539.R01.S.doc Timescale for action 30/07/07 30/07/07 Ker Maria Version 5.2 Page 25 significant changes to a service users condition occurs This is a repeated requirement - original timescale of 31/08/06 and 31/03/07 not met. 3. OP9 13(2) The registered manager must take the appropriate action to ensure that the nursing staff involved in medication administration complete the medication administration records accurately. In the case of non-administration that entries are made using the provided key to account for any omissions. This is a repeated requirement - original timescale of 31/05/06 and 15/01/07 not met. 4. OP36 18(2) That the registered manager ensures that an effective system is introduced to ensure all staff are formally supervised on a regular basis. Such supervision must include discusion of practise, philosophy of the care in the home and career devlopment needs. This is a repeated requirement. Time scale of 28/02/07 not met 5. OP30 18 (1) c (i) Ensure that all staff are provided with refresher training in Safeguarding Adults, Equality & Diversity and Customer Care & Values in order to provide residents with care in a manner which maintains their right to privacy, dignity and autonomy 30/09/07 30/08/07 30/07/07 Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 26 6. OP29 19 Ensure that all staff are properly recruited and that all necessary checks are carried out to safeguard residents from harm Ensure that the Manager registers with the CSCI 30/08/07 7. OP31 8 30/08/07 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 OP7 Good Practice Recommendations That the Organisation considers how best to use paper records as a back up when computer records are unavailable to staff Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ker Maria DS0000019236.V337539.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!