Inspection on 29/11/07 for Ker Maria

This inspection was carried out on 29th November 2007.

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 29/06/07

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 Delia Styles Unannounced Inspection 10:45 29 and 30th November 2007 th 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.V348220.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.V348220.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 vacant post 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.V348220.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 30th June 2007 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. The ground floor has 20 single bedrooms, eight of which are en-suite. The first floor has 21 bedrooms of which six have en-suite facilities. The proprietors for the home are the Augustine Sisters who delegate the day-to-day management of the home to the manager. Information to help potential residents 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 residents, with additional copies held in the home. The fees charged are presently between £640.00 and £670.00. Additional charges are made for such things as hairdressing, newspapers and personal toiletries. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Thursday 29th and Friday 30th November 2007 and a total of 12 hours were spent in the home. It was an unannounced ‘Key Inspection’ during which the inspector assessed the standards considered most important (‘key’) by the Commission out of the 38 standards set by the government for care homes for older people. It was the second inspection of the home in 12 months because the outcomes in three important areas – ‘Health and Personal Care’ , ‘Complaints and Protection’ and ‘Management and Administration’ – were poor at previous inspections. There was a total of 7 requirements made at the last inspection in June 2007, of which 4 were requirements that had been repeated over two previous inspections and were still not wholly met, so the home was given additional time for completion. This shows that the home has repeatedly failed to take prompt action to improve aspects of care and service to residents in the areas highlighted at inspections. A warning letter was sent to the provider in August 2007 stating that we must be informed about the actions taken by the home to address the requirements made within the timescales stated and that continued failure to improve will result in enforcement action by the Commission. The current home owners – the Augustinian Sisters – have the legal responsibility to ensure that the requirements made as a result of this inspection are met. The inspector saw all areas of the home and looked at a sample of records and documents relating to the care of the residents. The inspector met most of the residents, and three relatives who were visiting. The inspector also spent time talking to staff and observing how care was being delivered to residents. The temporary manager was available on both days and feed back was given at the end of the inspection. We found there was evidence that the manager and staff have worked to address problems identified in previous reports. However, we do not have confidence that the improvements will be maintained, because of the changes in management and ownership of the home that are to take place in the near future. Lack of communication between the current proprietors and the home has had a negative effect on staff morale and recruitment, and caused residents and their families and representatives anxiety about the future of the home. The inspector would like to thank the temporary manager, residents and staff for their time and assistance during the inspection. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 7 Further work is needed to make sure that the information in residents’ care records is kept up to date and that significant changes are recorded so that staff can show what actions they are taking to address any problem areas. The homes procedures for investigating and following up complaints must be improved, so that residents, their families and representatives can be confident that any concerns are dealt with promptly and effectively within the organisations own stated timescales. The provider must review the number and skill mix of staff employed, and increase the number of permanent staff, so that there are always enough suitably skilled and experienced staff available to meet the assessed care needs of the residents. The staff recruitment procedures are undertaken through the organisation’s Human Resources staff in Sussex. At this inspection, there were no paper records about staff held in the home and electronic records were not available to the manager. The procedures must be improved to demonstrate that all necessary checks have been done to ensure the safety of the residents and that the manager has written confirmation from the employer that prospective workers are suitable to work at the care home. The care home must ensure any agency supplying staff provides confirmation to the home that staff supplied have satisfactory Criminal Records Bureau (CRB) and, for registered nurses, that they are currently registered with the Nursing and Midwifery Council (NMC) as fit to practice. The home still has no effective system for the regular, formal supervision of staff. It is important that staff have a regular formal time of discussion with managers so that they can review their progress in their work and identify any training and development needs. This is an outstanding requirement from two previous inspections. The registered provider (the Sisters of St Augustine) must comply with Regulation 26 of the Care Homes Regulations 2001 and the Care Standards Act 2000. This means having a representative of the organisation visit the home unannounced at least monthly, and providing a report of their visits, in order to monitor the well-being of the residents and check that the home is being effectively managed in the residents’ best interests. The registered provider has failed to inform the Commission of all ‘untoward’ incidents as required under Regulation 37 of the Care homes Regulations 2001 – for example, deaths, serious injury or any thing that adversely affects the well being or safety of residents. This means that the organisation is not reporting or monitoring these incidents properly, so that action needed to prevent accidents or outbreaks of infection may not be effective in protecting residents from avoidable harm. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 8 The organisation must inform the Commission and the residents and staff of about the on-going management arrangements for the home. The recent poor communication between the Sisters and the residents, relatives, and staff has had a negative effect on peoples’ sense of security. The engineering checks needed to the passenger lift must be undertaken to reduce the risk of equipment failure and potential harm to residents, and to comply with the terms of the insurance policy. 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.V348220.R01.S.doc Version 5.2 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.V348220.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 does not apply – the home does not provide intermediate care Quality in this outcome area is good. Prospective residents are fully assessed prior to admission to ensure their needs can be effectively met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive set of information about the home – the Statement of Purpose, Residents’ Handbook, current fee rate, information about the history of the provider organisation, the congregation of ‘The Sisters of St Augustine of the Mercy of Jesus’, summary of the complaints procedure and Statement of Terms and Conditions - is given to all prospective residents. It was noted that the temporary manager is named as the ‘registered manager’: this is misleading as the manager has not applied to be registered with the Commission, and his contract of employment finishes at the end of December 2007. The Statement of Purpose should be amended to correctly reflect the management arrangements for the home. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 11 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 manager or assistant manager undertakes the pre-admission assessment of prospective residents. The completed documentation seen was of a good standard and provided the essential information needed to provide the basis of the residents’ care plans. 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 the person’s admission. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10 Quality in this outcome area is adequate. Further improvements to the care planning system have been made since the last inspection but there is still a need to develop the written records so that they are up to date and adequately provide staff with the information they need to satisfactorily meet residents’ needs. The systems for the administration of medicines have also improved with good liaison with the supplying pharmacist to ensure residents’ medication needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of 4 residents care records was looked at. Since the last inspection, the home has kept paper copies of most of the care plans and recent care records for each resident in addition to the computerised care plan system. This provides staff with essential information about residents’ care needs should the computer system fail and enables temporary or agency staff to update themselves about the residents. The home has started to gather information from residents and relatives in the form of ‘Life Profiles’ in which residents are invited to describe their past Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 13 occupation, family and social network and their hobbies and interests. This should help staff to get to know new residents and plan their care with them more effectively and in a more ‘person-centred’ way. From the records seen, we consider that more work is needed to link risk assessment information – for example, residents’ risk of malnutrition or developing pressure-related skin damage (pressure ‘sores’/’ulcers’) – with the planned care and the monitoring of the risk over time. One person’s care record showed a significant weight loss of more than 3 Kilograms in a 4 week period, but this had not been noticed by staff and no action had been planned, for example, referring them to a dietician for advice again. Other examples noted were the lack of recording of action taken to provide necessary pressure relieving mattresses and seat cushions where a resident had been admitted with damaged pressure areas. Though the specialist equipment was in place, there was no record of when, or what type of equipment had been provided. There was no care plan for the skin care and prevention of infection for a person had recently completed a course of treatment as a hospital outpatient. It is particularly important to keep the written records of care and treatment up to date, so that all staff (especially part time and agency workers) are aware of treatment changes that have been made, and to maintain continuity of care for residents. However, during the two days of the inspection residents looked well cared for, comfortable and well presented. Relatives spoken with said that the care was very good. Staff spoken with also felt that the standard of care they provide is good and in discussion, showed they have a good understanding of residents’ individual care needs. The home now uses a monitored dosage system (MDS) of packaging for residents’ prescribed medicines– a local high street chemist dispenses the medication in pre-filled blister packs with each individual’s medication prepared with tablets for morning, afternoon, evening and night time ‘rounds’, as required. Staff said this system works well. A pharmacist from the dispensing chemist was visiting the home on the first day of the inspection and checked medications for residents on the ground floor. Staff said the pharmacist was very helpful in advising about liquid preparations of prescribed medications that could be provided for residents who have difficulty in swallowing tablets or capsules. The pharmacist has also informed staff about the medication training that they can provide. The medication administration record (MAR) charts for 4 residents were checked. These were correctly completed and with no omissions, indicating that the prescribed medication had been correctly administered. However, for one person a handwritten change had been made to their MAR chart by a member of the nursing staff that had not been countersigned by the prescribing GP or by a second nurse - this is ‘best practice’ to avoid errors in Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 14 transcribing the changed medication orders that could result in harm to the resident. Throughout the inspection period, staff were observed to provide care in a kind and respectful way that maintained residents privacy and dignity. However, discussion with the temporary manager and a formal complaint reported to the Commission by a relative during the inspection period, confirmed that there are still problems with some individual staff members’ attitude and practices that are poor. The home manager and provider undertook to investigate the most recent incident and to take action to prevent a recurrence. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 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. However, comment cards received in June and the homes’ own assessment of its quality in this area indicate that there is a need for more opportunities for outings and organised trips out, and use of the gardens, especially for the more mobile and physically able residents. The home employs two activity organisers who provide a range of activities, quizzes and games. At the time of the inspection staff were starting the preparations for Christmas – putting up the trees and decorations. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 16 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. Some residents and relatives felt concerned that when the home is sold to new proprietors, the chapel facility, and pastoral links with local churches will be lost. On the second day of the inspection a local Church of England representative was visiting residents around the home before leading a service of Holy Communion in the afternoon. 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 promote and maintain links with the local community and which provide residents families with the opportunity to meet with the staff and residents on an informal and regular basis. Money raised from a number of social events provides a fund for the activities organisers to make purchases for Christmas and games and equipment. The food is considered by the residents and their relatives to be good. Residents are encouraged to take meals in the dining rooms so that they have more opportunity to socialise, but a number choose to eat in their rooms. 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. The home has recently altered the mealtimes to allow more time between meals at the request of residents and relatives. Breakfast is now at 8 am, lunch between 12.30 and 13.00 and supper between 17.30 and 18.00. Milky drinks and snacks, toast or sandwiches, which are served by staff from the satellite kitchens, are available between mealtimes. 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.V348220.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. Since the last inspection the arrangements for training for staff about safeguarding adults issues are in place. However, the management responses and follow-up processes in relation to complaints, and the procedures for referral to the local Safeguarding team are still not consistently applied, leaving residents at potential risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an accessible complaints procedure that is included in the folder of information given to all residents and their representatives. Since the last inspection a programme of training for staff has been put into place about Safeguarding Adults, and how to recognise and report suspected abuse. A trainer from an independent company was at the home on the second day of the inspection to provide training, and was due to lead another session in December. The temporary manager could not confirm whether the trainer explained the role of the local social services safeguarding team, or whether staff are made aware of the local multi-agency safeguarding policies and procedures and how to report any concerns to them. We are concerned that, despite a number of recent concerns and incidents that should have been referred to the ‘Safeguarding Adults’ Co-ordinator at the Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 18 Local Authority for their advice and support in the past, there is still no consistent policy or practice implemented by the home providers and manager. This was again evidenced shortly after the inspection, when a relative made a formal complaint to the provider and the Commission. The manager had not contacted the Local Authority and providers about the complaint and had not initiated an internal investigation of the incident. At a meeting with the providers, 5 days following the complaint, the Commission had not been informed about the actions taken by the home as a result of the complaint. The homes’ complaints forms are held electronically. When asked about the action staff would take if they received a complaint, they said they would complete the form on-line and send it to the Head office. It was not clear how staff would report concerns or ‘grumbles’ to the manager or how the home would record these and show that action had been taken to address people’s concerns. The manager had a file with correspondence relating to 6 formal complaints received in the past 6 months. There is no clear audit trail to show how what action had been taken, how quickly, and if the outcomes were satisfactory to the complainants. It is important that all staff are aware of, and adhere to the homes procedure for handling and processing complaints so that the home can demonstrate that complaints are investigated promptly and effectively. Residents, their representatives, and the homes staff need to be confident that their concerns are acted upon and that, where there is evidence of poor practice and care, the home takes rigorous action to prevent a recurrence. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Overall, the standard of the environment is good providing residents with a comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is clean, well decorated and welcoming. At the time of this inspection, staff were busy setting up Christmas trees and decorations. Communal sitting rooms on the ground and first floor are spacious bright and airy and comfortably furnished and most residents spend much of the day in the sitting rooms where they can join in or watch activities. The design of the building does present some problems for transferring some more dependent residents around the building – for example the narrow width of ground floor corridors and door frames, makes access to rooms and the use of hoists difficult for staff to assist residents who are more dependent. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 20 We understand that the prospective new owners intend to build a purpose built home in the grounds that will meet the current standards for care homes and address the problems of the current home environment. The home employs a full time maintenance person to deal with the day-to-day repairs and maintenance in the home, and organises the routine service and upkeep of the equipment. The manager reported that there had been difficulties in recruiting cleaning staff but new staff had recently been appointed. The temporary manager admitted he was unclear about the housekeeping role and could not verify whether new cleaning staff had received training in the correct use of cleaning chemicals and equipment. The laundry is in a separate outbuilding. It is clean, tidy and well organised, with appropriate separation of dirty and clean laundry work. There are designated laundry staff on duty during the day. The manager confirmed that night staff do not leave the main building to undertake laundry work at night. Residents’ clothing and bed linen looked clean and pressed. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. The staff morale is low with high levels of sickness and turnover of staff. This situation is potentially detrimental to the consistency of care offered within the home. The recruitment practices at this home remain inadequate with limited evidence that the appropriate checks are being carried out, potentially leaving residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing numbers for the home were discussed with the manager. The duty rota seen confirmed that the home is regularly staffed by one registered nurse and 5 care staff on each floor during the morning shift (07.45 to 14:00) and one registered nurse and 4 care staff during the afternoon/evening (13:45 to 20:00). At night (from 19:45 – 08:00) there is one RGN and 4 care staff for the whole home. The manager is supernumerary and assistant manager now has more supernumerary hours to allow her to co-ordinate the care and training throughout the home. From direct observation during this inspection and the information provided in the homes AQAA it is clear that the physical dependency of most residents remains high – for example, 75 of residents are doubly incontinent and have dementia; at least 4 residents are bed fast because of their age and frailty; Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 22 just over 50 of the residents need two or more staff to help with their care; and 75 need help, supervision or prompts to eat their meals. A large number of agency workers are currently working at the home to cover gaps in the roster. Permanent staff also cover colleagues’ absence by working additional shifts over and above their contracted hours. The home regularly uses 2 agencies – one for the supply of Registered Nurses and another for care assistants. Though the agency staff supplied are usually ‘regulars’ and so get to know the home and residents over time, the failure to recruit permanent staff to the home is of concern. Relatives have also raised their concerns about staffing – in relation to staff motivation, absence and sickness levels - as an on-going problem, as evidenced in their comment cards (June 07) and Relatives’ Meetings (minutes of meetings held in August and September 2007). Comments made in surveys from relatives in June 2007 reflect that low numbers of staff particularly at night and at weekends is a continuing concern: one person wrote (June 07) ‘I feel 2 carers at night for 20 clients many of whom need 2 carers to move them, is not sufficient’. Another person considered that ‘agency staff’ did not always have the right skills and experience to look after people properly and added ‘if it were not for the few loyal carers, the home would fold’. The sample rota (covering 19th November to December 2nd 2007) showed that between one and four shifts were covered by agency staff on each weekday and between 1 and 3 shifts were covered by bank staff or regular staff working overtime on all days (according to the sampled rota, agency staff are not used at weekends). Several staff who had ‘picked up’ additional shifts were working a mixture of night and 12-hour day shifts in the same week, and with irregular time off in between shifts. There is a potential for staff to become overtired and more prone to sickness and injuries when working long hours, which puts residents at potential risk of inconsistent or poor care. From survey responses received at around the time of the inspection in June 07 and from discussions with relatives, residents and staff during this visit, it was clear that most staff are committed to the residents and achieve a good standard of care but the morale of staff has been adversely affected by having 3 different home managers in a short time and the lack of information about their future employment when the home is sold. The provider must review the staffing levels and employ sufficient numbers of permanent staff with the appropriate skills and training to meet the care needs of residents at all times. There was evidence that the home has improved the training programme for all staff and the assistant manager has taken on the role of co-ordinating and Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 23 arranging training in the home. The manager said that in order to provide staff with training and development there had to be sufficient staff available to maintain the care for residents whilst releasing others to attend training. One recently recruited carer confirmed that s/he had received induction training that included infection control, basic health and safety, manual handling, basic food hygiene and use of hoists. There were copies of this individual’s certificates of training attendance. Two other carers spoken with agreed that there is a lot of training organised now – ‘something on every month’. The assistant manager also reported that there is an increase in the number of staff who have achieved or are working towards National Vocational Qualification in care (NVQ): 5 care staff have NVQ Level 2 or above; 8 carers are working towards NVQ Level 2 and 4 towards NVQ Level 3. Several staff had completed a distance-learning course in palliative care that had been very good; more staff are planning to undertake this course in the future. As at the last inspection, we found there are no recruitment/staff files held on site. The temporary manager explained that prospective employees complete an application form and Criminal Records Bureau (CRB) form at the home and this is then forwarded to the homes Human Resources department who follow up references and process the necessary checks. From discussion with the manager and Human Resources representative, it was clear that process of transferring staff data into the computer system was still ongoing. The temporary manager had created basic paper files to keep in the home with contact details and a record of training for new staff. Staff records were still not accessible to the manager on line. The Human Resources department gives the temporary manager verbal confirmation when the necessary CRB clearances have been obtained and that the workers can start in the home. The inspector requested that copies of the 5 most recent employee files were faxed to the home, to check that the recruitment process is consistent and robust. These were not available by the time the inspection visit ended. The providers were requested to supply this information during a meeting in the week after the inspection and this was done. The paperwork received showed that new staff had satisfactory references and CRB clearance before being started in the home. However, the home manager does not have access to, or have confirmation in writing, that the employer has obtained all the information and documents specified to evidence that the people employed are ‘fit to work at the care home’: for example, proof of identity (including a recent photograph), and Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 24 evidence of qualifications (verification of registered nurses’ current registration with the Nursing and Midwifery Council (NMC); and evidence of training/qualifications for the persons relevant to the work that is to be performed). There was no evidence of an interview process having taken place, or a record of the questions asked at interview, or the employers’ assessment of the applicants’ suitability for the post they had applied for. The temporary manager was unable to confirm that agency staff had current satisfactory CRB status or evidence of professional training and/or qualification. Residents are therefore potentially at risk from inadequately trained, qualified or supervised staff who may not have the relevant skills and abilities to care for them. The home owners/employers must ensure that they have a consistently robust and rigorous process for the selection and recruitment of staff and that the home manager receives all the relevant information about employees to safeguard the residents in the home; and so that the manager and senior staff can support and assist new employees appropriately in their work. The home must have verification from the agencies supplying staff to work at the home that their workers have current CRB and NMC status and relevant skills and experience to care for residents, before permitting agency staff to work. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 25 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): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. There is no clear development plan for the home because of the uncertainty about the change of registered provider and the lack of continuity in the management arrangements. As a result, staff residents and their families are anxious about the future of the home and feel that they are not being consulted about the changes. The organisation does not review the performance of the home effectively. Communication between the home and provider organisation about management, maintenance and staffing issues is inadequate, with a potentially poor impact on the health, safety and wellbeing of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current temporary manager has been in post since March 2007. He is an experienced RGN & RMN, though not in care of older people. The manager was Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 26 recruited from an agency and is on a temporary contract which ends on December 31/12/07 (last working day 12/12/07). From direct observation and comments from relatives, it appears that the manager has made some headway in improving the standards in the home and meeting the outstanding requirements from earlier inspections. A team of senior nurses supports him in the day-to-day running of the home. Implementation of a system of rotation of staff between the ground and first floor had not been well accepted by staff, the manager said, but is intended to ensure that all staff have a good understanding of the care needs of all the residents and that the home is not run as two separate units. The home had introduced monthly resident and relatives meetings as part of the quality assurance process but these had been discontinued because the manager and relatives agreed that with no recent information about the future ownership and plans for the home from the present owners it was felt that there was a lack of purpose for further meetings. The monthly, unannounced visits to the home by a representative of the owners (a consultant employed by them) had also ceased. The last formal ‘Regulation 26’ report was seen, dated August 2007; the September report form was signed but had no content. It is a requirement (under Regulation 26 of the Care Standards Act 2000 and Care Homes Regulations 2001) that where a provider is not in day-to-day charge of a home they ensure a representative visits the home and completes a written report on the conduct of the home. This is another means of the residents being able to give their views on the home. The manager admitted that the planned programme of formal supervision for care staff has still not been implemented largely because he has been very busy with the day-to-day management of the home. This remains an outstanding requirement from previous inspections. It is important that staff have a regular formal time of discussion with a senior staff member so that they can review their progress in their work and identify any training and development needs. The homes system for the safekeeping and recording of small amounts of residents’ personal cash had been reviewed since the last inspection. The manager said that, where possible, relatives or representatives of residents manage the finances of those residents unable or not wishing to do this for themselves. The home now keeps a receipt book to record all the monies held in the safe, but all the cash for residents was held in one envelope and it was not clear how the separate transactions could be recorded to show each person’s residual total. It is strongly advised that further improvements are made to the system so that there is a clear audit trail and it is easier to identify the amounts held on behalf of individual residents. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 27 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. However, a recent inspection of the passenger lift had been incomplete and a letter from the insurers indicated that without the required checks, the home would be operating the lift ‘in breach of regulations.’ The inspector brought this to the attention of the manager and the maintenance man who took prompt action to arrange for the specialist company to do the necessary checks. In the interim the lift was to be used only for the transport of laundry and heated meals trolleys and notices were displayed to inform visitors and staff of this. From the direct observation and discussion with the manager during the inspection it was evident that some incidents that had occurred had not been reported as required (Regulation 37 of the Care Standards Regulations 2001). For example, where residents have fallen and sustained a serious injury, such as a fractured limb, further confirmed cases of scabies affecting residents (the third outbreak in 12 months) and a reported allegation of abuse. This indicates that the homes owners and temporary manager are under-reporting deaths, injuries or incidents affecting the well being of residents and is a failure to notify the Commission and maintain records required for the protection of residents. In one sluice room it was noted that cleaning fluids had been decanted from their original containers into unmarked spray containers. Some written instructions about the dilution of the original product were pinned up for staff guidance. Cleaning fluids/chemicals should not be transferred from the original containers, because the original hazard rating of the product, the manufacturer’s instructions for safe use and first aid treatment must be available to workers. Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 28 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 1 1 2 Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 29 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 15 (2) Requirement Care plans must be updated when significant changes to a resident’s care needs or condition occurs This is a repeated requirement - original timescales of 31/08/06 and 31/03/07 not met. Any complaint made under the complaints procedure must be fully investigated. A record of all complaints made and the action taken by the registered person in respect of any such complaint must be maintained. All staff must adhere to the practices and procedures for prompt reporting of suspected abuse to ensure the protection of residents. The registered person must review the number and skill mix of staff to ensure that there are at all times suitably qualified, competent and experienced staff employed to meet the health and welfare needs of the residents The employer must ensure that a consistent and thorough process DS0000019236.V348220.R01.S.doc Timescale for action 31/01/08 2. OP16 22 (3) Schedule 4 31/01/08 3. OP18 13 (6) 31/01/08 4. OP27 18 (1) 31/01/08 5. OP29 19 (4) Schedule 31/01/08 Ker Maria Version 5.2 Page 30 2 6. OP33 24 (1)(2) (3) 7. OP36 18(2) 8. OP37 37 9. OP37 26 10. OP31 8 11. Ker Maria OP38 23 (2) (c) of selection and recruitment of staff is in place. The employer must confirm in writing to the home manager that people employed to work at the care home are fit to do so and that full and satisfactory information is available to that effect. The home must establish and maintain a system for reviewing and improving the quality of care provided at the care home. Residents and their representatives are consulted about their views as part of the quality assurance review process. 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 discussion of practice and philosophy of the care in the home and career development needs of the people employed. This is a repeated requirement – original timescale of 28/02/07 not met Notification of death, illness and other events that adversely affect the wellbeing or safety of residents must be given to the Commission without delay. Visits by the registered provider and copies of the reports required to be made under the terms of this regulation must be carried out. The provider must give notice to the Commission of the appointment of a person to manage the care home. Ensure that the passenger lift is maintained in good working DS0000019236.V348220.R01.S.doc 28/02/08 28/02/08 31/01/08 31/01/08 31/01/08 31/01/08 Page 31 Version 5.2 order. 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 OP1 Good Practice Recommendations Amend the Statement of Purpose and Service User Guide to show the management arrangements of the home and remove the incorrect reference to the temporary manager being the ‘registered’ manager. It recommended when hand written amendments are made onto the printed MAR charts to indicate a change to prescribed medications, that a second nurse checks and countersigns the first nurse’s transcription (if the prescribing doctor is not available to do so) as an additional check and safeguard against errors. To ensure the provider and manager is made aware of all complaints or concerns it is recommended that all nurses in charge have access to the complaints form to record any issues when the manager is not present. Improve the system for recording and auditing of any transactions and balances of personal monies held on behalf of residents in the home. Ensure that chemicals and cleaning products are stored in their original containers to comply with COSHH and protect staff and residents from injury from misuse or spillage. 2. OP9 3. OP16 4. 5. OP35 OP38 Ker Maria DS0000019236.V348220.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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