Inspection on 30/10/08 for Ker Maria

This inspection was carried out on 30th October 2008.

CSCI found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ker Maria 30/09/09

Ker Maria 07/04/09

Ker Maria 17/04/08

Ker Maria 29/11/07

Ker Maria 29/06/07

Ker Maria 18/12/06

Ker Maria 25/05/06

Ker Maria 16/11/05

Ker Maria 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 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Ker Maria The Retreat Aylesbury Road Princes Risborough Aylesbury Buckinghamshire HP27 0JG Lead Inspector Joan Browne Unannounced Inspection 30th October 2008 09:00 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.V372981.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.V372981.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 Manager post vacant 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.V372981.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 17th April 2008 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 home’s Statement of Purpose and the Service User’s Guide. Both of these documents are provided to potential service users, with additional copies held in the home. The fees charged are presently between £670.00 and £700.00. Additional charges are made for such things as hairdressing, newspapers and personal toiletries. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Joan Browne on 30 October 2008 and lasted for eight and a half hours; commencing at 09:00 hours and concluding at 17:30 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service. This document, which includes information from a variety of sources, was not received in good time. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document is referred to throughout the report. The manager of the home was in attendance throughout the visit. The information contained in this report was gathered mainly from observation by the inspector, surveys, speaking with a number of service users, a health care professional, care staff and a relative. Further information was gathered from records kept at the home. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. Four requirements and eight recommendations of good practice were issued on this visit. Please see health and personal care outcomes, complaints and protection outcomes, Staffing Outcomes and Management and Administration outcomes for full disclosure. Feedback was given to the manager on the outcome of this visit. We would like to thank all the service users and care staff that made the visit so productive and pleasant on the day. In this document the pronouns “we and us” are used to represent the Commission for Social care inspection. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There has been an improvement in the development of care plans to ensure that care is provided in a person centred manner. Some areas of the home have been re-painted to ensure that people live in a home that is safe and well maintained. Suitable cleaning arrangements have been put in place to ensure that floor coverings are appropriately maintained. The covering on the walls and floor of the lift has been replaced to ensure people using the service and members of the public safety. The water system in the home has been treated to prevent the risk of Legionella and to ensure people using the service health and safety are promoted. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 7 What they could do better: 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.V372981.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.V372981.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): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that prospective people to use the service have a preadmission assessment, which they and people close to them have been involved in. EVIDENCE: The home ensures that a comprehensive pre-admission assessment is undertaken for prospective residents. This is usually carried out in the persons own home or in hospital or a residential setting with the involvement of family members or health and social care professionals. The manager or a suitably qualified nurse carries out the assessment. The annual quality assurance assessment (AQAA) stated that the pre- assessment of individuals needs is provided in a hard copy to the staff team prior to admission from which a computer record is created. The pre-admission assessment records for two residents recently admitted to the home was examined and demonstrated that a thorough assessment was undertaken. The AQAA stated that prospective residents are provided with a comprehensive brochure about the home and a statement of terms of admission. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 10 Ker Maria DS0000019236.V372981.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): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has made an improvement by ensuring that care plans are regularly reviewed and written in a person centred manner. Staffs practice in the administration, recording, handling and disposal of medication is not consistent and could pose a risk to peoples health and welfare. EVIDENCE: A sample of three care plans was looked at. The plans consisted of a standard format addressing the following core areas: breathing, communication, control of body temperature, dying, eating and drinking, elimination, maintaining a safe environment, mobility and personal hygiene. Staff spoken to said that whenever changes occur the care plan is reviewed to reflect the new changes and this was evidenced by the computer generated records seen. We were told that the home had a system in place to ensure that the care plan was Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 12 reviewed monthly. The three care plans examined were up to date and had been developed in a person centred manner. The manager told us that training was provided to all staff to ensure that they were proficient in using the computerised care plan system. Staff spoken to confirmed that they were given training on its use. It is acknowledged that the standard of recording in the plans seen had improved and care plans were being reviewed monthly or as and when there were changes in individuals needs. The annual quality assurance assessment (AQAA) stated that a number of care plan review meetings had taken place with residents and family members. The AQAA stated that all permanent residents were registered with two local general practitioner (GP) surgeries in the area. One surgery provides a doctors round every Thursday. There was also good liaison and support provided by the second surgery. The Harmony on call system provides out of hours support when required. We spoke to a general practitioner during our visit and he confirmed that he has a good relationship with the homes staff. He said that he could not fault the care that the home was providing to residents. He also said that he had confidence in the clinical managers performance. Access to specialist health care professionals is available through the GP practice as required. Chiropody treatment is provided six weekly, dental and optical treatments are available as and when required. Weekly access to hairdressing facility is available at a cost to residents. Those residents who responded to the Commissions survey said that they always or usually receive the medical support needed. Staff spoken to were extremely proud of the standard of care they provided to the residents. We looked at the fluid balance charts and the turning charts for residents who were nursed in bed and found that staffs practice was not always consistent. Significant gaps were noted in some charts that were examined. For example, on one fluid chart for a particular resident between 19:00 pm and 07:00 am there was no record of fluid offered. On a second chart examined between 18:00 pm and 07:00 am no written entries of fluid offered were recorded. On some charts the input and output totals were not added up. Not all residents who were nursed in bed had turning charts. It is required that provision is made for fluid balance charts and turning charts to be appropriately maintained to ensure that residents health and welfare is promoted. The home uses a monitored dosage system (MDS) packaging for residents prescribed medication. On the day of the site visit we were told that there were no residents assessed as having the capacity to self-medicate. The medication administration record (MAR) sheets were examined and some shortfalls were identified. For example, staffs practice was not consistent when recording handwritten entries on the MAR sheet. We noted that not all handwritten entries on the MAR sheets were countersigned by a second staff member to minimise the risk of error when transcribing. On one particular service user MAR sheet three unexplained gaps were noted. Scribbled over Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 13 entries were noted on some MAR sheets. The controlled drug register was checked and medication in the cupboard did not correspond with the register. For example, the amount of Temazepam liquid medication held in the cupboard for a particular resident exceeded the amount recorded. There was a note written on one bottle dated 16/07/08 to be destroyed. The manager was unable to give an explanation at the time of the inspection why the medication was not destroyed. However, after the inspection the Commission was informed that the home was waiting for a special disposal kit from the waste disposal supplier to dispose of the medication appropriately. We also noted that there were Buprenorphine patches (which is given for pain) in the cupboard belonging to a resident who had passed away more than seven days ago. The controlled drug liquid bottles were sticky and the labels were not legible because staff were not pouring the liquids away from the labels to prevent discolouration to the labels when pouring. It is required that the home disposes of controlled medication at the earliest opportunity. There should be a clear audit trail for all medication stored in the controlled drug cupboard. Staffs practice in the handling, administration and recording of medication must be consistent to ensure that residents health and welfare is not compromised. We noted that the home had developed a laminated person centred medication administration record front sheets describing how individuals wished to take their medication. This is deemed as good practice. We noted that three residents were having their medication administered covertly. Evidence was seen that this was in agreement with family members and the general practitioner. The home should ensure that the protocol is kept under review in line with the mental capacity act and an approved assessor assesses individuals mental capacity. Staff were observed treating residents in a respectful manner and knocking on bedrooms doors before entering. In discussion with a number of residents it was evident that they were not fully able to answer questions asked and would reply yes to every question asked. Residents, who were able to understand the questions, told us that they were treated with respect and dignity. A visitor spoken to during the site visit said that staff respected her husbands privacy and dignity and were very kind and caring. Residents appearance was clean and tidy with attention to detail. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 14 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 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Meaningful activities are provided to people using the service to ensure that their diverse needs and interests are catered for. Nutritious and wholesome meals are provided in pleasing surroundings. EVIDENCE: The home employs a part-time activity organiser. The annual quality assurance assessment (AQAA) stated that the homes approach to activities is person centred and begins with the development of an individual profile soon after admission by the activity co-ordinator. Family members are encouraged to assist with individuals life profiles detailing the family history and the individuals likes, interests and hobbies. There was a monthly calendar of daily activities displayed on the notice board to inform residents of events that were taking place. These included reminiscence, afternoon matinee, aromatherapy, cheese and wine party, watercolour painting and bingo. On the day of the visit the activity organiser was making Halloween decorations for the homes Halloween party. Staff support residents to promote their spiritual needs. The home has a chapel and the local Catholic priest and Church of England priest visit weekly to facilitate Holy Communion. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 15 One relative was spoken to during the site visit. The individual said that they were made to feel welcome by staff and provided with refreshments if required. Evidence of refreshments provided was seen. We were told that residents were able to receive visitors in private in their bedrooms and there were no restrictions on visiting. The home ensures that residents are made aware of their entitlement to bring in their own furniture if they wish to. Information in the AQAA stated that where a residents cognitive abilities are impaired a person centred care plan is developed with as much input as possible from friends and relatives to enable staff to provide care sensitively to meet the individuals preferences and choices. Residents are provided with three meals daily and hot and cold drinks and snacks are available throughout the day. People who responded to the Commissions survey said that they always or usually liked the meals that were provided. An additional comment from a respondent said that the meals could be hotter. The annual quality assurance assessment (AQAA) stated that the meals provided were of a high standard. Special events are catered for including all religious calendar dates, and other special days of celebration. Residents who have difficulty with swallowing have food prepared in accordance with a speech and language therapist assessment. Meals served were well presented with tables covered with tablecloths, linen napkins, condiments and the appropriate cutlery. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 16 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 & 18 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a complaints procedure to ensure that people are able to raise their concerns and action taken to put things right. Weaknesses detected in the managers lack of knowledge and awareness in the local multi-agency safeguarding of vulnerable adults procedure has the potential of putting people at risk of harm. EVIDENCE: The home has a complaints procedure, which is included in the homes brochure. A laminated copy of the complaints procedure was displayed in residents bedrooms and on the homes notice board. The homes annual quality assurance assessment reflected that within the past twelve months the home had received fourteen complaints. Two of these complaints had been upheld. Two recommendations were made at the previous key inspection to ensure that the complaints procedure reflects the current homes manager name and there is a clear audit trail of all complaints investigated with satisfactory outcomes. The manager told us that the complaints procedure had been reviewed. The complaints folder was examined and evidence seen demonstrated that an audit trail of all complaints investigated was in place. Residents who responded to the Commissions survey said that they knew how to make a complaint. On the day of the site visit the manager made us aware that a resident had made a serious allegation against an agency member of staff. The manager Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 17 carried out his own investigation and did not report the incident to the safeguarding of vulnerable adults team or to the police. The residents relative was made aware of the allegation. He concluded that the allegation was not founded. He was advised that the incident should be reported to the safeguarding of vulnerable adult team and the Bucks County Council multiagency safeguarding protocol should be implemented. This was done immediately and a strategy meeting under the safeguarding of vulnerable adults has been arranged. The staff-training matrix seen reflected that staff had undertaken updated training in the safeguarding of vulnerable adults. There is also a flow chart outlining the action to be taken in the event of alleged abuse, which was displayed on the staffs notice board. The management and staff team must be aware of the action to be taken and their responsibilities should they be told of any alleged incidents of abuse. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 18 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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Work was in progress to ensure that the home is safe and well maintained, which should enable people to live in a comfortable, pleasant and hygienic environment to meet their diverse needs. EVIDENCE: The home provides accommodation for forty-one residents in two units across two floors. Each unit is self-contained and has a kitchenette area, lounge/dining area, bathrooms and toilets. The ground floor unit has twenty single bedrooms eight of which are en suites. The first floor has twenty-one with six en suites. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 19 We were told that the requirements made at the local fire services inspection had been complied with. The communal areas were spacious, bright airy and comfortably furnished. The grounds were tidy and accessible to residents including wheelchair users. Specialist equipment such as grab rails, hoists and other aids are provided in corridors, bathrooms, toilets, communal areas and residents bedrooms to maximise their independence. We noted that work had commenced to touch up the chipped paintwork in corridors, on skirting boards and bedroom doors. The annual quality assurance assessment (AQAA) stated that bathroom doors on both floors had been widened to accommodate wheelchairs. Three bedrooms were examined during this inspection and they were satisfactorily maintained and personalised with small items of furniture, pictures and mementoes. The home was clean, pleasant and hygienic in communal areas and free from odours. We were told that the home now ensures that a professional cleaning operative regularly steams carpets in corridors and problematic areas. The AQAA stated that capital works had been undertaken to improve access to the laundry area. The home has policies and procedures for the control of infection including the safe handling and disposal of clinical waste. Staff training records examined reflected that infection control training was up to date. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 20 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, 29, & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home needs to recognise the importance of effective recruitment procedures to ensure that people using the service are protected from staff that may not be suitable to work with vulnerable adults. EVIDENCE: The home is staffed by a multi-cultural staff team. The staffing roster reflected that one registered nurse and five care staff are on each floor during the morning shift and one registered nurse and four carers during the afternoon/evening shit. During the night there is one registered nurse and four carers. The staffing numbers demonstrated that there were adequate staff on duty to provide care and attention to residents for any twenty-four hour period to meet their assessed care needs. The annual quality assurance assessment stated that within the last twelve months the home had recruited a permanent administrator, two qualified registered nurses, ten full-time care assistants, two part-time care assistants, a junior chef, four housekeepers and a laundry assistant. Ten staffs files were examined. Files contained application forms, contracts of employment, evidence of interview format and answers given, declaration statements of physical fitness and two written references. We noted that one reference was addressed to whom it may concern. To comply with best Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 21 practice guidelines references should be addressed to the person who requested them and not To whom it may concern. One staff member was working with a PoVA first check and was waiting for a full criminal record bureau (CRB) clearance. The manager said that the member of staff was being supervised. However, there was no evidence seen to verify that an appointed named person had been designated to supervise the individual. The manager must ensure that when he appoints individuals ahead of the full CRB disclosure being issued an appropriately qualified and experienced person should be appointed to supervise these members of staff until the full CRB disclosure has been obtained. The named person, so far as is possible must be on duty at the same time as the new member of staff. (Please note that there may be more than one named person.) To comply with best practice there should be written evidence in trained nurses personal files to verify that their pin numbers have been checked with the nursing and midwifery council (NMC). Three staff members who responded to the Commissions survey said that their induction covered everything they needed to know to do the job. A fourth respondent said it did not cover everything at all. The manager said that staff had been inducted to skills for care standard. The manager must consider keeping copies of individuals induction programme in their personnel files to verify that they have been appropriately inducted. The AQAA stated that staff receive annual updates in all mandatory training through a combined strategy of in-house training, directly contracted training providers and training through the local authoritys cluster group training which is conducted on-site. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 22 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 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home aims to provide a consistent and well managed service but lack of management awareness and efficient systems in place to monitor staff performance and adherence to policies and procedures could put people using the service at risk. EVIDENCE: The current home manager is a registered psychiatric nurse with a background in management. He has several years experience in a senior management capacity. The manager is accountable to the Augustinian sisters. He does not hold the registered managers awards or the national vocational qualification (NVQ) at level 4. The clinical manager, registered nurses, carers and support staff support the manager in the day-to-day operation of the home. To date the manager has not started the process to be registered with the Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 23 Commission. Staff spoken to said that the manager was approachable and morale in the home had improved. Staff spoken to confirmed that regular staff meetings are held and they are given the opportunity to raise concerns and make suggestions. There is also a suggestion box in the home for staff and relatives to volunteer suggestions on how the service could be improved. The home aims to ensure that staff receive one to one supervision every six weeks. Staff spoken to confirmed that they were receiving supervision. However, there have been occasions when the time frame has not been achieved. There was no evidence seen to verify that the manager was receiving formal one to one supervision from his line manager. Copies of regulation 26 report visits were seen reflecting that since April 2008 the registered provider had undertaken five visits to the service. This inspection highlighted that the homes monitoring and auditing systems need to be improved further. Efficient systems need to be in place to monitor staff adherence to policies and procedures during their practice. The home also needs to ensure that its safeguarding policy is followed and put into practice. We noted that the home had introduced a shift handover and allocation sheet to prompt staff on the level of dependency of the residents along with any infection control issues. The presentation of some sheets was not in good order and reflected poor practice. The home should ensure that records required for the protection of people using the service should be kept in good order and appropriately maintained. The annual quality assurance assessment (AQAA) was not returned to us by the date it was requested. The evidence to support the comments made in the AQAA was satisfactory and detailed plans for improvement within the next twelve months. We were told that the home does not look after residents money. Residents are invoiced for purchases made on their behalf such as, toiletries, hairdressing and chiropody. A sample of health and safety records was examined and these were generally in good order. The fire building risk assessment was reviewed in April 2008. The hot water temperature record reflected that monthly checks were carried out and they were within the normal range. The outstanding work on the water system to prevent the risk of Legionella had been carried out. The covering on the walls and floor of the passenger lift had been replaced. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 24 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 3 8 2 9 2 10 3 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 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 3 Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 12 Requirement Timescale for action 04/12/08 2. OP 9 13 3. OP18 13 4. OP31 8 It is required that provision is made for fluid balance charts and turning charts to be appropriately maintained. This is to ensure that people using the service health and welfare is promoted. Staffs practice in the recording, 04/12/08 handling, safekeeping, safe administration and disposal of medicines in the home must be consistent. This is to ensure that people using the service health and welfare is not compromised. The manager must ensure that 04/12/08 he follows the appropriate protocol in relation to any reported alleged allegations. This is to ensure that people using the service are not put at risk of harm. The manager must start the 04/12/08 registration process. To ensure that he is registered with the Commission. Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations Handwritten entries on the medication administration record (MAR) sheets should be signed by a second member of staff to minimise the risk of error when transcribing. The home should comply with best practice guidelines and dispose of medicines after seven days when a person dies. The manager should ensure that he reports all notifiable incidents occurring in the home in a timely manner. To comply with best practice guidelines references should be addressed to the person who requested them and not To whom it may concern. The manager should ensure that when he appoints staff whilst waiting for a full criminal record bureau (CRB) disclosure they should be supervised by an appropriate qualified person(s) until the full CRB has been obtained. To comply with best practice there should be written evidence in trained nurses personal files to verify that their pin numbers have been checked with the nursing and midwifery council (NMC). Copies of staff induction programme should be kept in their personal files to verify that they have been appropriately inducted. Records required for the protection of people using the service should be kept in good order. 2. 3. 4. 5. OP9 OP18 OP29 OP29 6 OP29 7. 8. OP37 OP37 Ker Maria DS0000019236.V372981.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office 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. Extracts may not be used or reproduced without the express permission of CSCI Ker Maria DS0000019236.V372981.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. 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