Inspection on 30/09/09 for Ker Maria

This inspection was carried out on 30th September 2009.

CQC 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 CQC judgement.

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

Other inspections for this house

Ker Maria 07/04/09

Ker Maria 30/10/08

Ker Maria 17/04/08

Ker Maria 29/11/07

Ker Maria 29/06/07

Ker Maria 18/12/06

Ker Maria 25/05/06

Ker Maria 16/11/05

Ker Maria 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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ker Maria The Retreat Aylesbury Road Princes Risborough Aylesbury Buckinghamshire HP27 0JG Lead Inspector Joan Browne Key Unannounced Inspection 30th September 2009 10:00p DS0000019236.V377743.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ker Maria DS0000019236.V377743.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) smonica@anh.org.uk The Augustinian Sisters Elizabeth Denneny 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.V377743.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 7th April 2009 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 people using the service, in two units across two floors. Each unit is self-contained and has a kitchenette area, a lounge/dining area, bathrooms and toilets. 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. Information to help prospective people using the service 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 prospective people using the service, with additional copies held in the home. Additional charges are made for such things as hairdressing, newspapers and personal toiletries. Ker Maria DS0000019236.V377743.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 1 star. This means that people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on the 30 September 2009 and covered all of the key National Minimum Standards for older people. The inspection lasted for approximately seven and a half hours; commencing at 10:00 am and concluding at 17:30 pm. The last key inspection of the service took place on 7 April 2009. Prior to the inspection surveys were sent to a selection of people living at the home, staff and visiting professionals. Six people using the service, four staff members and three health and social care professionals completed surveys and their replies have helped to form judgements about the service. The registered manager, the senior registered nurse, six people using the service, six staff and four relatives were also involved in the inspection process and their responses and views of the home have been incorporated into the report. Further information was gained by observing staffs practice, examination of care plan documentation, staffs records, health and safety records and a tour of the premises. Three requirements were made and these can be found at the end of the report in the requirements section with fuller discussions in the text of the report under standards 7, 8 and 38. The Commission issued a notice of proposal in July 2009 to impose a condition on the homes registration. Feedback was given to the manager and the senior registered nurse on the inspection findings. We (the Commission) would like to thank all the people who use the service and staff who made the visit so productive and pleasant on the day. What the service does well: People using the service said that the home was warm and welcoming. People using the service said that they have a good relationship with staff members and staff were very caring. People using the service said that the home provided high standards of care and cleanliness. People using the service said that they were happy living in the home and it was lovely to see the nuns back here again. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.2 Page 6 The home has facilities in place to enable people to promote their spiritual needs. Staff who responded to the Commissions survey said that they felt confident and supported by the sisters. Staff who responded to the Commissions survey said that they were providing a high standard of care to the people using the service. The home ensures that people using the service are provided with a choice of wholesome and appealing meals in pleasing surroundings. The home ensures that relatives and friends are able to visit at anytime within reason. The home employs an activity person to ensure that people are encouraged to have a stimulating lifestyle. What has improved since the last inspection? What they could do better: Information about individuals needs in the care plan documentation must be clear to enable staff to meet all identified needs. Consideration must be made for the care plan audit tool to be reviewed. This is to ensure that it is comprehensive and includes headings such as date, outcome and action. The homes monitoring system must be improved to ensure that it is robust and treatment provided by all staff is delivered consistently in line with the homes procedures to promote peoples health and welfare. The controlled measures in risk assessments must be signed and fully actioned. This is to ensure that unnecessary risks to the health and safety of people using the service and staff are identified and so far as possible eliminated. Advice must be sort from the general practitioner to ascertain the acceptable daily average fluid intake that people should take to minimise the risk of dehydration. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.2 Page 7 Medication administration record sheets must reflect the number of tablets that have been prescribed. This is to ensure that there is a clear audit trail of medicines entering the home. Consideration must be made for the activity person to undertake some form of activity training and dementia training to enhance her skills in encouraging people to take part in organised activities. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using 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. Peoples needs are assessed prior to being admitted into the home. This enables the home to be confident that it has the capacity to meet the assessed needs of the prospective person to use the service. EVIDENCE: The AQAA informed that a comprehensive pre- admission assessment is carried out on any prospective person to use the service usually in his/her own home or in a hospital or residential setting. The assessment is carried out by the manager or a suitably qualified registered nurse. Review of a random sample of people using the service files including one person recently admitted to the home demonstrated that pre-admission assessments were carried out Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 10 and relatives were involved in the assessment process. Five people who responded to the Commissions survey said that they had received enough information to help them decide if the home was the right place for them before they moved in. Relatives spoken to during the inspection confirmed that they were provided with adequate information about the service. The following comments were noted: we have nothing but praise for the home. I visited several homes in the area but I knew this was the right one from the start. We have nothing but praise for the home. In fact we have recommended the home to several friends who have had to let their parents go into care. I am happy here as I knew of Ker Marie for some years before coming here. The home does not provide intermediate care. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using 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 implemented systems to ensure that peoples diverse, health and personal needs are adequately met. Further improvement is needed to ensure that they are consistent and robust. EVIDENCE: The care plans for six people using the service were examined. The plans consisted of a standardised format addressing the following activity (need) areas: communication, control of body temperature, dying, eating and drinking, eliminating, expressing sexuality, maintaining a safe environment, mobility and personal hygiene. The standard of recording in care plans was variable. Some plans lacked detail on how needs should be met. The term used in the care plan format to describe identified needs was condition. The statements in some care plans to describe individuals condition (identified needs) were not always applicable. For example, in three care plans it was Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 12 noted that the identified needs relating to individuals wishes in the event of death was not clear. Other aspects relating to family members, religion, requests for burial and resuscitation status were also mentioned. The following information was noted:x is of Roman Catholic faith. X has relatives and friends. Is a practicing Roman Catholic and his faith is important to him. X is a member of the Roman Catholic church. The section expressing sexuality in a particular care plan described the individuals religion which was not relevant to this particular need. It was evident that some statements in care plans were not relevant and as a result plans were not personalised to reflect peoples individuality. In two care plans we noted a separate sheet which asked for the agreement of people using the service/relative to verify their involvement in the review process. These were seen to be signed and dated September 2009. It was not clear if the signatures belong to staff or relatives. There was no evidence of previous reviews. The manager is advised to ensure that agreement sheets detail clearly the names of people using the service, staff and relatives involved in the review process. The registered manager confirmed that risk assessments were reviewed threemonthly. Care plans and peoples weights were reviewed monthly and that the outcomes of these reviews were documented on the computer system. Due to technical difficulties on the day of the visit the inspectors could not access the care homes information technology system to verify that monthly assessment reviews had taken place. This is because the care homes information technology system was not operating due to a local British Telecom problem. It was agreed that the manager should forward this information within forty-eight hours. We can confirm that the information was submitted within the agreed timescale and the evidence seen verified that the care plans and weights were being reviewed monthly. The manager is advised to ensure that records relating to peoples weights are readily available. There was a system in place to ensure that peoples blood pressure was being monitored monthly. The scoring system for risk assessments relating to nutrition and water- low did not have clear guidance within the printed care plans to ascertain what scores should be applied to each section. The registered manager stated that this information could be accessed by staff on the computer system. We noted some inconsistency in the review of the care plan activities. For example, not all activities in the care plan were reviewed monthly, although the computer is updated monthly detailing this information. The registered manager informed us that she audits six care plans weekly, evidence of audits undertaken was made available. It was noted that the auditing system was implemented on 3 September 2009. Prior to this the care plans were audited although this process was not documented. The audit tool that was in place was not comprehensive. For example, it did not incorporate a date, action and outcome heading. The manager is advised to review the audit tool to ensure that it is clear reflecting actions and outcomes. We were told that all the people using the service were registered with a general practitioner of their choice. A general practitioner from the local Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 13 surgery visits the home weekly or as and when required. Chiropody support is available and people using the service are attended to every six weeks. We examined the record documentation for two people who were being nursed in bed. The records reflected some shortfalls in staffs practice. For example, on two particular turning charts gaps were noted. Gaps were also noted on the cream application charts for these individuals. The manager is advised to include these charts in her daily audits. This is to ensure that peoples health and welfare are promoted and there is a consistent practice in place. It was noted that some peoples daily fluid intake ranged between 300mls to 800mls. The manager was advised to seek advice from the general practitioner in relation to peoples daily fluid intake. This is to ensure that individuals are provided with the appropriate amount of fluid and the risk of them becoming dehydrated is minimised. People identified at risk of developing tissue damage had care plans in place detailing the measures in place to prevent tissue damage occurring. Health care professionals who responded to the Commissions survey said that the home always seek advice and act on it to meet peoples social and health care needs and improve their well-being. The following additional comments were noted from a health care professional: The care given by the staff in Ker Maria has been exemplary. The nursing sisters are presently re-instating their influence and this reflects in a return to personally high standards. Relatives spoken to said that they were very satisfied with the care provision. The following comments were noted from a relative: I cannot speak too highly of the level of love and care given to my mother. All the staff have gone out of their way to help her during what has been a difficult and challenging time for everyone. A statutory requirement notice was served in February 2009 in relation to poor medication practices. To ensure that this had been complied with we looked at the homes medication procedure for the safe handling, administration and recording of medication. The medication administration record (MAR) sheets for the two units were examined and no gaps were noted. The homes manager informed that the MAR sheets were checked on a daily basis. The area where medication was being stored was clean and tidy. All prescribed medications were in stock so that they can be administered as prescribed. Daily temperature checks of the medication refrigerator were being carried out. A random check of controlled drugs against levels in the controlled drug book identified that the stock levels were correct. There was a sample of all trained nurses signatures in the medication record folder. This is deemed as good practice. Photographs of people using the service were in the medication record folder to minimise the risk of errors occurring during medication administration. There was no one living in the home on the day of the visit that had been assessed as capable to self-medicate. A tablet for a particular person was being crushed. There was a consent form in place which was signed by the general practitioner agreeing for the medication to be crushed. Written information was in place confirming that the relatives consent was Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 14 sought. The manager was advised to request that the medical practitioner prints his/her name so that the signature can be recognised/matched against the signature. It was noted that the medication administration record (MAR) sheets were not signed to reflect accuracy and safe delivery into the home. This was recorded on a separate electronic sheet. The manager is advised to review this practice. Written guidelines for staff to follow when administering as required (PRN) medication had been developed. The inspectors observed staff assisting people in a kind and respectful manner. Staff spoken to said that they were confident that they were providing a very good standard of care to people using the service and were aware of the importance of promoting peoples privacy and dignity. We observed that not all staff wore name badges to enable people using the service with memory impairment and visitors to be sure of whom they were speaking to. Health care professionals who responded to the Commissions survey said that the homes staff always or usually respected peoples privacy and dignity. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: 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. 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 care plans examined detailed how people using the service should be encouraged to exercise their choice in relation to leisure, social activities and cultural interests. The home employs a part-time activity person. The weeks activity programme was displayed on the notice board to remind people and their relatives of what was on offer. Art work and paintings belonging to individuals were displayed in the front entrance of the home. It was noted that the atmosphere on the first floor was different from the ground floor. People on the first floor did not appear to participate in the activities provided. The activity person confirmed that she tries to involve everyone but finds it challenging. Consideration must be made for the activity person to undertake some form of activity training and dementia training to enable her to be more Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 16 successful in encouraging people using the service to take part in organised activities. A respondent to the Commissions survey said that the activity coordinator works hard to encourage people using the service to take part in things that she has organised. Staff support people using the service 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. Relatives spoken to during the site visit said that they were made to feel welcome by staff and were provided with refreshments if required. Evidence of refreshments provided was seen. We were told that individuals were able to receive visitors in a private area or their bedrooms and there were no restrictions on visiting. The home ensures that people are made aware of their entitlement to bring in their own furniture if they wish to. Information in the AQAA stated that where a persons 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. People using the service are provided with three meals daily with hot and cold drinks and snacks available throughout the day. 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. Individuals who have difficulty with swallowing have food prepared in accordance with a speech and language therapist assessment. Meals served were well presented in pleasant surroundings. Staff were observed providing assistance to individuals in a relaxed and discrete manner. People who were spoken to on the day of the site visit were complimentary about the high standard of meals that were being provided. They confirmed that the chef would provide an alternative meal if they did not like what was on the menu. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 People using 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 has a satisfactory complaints policy and procedure in place, which means that people using the service and relatives concerns are listened to and acted upon. There is a robust safeguarding of vulnerable adults policy in place which should ensure that people are protected from any potential risk of harm or abuse. EVIDENCE: A copy of the homes complaints procedure was displayed on the notice board and in individuals bedrooms. There was also a suggestion box displayed in the home to enable people using the service, staff and relatives to make suggestions. At the previous key inspection a requirement was made for the home to fully investigate all complaints. The manager informed that the home had received three verbal complaints. Two of the complaints were from the same complainant. These were recorded in the folder and the actions taken in response to them were fully recorded. During the inspection a relative raised some concerns and these were referred to the registered manager to be dealt with. We contacted the complainants after the inspection to ensure that they were satisfied with how their complaints were investigated. The first complainant said that they were very happy with the outcome and the concern was put right immediately. The second complainant could not Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 18 remember raising any concerns and was complimentary about the service. The following comments were noted: I am very happy with the care the home provides. Since the nuns have taken over I feel so happy. The manager confirmed that the homes safeguarding of vulnerable adult policy and procedure was reviewed in line with Buckinghamshire County Council local safeguarding procedure and had been ratified. The home has made us aware of potential safeguarding incidents that they had reported to Social Services who take the lead on safeguarding matters. The staff-training matrix seen reflected that staff had undertaken updated training in the safeguarding of vulnerable adults. Staff spoken to confirmed that they had undertaken updated training and were aware of the action to be taken if they suspected or witnessed an incident of abuse. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19& 26 People using 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. Ongoing Improvement and upgrading of areas of the home would be beneficial to ensure that people live in a safe and well maintained environment. 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. The communal areas were spacious, bright airy and comfortably furnished. The grounds were tidy and accessible to people using the service including Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 20 wheelchair users. Specialist equipment such as grab rails, hoists and other aids were provided in corridors, bathrooms, toilets, communal areas and individuals bedrooms to maximise their independence. At the previous key inspection a requirement was made for a detailed programme of maintenance, repair, renewal and decoration of the premises, furniture and fittings should be provided. We can confirm that the quiet room had been redecorated and the floor covering replaced. The kitchenette on the ground floor had been upgraded and some dining chairs and armchairs had been replaced. The home did not have a written maintenance plan in place. However, a maintenance plan with timescales was forwarded to the Commission within twenty-four hours after the inspection. It was identified that further maintenance work in bathrooms and shower rooms needed to be undertaken. For example, damp ceilings in the shower room and bathrooms on the ground floor needed to be remedied. Chipped paintwork on the skirting board on the ground floor toilet needed repainting. Trailing wires in the server room needed to be secured. These outstanding works have been put on the maintenance plan to be carried out within the next couple of months. Some staff who responded to the Commissions survey said that the home could benefit from modern bath systems. The home was clean, pleasant and hygienic in communal areas and free from odours. The manager was advised to ensure that slings were not shared between people using the service and they are laundered in a hot wash cycle to minimise the risk of cross infection. The training matrix reflected that staff had undertaken updated training in infection control which was ongoing. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 People using 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. Staff in the home are trained, skilled and available in sufficient numbers to fulfil the aims of the home and meet the changing needs of the people using the service. EVIDENCE: The home employs a multi-cultural staff team to meet peoples diverse needs. The rota demonstrated that the number and grade of staff on duty to provide care and attention to people using the service for any twenty-four hour period was suitable to meet their assessed care needs. Staff spoken to said that they enjoyed working at the home and felt valued. Staff who responded to the Commissions survey said that they felt more confident with the support from the sisters. The following additional comments were noted: The home has been much better in all ways since the Augustinian nuns have returned to manage the home. The nuns are dedicated and hardworking and were a good example. I have worked in care homes for nearly thirty years now. This is the best organisation I have worked for. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 22 The home has a programme of planned training in place. 53 of care staff had attained the national vocational qualification (NVQ) at level 2. The home is part of a local cluster group and staff are encouraged and enabled to undertake developmental training as well as mandatory training. In the two newly appointed staffs files examined it was evident that they were undertaking the skills for care common induction programme. The recruitment files of two recently recruited staff members were examined. It was found that they contained the required documents to verify that appropriate checks had been undertaken. Individuals’ identity had been checked, two references, PoVA first check and enhanced criminal record bureau clearances obtained. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35 36& 38 People using 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 service but weaknesses in maintaining appropriate records, risk assessments relating to safe-working practices and having an effective auditing system in place can impede the service delivery and outcomes for people using the service. EVIDENCE: The manager was recently registered with the Commission. She is a registered nurse, registered mental health nurse and holds the NVQ level 4 certificate. She recently undertook updated training in challenging behaviour, the mental capacity act and the deprivation of liberty safeguarding. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 24 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. We were told that user satisfaction questionnaires had been sent to people using the service, relatives, friends and other stake holders and these were waiting to be returned to be analysed. The home aims to ensure that staff receive one to one supervision every six weeks. Staff spoken to confirmed that they were receiving supervision. This inspection highlighted that the homes risk management monitoring and auditing systems need to be improved further. Care plans need to provide relevant information and detailed guidance on how individuals identified care needs should be adequately met. Efficient systems need to be in place to monitor staff adherence to policies and procedures during their practice. We were told that the home does not look after people using the service money. They 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 hot water temperature record reflected that monthly checks were being carried out and they were within the normal range. Risk assessments dated 06/04/2009 were in place for health & safety areas such as working at height, working with power tools, biological hazards, electricity, using sharp tools, painting, asbestos, noise, manual handling, and hazardous substances (COSSH), Slips and trips, working on or near to dangerous machinery. Some of the control measures required had not been signed to say that they had been actioned. The property officer confirmed that the control measures had not been actioned to-date. The manager is required to ensure that control measures in completed risk assessments are signed and fully actioned. This is to ensure that unnecessary risks to the health or safety of people using the service and staff are identified and so far as possible eliminated. Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 25 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 2 8 2 9 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 26 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 OP7 Regulation 15 Requirement Care plans must be clear and relevant to include detailed information on how needs should be met. This is to ensure that there is clear guidance in place to enable staff to adequately meet all identified needs. It is required that a robust auditing system is put in place to ensure that treatment records are consistently maintained by all staff. This is to ensure that peoples health and welfare are promoted. The controlled measures in completed risk assessments must be signed and fully actioned. This is to ensure that unnecessary risks to the health and safety of people using the service and staff are identified and so far as possible eliminated. Timescale for action 30/11/09 2. OP8 17 30/11/09 3. OP38 13(c) 30/11/09 Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ker Maria DS0000019236.V377743.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Southeast Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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