Care Home: Ker Maria

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What the care home does well Service users said that `the home was warm and welcoming.` Service users said that `they have a good relationship with staff members and staff were very caring.` Service users said that `there was a high standard of cleanliness in the home`. A service user respondent said that `the home acts on health issues as promptly as possible.` A relative respondent said that `overall the home has a general air of happiness among its staff.` Prospective service users` needs are assessed prior to being admitted to the home to ensure that the home can meet all identified needs. The home has facilities in place to enable service users to promote their spiritual interests. There are no restrictions on visiting which means that relatives are able to visit at anytime within reason. The home ensures that service users are provided with a choice of wholesome meals in pleasant surroundings. The home ensures that staff are provided with the appropriate training to meet service users` diverse needs and to ensure that the home`s aims and objectives are adequately met. What has improved since the last inspection? Service users` safety and well being are appropriately maintained. The care plans are more comprehensive, relevant and detailed providing staff with adequate information to meet service users` identified needs. The home has sustained its improvement in the safe handling, recording and administration of medication which means that service users` health and welfare are promoted and protected. What the care home could do better: The manager is aware of areas in the home that need improving. Consideration must be made for more individualised and meaningful activities to be provided to those service users that are not able to engage in group activities.Ker MariaDS0000019236.V378590.R01.S.doc Version 5.2 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 2nd December 2009 09:00 DS0000019236.V378590.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.V378590.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.V378590.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.V378590.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 September 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 service users, 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 potential service users 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 service users, with additional copies held in the home. Additional charges are made for such things as hairdressing, newspapers and personal toiletries. Ker Maria DS0000019236.V378590.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 2 stars. This means that people who use this service experience good quality outcomes. This unannounced key inspection was carried out on the 2 December 2009 and covered all of the key National Minimum Standards for older people. The inspection lasted for approximately nine hours; commencing at 10:20 am and concluding at 19:25 pm. The last key inspection of the service took place on 30 September 2009. Prior to the inspection a detailed self assessment questionnaire known as the annual quality assurance assessment (AQAA) was sent to the home for completion and surveys were sent to a selection of service users living at the home, staff and visiting professionals. The AQAA was returned by the due date and gave a reasonable picture of the current situation within the service. Seven service users, seven staff, two 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 service users, three staff and six 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 the care plan documentation, staffs records, health and safety records and a tour of the premises. The home did not have a registered manager for sometime. There were concerns that the needs of service users, their safety and welfare may not have been fully met. A notice of proposal was issued in July 2009 to impose a condition on the homes registration that an experienced person be registered as manager. And no further service users be admitted to the home without written consent of the Care Quality Commission. Following this inspection a management review of the service was held and it has been agreed to withdraw the notice of proposal. This inspection highlighted that the homes care planning system had improved. Service users care plans were comprehensive, relevant, and easy to follow and detailed how identified needs should be met. The homes monitoring system has been further developed to ensure that staffs practice is consistent and complies with the homes policies and procedures. Environmental risk assessments have been reviewed and any identified risks are supported with a plan of action detailing how the risk is to be managed. The home has sustained its improvement in the safe handling recording and administration of medication. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.2 Page 6 The manager has reassured us that improvements made so far and all further necessary improvements will be maintained and sustained. No requirements were made on this visit. Feedback was given to the manager and the senior registered nurse on the inspection findings. We (the Commission) would like to thank all the service users, relatives and staff who made the visit so productive and pleasant on the day. What the service does well: Service users said that the home was warm and welcoming. Service users said that they have a good relationship with staff members and staff were very caring. Service users said that there was a high standard of cleanliness in the home. A service user respondent said that the home acts on health issues as promptly as possible. A relative respondent said that overall the home has a general air of happiness among its staff. Prospective service users needs are assessed prior to being admitted to the home to ensure that the home can meet all identified needs. The home has facilities in place to enable service users to promote their spiritual interests. There are no restrictions on visiting which means that relatives are able to visit at anytime within reason. The home ensures that service users are provided with a choice of wholesome meals in pleasant surroundings. The home ensures that staff are provided with the appropriate training to meet service users diverse needs and to ensure that the homes aims and objectives are adequately met. What has improved since the last inspection? What they could do better: The manager is aware of areas in the home that need improving. Consideration must be made for more individualised and meaningful activities to be provided to those service users that are not able to engage in group activities. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.2 Page 7 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.V378590.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.V378590.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. Service users 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 service user. EVIDENCE: The manager confirmed that there have been no new admissions since the last key inspection. The AQAA stated that prospective service users have a preadmission assessment before being admitted to the home. The assessment is carried out by a trained nurse and the service user and his or her representative are involved in the process. We were told that the preadmission assessment sheet was recently updated to provide more specific Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 10 information. Relatives spoken to during the inspection confirmed that they were provided with enough information about the service. The following comments were noted: We visited several homes in the area but knew this was the right one when we entered the door. The sisters and staff answered all our queries. The home does not provide intermediate care. Ker Maria DS0000019236.V378590.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system in the home has improved. This means that the care plans now contain clear information for staff to follow and satisfactorily meet service users identified needs. EVIDENCE: The care plans for six service users were examined. The plans consisted of a standardised format addressing twelve areas of need. A requirement was made at the previous key inspection for care plans to be clear and relevant detailing how needs should be met. It is pleasing to report that the requirement had been complied with. The plans examined were comprehensive, relevant and contained detailed information to enable staff to provide the appropriate level of care to meet service users identified needs. The plans were reviewed monthly or as and when required. For example, a Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 12 particular service user was discharged from hospital and the care plan was reviewed to incorporate the changes to the individuals identified needs. Any potential or actual risks identified relating to moving and handling, falls, mobility, tissue viability and nutrition were supported with plans detailing how risks would be managed. Some of the plans seen were signed by service users relatives to confirm their involvement in the care plan. A relative spoken to during the inspection confirmed their involvement in the planning and reviewing of the care plan and was confident that the homes staff were following the care plan and were very supportive. The registered manager informed us that she audits the care plans weekly. The auditing tool had been reviewed by the home to reflect clear actions and outcomes. The AQAA informed that service users were registered with a general practitioner (GP) who visits the home weekly or as and when required. Service users are attended to by a chiropodist who visits the home approximately every six weeks. Access to specialist healthcare is via the GP surgery. The AQAA stated that an optician visits the home when required. We noted that service users weights and vital signs were being monitored monthly. Nutritional and tissue viability assessments were also being reviewed monthly. Individuals at risk of developing tissue damage were provided with the appropriate equipment such as pressure relieving mattresses and cushions. The home has developed a system to ensure that service users fluid intake and output sheets are monitored closely. A designated staff member on the night shift was responsible for maintaining the records. A marked improvement in service users daily fluid intake was noted which ranged between 800mls to 1050mls. Staff spoken to were confident that they were providing a high standard of care to service users. The medication administration record (MAR) sheets were examined and no gaps were noted. The manager said that the MAR sheets were audited daily. We saw evidence of daily audits undertaken with details of any remedial action taken. The area where medication is stored was clean and tidy. Temperature checks of the medication refrigerator were carried out daily. A random check of controlled drugs against levels in the controlled register identified that the stock levels balanced with the record. A sample of all trained nurses signatures was kept in the medication record folder and this is deemed as good practice. Photographs of service users were in the medication record folder to minimise the risk of errors occurring during medication administration. The senior nurse explained the computerised system that the home had developed to ensure that a clear audit trail of medication entering and leaving the home was in place. The AQAA informed that service users medication is reviewed regularly with the GP. Two Health care professionals who responded to the Commissions survey said that the home always monitor service users health care needs to ensure that they are adequately met. The following additional comments were noted: The home provides good social and health care. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 13 Staff were observed assisting and interacting with service users in a kind and respectful manner. Service users attire was clean and tidy with attention to detail. The following comments were noted from a service user: I have my privacy and also the help when I need it. All the relatives spoken to on the day of the site visit were confident that staff respected service users privacy and dignity and were complimentary about the care provision. The following comments were noted: The care the staff provide is exemplary. I visit my mother on different days of the week and she is always well presented and her hair is tidy. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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. 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 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 an activity programme in place but more individualised and meaningful activities need to be provided to those service users that are not able to engage in group activities. Meals provided were of a high standard and served in pleasing surroundings. EVIDENCE: The care plans examined detailed how staff should be supporting service users to exercise their choice in relation to leisure, social activities and cultural interests. The home employs an activity person five days a week. The weeks activity programme was displayed on the notice board to remind service users and their relatives of what was on offer. Art work and paintings were displayed in the front entrance of the home. On the day of the inspection the school children from the local school entertained service users singing Christmas Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 15 carols. It was noted that the activity provided to those service users who were being nursed in bed was limited. The manager was advised at the last key inspection to source an appropriate training course for the activity person to undertake to enable her to fully meet the needs of those service users that were not able to participate in group activities and would benefit from one to one activity. We were told that arrangements have been made for the activity person and two care staff to undertake training in January 2010. Staff and relatives spoken to said that the activity person works hard to encourage service users to participate in activities. A discussion was held with the activity person regarding the best way to record and monitor what activities service users participate in and their preferences. Staff support service users to promote their spiritual needs. For example, the home has a chapel and the local Catholic priest and Church of England priest visit regularly to facilitate mass and 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 AQAA informed that service users were encouraged to personalise their rooms and can bring in personal possessions as long as they comply with health and safety guidelines. The home operates a four-week menu. Service users are provided with three meals daily with hot and cold drinks and snacks available throughout the day. We observed jugs of fruit juices and water were placed in the lounges and staff were observed offering drinks to service users. The lunch menu consisted of two choices of main course, a starter and dessert. Service users and visitors said that meals provided were of a high standard. The following comments were noted: The food here is excellent. We can ask for what we like nothing is too much trouble for the chef. They confirmed that the chef would provide an alternative meal if they did not like what was on the menu. Individuals who have difficulty with swallowing were provided with pureed meals. Meals served were well presented. Staff were observed providing assistance to individuals in a relaxed and discrete manner. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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. 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 complaints and safeguarding policy in place. This should ensure that service users would be confident that their complaints would be investigated and they would be 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 service users, staff and relatives to make suggestions. The home keeps a record of complaints which includes details of the investigation and action taken. The manager said that since the last key inspection the home has not had any complaints. Relatives spoken to during the inspection said that they were aware of the homes complaints procedure and were confident if they had to raise a concern it would be looked into and action taken to put things right. The home has a safeguarding of vulnerable adult policy which incorporates Bucks County Councils safeguarding protocol. The AQAA stated that staff undertake safeguarding of vulnerable adults training twice yearly. The training Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 17 records seen supported this statement. Staff were knowledgeable about what action should be taken if they suspected or witnessed an incident of abuse. The home has made us aware of four potential safeguarding incidents that they had reported to Social Services who take the lead on safeguarding matters. Two referrals were investigated. An entry in the diary notes for a particular service user looked like the individual had physically attacked a visitor. The manager was not aware of the incident and was requested to investigate the incident. We have since been told that the terminology used to describe the service users behaviour may have been misleading. The manager is advised to ensure that information recorded in the diary notes is clear to avoid any misunderstanding. Service users and relatives spoken to during the inspection said that they were happy with the service provision, felt safe and well supported by the manager and staff team. The following additional comments were noted from respondents who responded to the Commissions surveys: I feel safe and secure here and do not require anymore than the comforts I have at the moment. I feel safe here and would like to stay here for the rest of my life. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within the home is satisfactory. This means that service users are provided with a homely, clean, comfortable, pleasant and hygienic place to live and their diverse needs are promoted. EVIDENCE: The home provides accommodation for forty-one service users 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.V378590.R01.S.doc Version 5.3 Page 19 The communal areas were spacious, bright, airy and comfortably furnished. The grounds were tidy and accessible to service users including wheelchair users. Grab rails and other aids in corridors, bathrooms, toilets, communal rooms and where necessary in service users bedrooms were provided. Bedrooms seen were personalised with family photographs and mementos. It was noted that the maintenance work identified in the homes maintenance plan at the last key inspection as needing attention had been carried out. The home was clean, pleasant, hygienic and free from odours. Alcohol hand gel solutions were situated discretely in areas of the home for staff and relatives to use to minimise the risk of cross infection. The laundry area which is situated away from where food is stored and prepared was clean and tidy. The floor and walls were free from dust. The washing machines have the specified programming ability to meet disinfection standards. The training matrix reflected that staff had undertaken updated training in infection control which was ongoing. Service users who responded to the Commissions survey said that the home was always fresh and clean. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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. 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. The home has a training programme which means that staff receive relevant training which is focussed on delivering improved outcomes for service users. EVIDENCE: The home employs a multi-cultural staff team to meet service users diverse needs. The rota demonstrated that the number and grade of staff on duty to provide care and attention to service users 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 supported and valued by the manager. Those staff who responded to the Commissions survey said that they were provided with relevant and up to date training to help them understand and meet the needs of service users. The following additional comments were noted: I like working at Ker Maria it is better than other places that I have worked. Since the sisters are back we feel supported and more like a team. It is very helpful that the nuns are prepared to participate in many aspects of the residents care therefore the users of the service are always catered for. Over 50 of care staff have attained the national vocational qualification (NVQ) at level 2 or 3. The home is part of a local cluster group and staff are Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 21 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 verifying 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.V378590.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 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’s monitoring and health and safety practices have improved. This means that service users and staff’s safety is promoted and protected. EVIDENCE: The manager is a registered general and 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 (DOLS). Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 Page 23 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 were sent to service users, relatives, friends and other stake holders. The outcome of which indicated that improvement was needed in the laundry. The home is now trialling a button labelling system to label service users personal clothing which appears to be effective. The AQAA contained information about changes the home has made and where it still needs to make improvements. Staff spoken to confirmed that they were receiving regular supervision. This inspection highlighted that the homes care planning system had improved. The information in care plans was more comprehensive, relevant and easy to follow detailing how identified needs should be met. The service has developed a monitoring system to ensure that staffs practice is consistent and comply with the homes policies and procedures. Environmental risk assessments have been reviewed and any identified risks are supported with a plan of action detailing how the risk is to be managed. We were told that the home does not look after service users money. Service users are invoiced for purchases made on their behalf such as, toiletries, hairdressing and chiropody. A sample of health and safety records were examined and found to be up to date and in good order. Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 X 3 X 3 X X 3 Ker Maria DS0000019236.V378590.R01.S.doc Version 5.3 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. Standard Regulation Requirement Timescale for action 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.V378590.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission South East 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. 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