Inspection on 18/07/05 for Cloisters

This inspection was carried out on 18th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Cloisters 29/05/07

Cloisters 20/07/06

Cloisters 10/01/06

Cloisters 31/01/05

Cloisters 27/07/04

Similar services:

Chirnside House

Emmaus House

East Croft Grange

Craignair

Croston Park Nursing Home

Conifers Nursing Home

Elmsdene Care Home

Crawfords Walk Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cloisters 5 Abbotsford Road Blundellsands Liverpool, Merseyside L23 6UX Lead Inspector Trish Thomas Unannounced 18th July 2005 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 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. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cloisters Address 5 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX 0151 924 3434 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Bernadette Neale Mrs Hazel Welsh Care Home 20 Category(ies) of DE - Dementia registration, with number of places Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 20 DE Date of last inspection 31st January 2005 Brief Description of the Service: Cloisters is a permanent care home, registered in the category of dementia for twenty elderly people. The home is owned by Mr. S. and Mrs. B. Neale, and the registered manager is Mrs. Hazel Welsh. The building is a detached Victorian house with a car park at the front and an enclosed and wellmaintained garden at the rear. Cloisters is close to a train station and bus routes and is situated in a quiet residential area. The home has a passenger lift to all levels and there are sixteen single and two double rooms, all with call bells. Bedrooms are located on the ground and upper floors. There are two large lounges and a dining room, which seats twenty people and is also used for activities sessions. The home is staffed throughout the day and night and care staff are trained to NVQ level in direct care. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The registered manager, Mrs. Hazel Welsh, was on duty and there were 18 in residence. The inspection took place during the morning and early afternoon. Nine residents and four members of staff were spoken with, records were inspected. The lounges, dining room, kitchen and gardens were visited. The findings of the inspection were generally positive. Residents looked well cared for and were appropriately dressed for the hot weather. Fans had been set out in the lounges for their comfort, and seating and shade provided in the garden, drinks were served to residents before and after lunch. Nine residents were spoken with after lunch in two lounges. Due to their levels of confusion, primary evidence on the care they were receiving, was from reading care plans, discussing their needs with the manager, reading Quality Assurance Questionnaires and directly observing residents’ interaction with staff. Care plans which were read, were well maintained in accordance with the last inspection requirements. What the service does well: Cloisters provides a specialist residential care service to older people who have dementia. The home provides a comfortable and well-maintained environment and, during the inspection attention had been paid to residents’ comfort and wellbeing. The manager and staff have many years experience in dementia care, and training and updates are ongoing. The home has a well-organised system for maintaining the records relating to care practice, staffing and health and safety. The home has a comprehensive procedures manual, which is available to staff. Care Plans were in place for all residents and, in practice, the process appeared to be benefiting them. Staff were observed treating residents respectfully and residents in the lounges were supervised at all times. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 Cloisters was meeting standards 1 and 2. Standard 6 does not apply to this home, which is not registered to provide intermediate care. Residents of Cloisters are assessed with dementia and admissions are arranged through family representatives, social workers or advocates. The prospective resident is involved in the process in accordance with their decision-making capacity. All admissions are subject to a written contract/statement of terms and conditions. EVIDENCE: Reference was made to the home’s service users’ guide and statement of terms and conditions, which are provided on admission and set out Cloisters’ services and facilities and the terms of residency, charges and notice periods. All prospective residents have been assessed with dementia and there was evidence in care files of professional assessments prior to admission. In accordance with residents’ mental state and levels of understanding, there was evidence of representatives’ involvement, at time of admission, in management of residents’ finances, and in the care planning process. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The home was meeting standards 7,9 and 10. In accordance with a requirement from the last inspection, residents’ mental health needs are now more comprehensively addressed in their care plans. The home has a satisfactory system in place for the management of residents’ medication. Residents appeared to be respected by staff. The home did not meet standard 8 with regards to provision of chiropody services for one resident. A requirement is made under Standard 8 Regulation 13 1 (b), that the manager must ensure that residents receive chiropody treatment in accordance with individual need. EVIDENCE: Three care plans were read in detail and a fourth was referred to, having met with the resident, to check out the last date of her chiropody treatment. The care plans, which were read, had been regularly reviewed and updated as necessary. Care plans had next-of-kin signatures. An improvement was noted in the planning process with regards to addressing the behaviour patterns residents in advanced stages of dementia. (Records referred to include consultants’ psychiatric assessments, community care reviews, internal assessments and reviews, weight charts, risk assessments, social histories). Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 10 Good practice was noted in that care plans had been updated with regards to the heat wave, experienced at the time of inspection. The home has a written medication procedure, which was discussed with a senior staff member. None of those in residence were self-medicating due to their levels of dementia. Staff who administer medication receive instruction (through shadowing/observation) and training. There is an established audit trail through the checking and recording of quantities, and pharmacy staff sign for returns. Medication is stored in a locked trolley, which is padlocked to the wall and the person in charge of administering prescribed medication is the nominated key-holder. A file is maintained of information on side effects of drugs, which staff refer to, for awareness of any possible change in the condition of a resident which may occur after taking their medication. Residents’ privacy was respected by staff, at the time of inspection, bathroom, bedroom and toilet doors were kept closed. Residents looked well cared for and obvious attention had been paid to their personal grooming. There are sixteen single bedrooms and two double bedrooms, where screening is provided to ensure residents’ privacy. Chiropody service, for one resident was discussed with the manager, Mrs. Welsh. She said she would make arrangements for the chiropodist to visit this lady, who was not wearing shoes whilst seated in the lounge, and whose toe-nails were in need of attention. (The care plan recorded her last chiropody treatment in May 05). Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The home was meeting standards 12,13,14,15. Activities and social events are arranged by staff for the residents, and residents’ relatives are made welcome when they visit. In providing choice to residents, there is an evident level of consultation through discussion with them and their representatives. Residents are provided with a varied and wholesome diet. EVIDENCE: The home has an activities calendar and provides a variety of in-house crafts, readings, music and board games. Religious ministers visit the home in accordance with the needs and preferences of residents, which are recorded on the care plan. Care plans contain social histories, and a member of staff said she found these useful in building up knowledge of each individual. There was evidence of representatives’ involvement in the care planning process, as their signatures had been obtained for the plans, which were read. Quality Assurance questionnaires were read and staff had obtained residents’ comments wherever possible. There is a four-week rotating menu, which is seasonally adjusted and there is an alternative menu available. Residents are weighed monthly, their weight charts are monitored and consistent loss of weight referred to the G.P. Two residents’ diabetic diets were being catered for, at the time of this inspection. There were good stocks of food in store and the kitchen was well equipped and well organised. The chef on duty had been trained to Intermediate Food Hygiene Certificate level. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home was meeting standards 16 and 18. The home has procedures in place for responding to complaints and protecting residents from abuse. EVIDENCE: The home has a complaints procedure and a record of complaints is maintained for inspection. One complaint has been investigated by CSCI since the last inspection and this was partially upheld. The home has an adult protection procedure and whistle blowing policy. The manager confirmed that staff have recently received training in protection of vulnerable adults (training courses have been provided to staff, both in-house and from an external training organisation). Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 The home was meeting standard 19 and 26. The home is well maintained and appears to meet the needs of the residents. The home was clean and hygienic in the areas visited. EVIDENCE: Cloisters is maintained to a very good standard and has a homely atmosphere. Furnishing and fittings are domestic in style and in keeping with the age of the building and the needs of residents. The building is in good decorative order and the garden is secluded, well maintained, accessible and secure for residents’ enjoyment, with seating and shade provided. The home has an ongoing maintenance programme and employs a handyperson. The home has procedures in place for the control of infection. The manager confirmed that staff have recently received training in infection control from an external provider and protective gloves and aprons are available to them. The home has a clinical waste disposal policy and employs domestic staff, who are included on the roster. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The home was meeting standards 27 and 30. Staff numbers are consistently maintained and NVQ and mandatory training are ongoing for staff. EVIDENCE: The staff roster provided evidence that staff numbers are maintained throughout the day and night. The manager referred to her training schedule and confirmed that over fifty percent of staff have NVQ level 2. Two members of care staff who were spoken with said they receive regular mandatory training updates. Staff confirmed they have recently taken courses in infection control, first aid updates and in protection of vulnerable adults. The home has a video on caring for people with dementia, which is available to staff to support their knowledge base of the specialist service provided in Cloisters. Staff do not take responsibility for administering prescribed medication until they have received instruction and training. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home was generally well maintained and hazard free, two shortfalls were noted and requirements are made under Regulation 13 (4) (a). EVIDENCE: Reference was made to the following certificates and records. Electrical Certificate 2/7/04 Portable Appliance Tests July 04 Environmental health officers’ visit 21/4/05 Lift Certificate 16/6/05 Fire Drill May 05 Last Fire Instruction 9/7/05 (6 monthly day staff, 3 monthly night staff). Fire Risk Assessment reviewed and dated by manager. Residents’ Fire Roll Call maintained. The Landlords’ Annual Gas Certificate was out of date (due June 05). Hazards were noted in the basement corridor near the lift. Cleaning equipment had been placed in an area used by residents when accessing the dining room. Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 17 No Are there any outstanding requirements from the last inspection? 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 8 Regulation 13 1 (b) Requirement Timescale for action 19/7/05 2. 38 13 4 (a) 3. 38 13 4 (a) The manager must ensure that residents receive chiropody treatment in accordance with individual need. Timescale ongoing from the date stated. The manager must provide CSCI By 19/9/05 with a copy of the homes up to date Gas Certificate. By the date stated. The manager must ensure that By 19/8/05 the basement corridor is maintained free of tripping hazards. 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 Good Practice Recommendations Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Burlington House, South Wing, 2nd floor Crosby Road North Waterloo, Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 Cloisters F53 F03 S5410 Cloisters V242189 180705 Stage 4.doc Version 1.40 Page 19 - 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. 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