CARE HOMES FOR OLDER PEOPLE
Cloisters 5 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX Lead Inspector
Mrs Trish Thomas Key Unannounced Inspection 29th May 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cloisters Address 5 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX 0151 924 3434 0151 9243434 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) Mrs Bernadette Neale Mr Stephen John Neale Mrs Hazel Welsh Care Home 20 Category(ies) of Dementia (20) registration, with number of places Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 20 DE. Date of last inspection 20th July 2006 Brief Description of the Service: Cloisters is a permanent care home, registered in the category of dementia for twenty elderly people. The registered providers are Mr. S. and Mrs. B. Neale, and the registered manager is Mrs. Hazel Welsh. Cloisters 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. Cloisters 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 floor 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 have NVQ qualifications. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit was un-announced over a five-hour period and the methods used were discussion with people who live in Cloisters, discussion with staff. The registered provider (Mrs. Bernadette Neale) was the responsible person in Mrs. Walsh, manager’s absence. A tour of the premises was carried out and records compiled in Cloisters relating to care, health & safety and staffing were read. Quality questionnaires completed by residents and their representatives were also read. What the service does well:
Prospective residents/their representatives are provided with an up to date statement of purpose, which includes description of the service provided, the number of places and accommodation and a copy of the complaint’s procedure. The people referred to Cloisters have had their needs assessed, including mental state and understanding, social, physical and health care needs. Staff receive relevant information from social workers/community psychiatric nurses about each individual who is referred to the service. Residents are supported in a way, which shows respect for their diversity. Brief summaries of interests and preferences are on record in their care plans, also each individual’s religion/culture and next of kin are recorded. To ensure that the service is suitable and provided in a way which is to each resident’s satisfaction, annual reviews take place with the resident and their representative present. Acknowledgement of respect for residents’ privacy and dignity is stated in the service principles of Cloisters, and staff receive training and instruction in these principles, through induction, supervision and ongoing appraisals. The manager has established a daily life and social activities book, which was read and provides good insight into the routines in Cloisters, and experiences of those who are living there. Staff confirmed that there are no restrictions on visiting times. A resident who commented said that visitors are made very welcome and given a drink, “They leave us in private when visitors come, I have no problems with the way my visitors are treated here.” The food stores were well stocked and there is a bright and well-presented dining room with seating and tables for twenty residents. A person who commented said, “There are no complaints about meals from me, the food is very good.” The menus record a variety of meals and special diets being Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 6 catered for. Residents are asked what they would like for their meal, and asked if they are satisfied with the meal when they had finished eating. Cloisters has a complaints procedure which is clearly stated and made available to residents and their representatives. Two residents said they did not have any complaints, another said, “Well I am sure they would have a lot of understanding if I was upset.” Cloisters is a converted Victorian building which is maintained to very good standards and decorated and furnished in a homely style. A resident said, “I am comfortable and the garden is well looked after.” Residents’ bedrooms are highly individualised with personal possessions and have nameplates on the doors, to assist residents who may become disorientated. The lounges are bright and comfortable. There are bedrooms, bathrooms and toilets on all floors, and a passenger lift to all floors. There are steps up to the front of the building and a ramp at the back, to assist residents who use wheelchairs or who may have difficulty using the steps. Cloisters employs domestic staff and the building was clean and odour free in the areas which were visited. First impressions of the Cloisters are very good from outside, and the interior provides a homely, secure and relaxing environment for those who live there. There is a low staff turnover, the majority of staff having worked in the home for several years. Over 50 of staff who are employed in Cloisters, have NVQ qualifications and a number are working towards this. Cloisters has a training and development programme and all staff have undertaken training which is suitable to their roles and job descriptions. Mrs. Hazel Welsh has been manager of Cloisters for 15 years and her qualifications include NVQ4, registered managers award and she is an NVQ work based assessor. There is a bi-annual quality assurance system in Cloisters, which is based on seeking the views of service users and/or their representatives through distributing questionnaires and addressing any shortfalls in service identified in the outcomes. What has improved since the last inspection?
The roof of Cloisters has recently been replaced, ornamental railings fitted in the garden, the front steps have been re-built and the side gate has been replaced. There is a designated parking area and the front garden has been
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 7 newly landscaped with colourful planting. Inside, new carpets have been laid in the lounges and hallways and new bedding and curtains purchased. To ensure that residents’ dignity and diversity is respected, reports and care plans are well written and relevant and improvements are evident in daily reports with the introduction of daily life books. All unwanted medication is returned to the pharmacy to ensure that an audit trail of drugs in maintained and out of date drugs are not on the premises. To avoid risks from food poisoning, food hygiene procedures were being followed, the food stores were clean and the storage and labelling of food was satisfactory. To ensure that residents are provided with the lifestyle of the choosing, daily life books have been established which provide a good insight into the home’s routines, choices available to them and the leisure activities, which they enjoy. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Prospective residents have the information they needs before moving in to Cloisters and their needs had been assessed to ensure that the service is suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1, 3. Prospective residents/their representatives are provided with an up to date statement of purpose, which includes description of the service provided, the number of places and accommodation and a copy of the complaint’s procedure. The complaints procedure has recently been given to residents again, and the manager has discussed the procedure and their right to make complaints with individual residents.
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 10 The people referred to Cloisters have had their needs assessed, including mental state and understanding, social, physical and health care needs. Staff receive relevant information from social workers/community psychiatric nurses about each individual who is referred to the service. Cloisters has a standard assessment form, which is followed by senior staff, to assess the needs of people who are referred, before they move in. Pre-admission assessments contained in residents’ files were read. The outcomes of assessments, in addition to information obtained from the individual, their representative and agencies involved in making the referral, provide evidence as to whether or not Cloisters can meet the needs of each person. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ health and personal care needs are set out in their individual care plans and they are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7,8,9,10. All residents of Cloisters have been assessed as having some degree of mental frailty/dementia and all have a care plan. The care plans follow a standard format, and those of two residents were looked at in detail. The outcomes of assessments were checked against action plans and risk assessments, and were found to be satisfactory. For example, for a person who has a history of falls, a risk assessment had been carried out and support plan written, likewise for residents requiring support for memory loss or agitation. In conversation with staff, it was evident that they have good knowledge of residents’ needs
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 12 and preferences, and they were aware of the actions to be followed to meet their needs. Residents are supported in a way, which shows respect for their diversity. Brief summaries of interests and preferences are on record in their care plans, also each individual’s religion/culture and next of kin and arrangements are made to meet any special religious or cultural needs. To ensure that the service is suitable and provided in a way, which is to each resident’s satisfaction, annual reviews take place with the resident and their representative present. In addition, residents’ care plans are reviewed regularly by staff and altered, as their needs change. Residents’ care plans contain brief medical histories and all residents are registered with local G.P.s. There was evidence in care files of referrals to chiropodists and district nurses as needed. The district nurse visits twice daily to administer insulin injections for one resident who is diabetic. There is also contact with the local mental health consultant, community psychiatric nurses and social workers when residents may need increased support or professional assessments. Cloisters has a procedure for managing residents’ medication and staff who administer medication have received relevant training, records of which were seen. The medication prescribed for two residents was looked at and there were supplies of each of the drugs in stock. The medication administration sheets had been signed as the medication was given out, and the amounts of the drugs in stock balanced with the amounts, which had been administered. Arrangements for the management of Warfarin for a third resident were discussed with staff, who were following instructions given by staff from the clinic, as the dose had been reviewed. There is a procedure in place for returning unwanted medication to the pharmacy and all medication was indate at the time of this visit. Residents looked very well cared for, obvious attention having been paid to their clothing and personal grooming. Residents did not comment in depth during the visit and they were observed following the routines of their home, where they were supervised, at all times, in a safe environment. Staff were observed treating residents with respect, offering choices and supporting them discreetly. Acknowledgement of respect for residents’ privacy and dignity is set out in the service principles of Cloisters, and staff receive training and instruction in these principles, through induction, supervision and ongoing appraisals. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents have a lifestyle, which suits their expectations and preferences and they are provided with a wholesome and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. The manager has established a daily life and social activities book, which was read and provides good insight into the routines in Cloisters, and experiences of those who are living there. A variety of in house group events are arranged daily and residents receive one to one support, for example, to go out regularly. A resident had been for afternoon tea recently, and to the beach with a member of staff escorting. There are regular church services and the Eucharistic minister was spoken with. Religious services and or communion take place regularly, according to the needs and beliefs of residents at the
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 14 time. There was evidence in records that residents are asked if they wish to attend the religious service. Staff confirmed that there are no restrictions on visiting times. A resident who commented said that visitors are made very welcome and given a drink, “They leave us in private when visitors come, I have no problems with the way my visitors are treated here.” Staff confirmed that residents who have no relatives have access to local advocacy services. The menus were read and showed variety of meals and special diets are catered for. There were records of residents being asked what they would like for their meal, and asked if they were satisfied with the meal when they had finished eating. The food stores were well stocked with fresh, frozen and chilled provisions. There is a bright and well-presented dining room with seating and tables for twenty residents. A resident who commented said, “There are no complaints about meals from me, the food is very good”. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Residents’ complaints are listened to and they are protected by the procedures and training provided for staff in complaints, protection and “whistle-blowing”. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 and 18. Cloisters has a complaints procedure which is clearly stated and made available to residents and their representatives. Two residents said they did not have any complaints, another said, “Well I am sure they would have a lot of understanding if I was upset.” A record of complaints is held in Cloisters, the last on record being dated January 2005. Cloisters has procedures for protection of vulnerable adults and “whistleblowing” and staff have received training. Staff who commented were aware of the need for the procedures and had received training in relevant aspects of safeguarding vulnerable people. The procedure and training certificates were read. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 16 Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Cloisters is a very well maintained building, it is comfortable, homely and maintained to high standards of hygiene. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19, 26. Cloisters is a converted Victorian building which is maintained to very good standards and decorated and furnished in a homely style. Residents’ bedrooms are highly individualised with personal possessions and the doors have nameplates to assist residents who may become disorientated. The lounges are bright and comfortable. There are bedrooms, bathrooms and toilets on all floors and a passenger lift to all floors. There are steps up to the
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 18 front of the building and a ramp at the back, to assist residents who use wheelchairs or may have difficulty using the steps. There is a nurse call system throughout the home and exits are linked to the alarm system to ensure residents’ safety and security. The rear garden is large with a locked gate at the side. Residents are able to move freely from the building to the garden, where seating and umbrellas are set out. The front and rear gardens are beautifully landscaped and well tended, there is also a small off street parking area at the front. First impressions of the Cloisters are very good from outside, and the interior provides a homely, secure and relaxing environment for those who live there. The roof of Cloisters has recently been replaced, ornamental railings fitted in the garden, the front steps have been re-built and the side gate has been replaced. A designated parking area has been created and the front garden has been newly landscaped with colourful planting. Inside, new carpets have been laid in the lounges and hallways and new bedding and curtains purchased. Cloisters employs domestic staff and the building was clean and odour free in the areas which were visited. There are cleaning schedules maintained to ensure accountability. Cloisters has procedures on control of substances hazardous to health and infection control, and staff have received related training (training certificates, procedures and cleaning schedules were seen). Cleaning materials and utensils are kept secure when not in use, and domestic staff are provided with training and protective clothing. Utility areas (kitchen, food stores and laundry) were well organised and clean. Food storage was satisfactory, frozen and chilled foods being labelled and dated to avoid contamination. Kitchen and laundry equipment was in working order. To further ensure the control of infection, a bay has been built to contain to contain the refuse bins. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ needs are met by the numbers and skill mix of staff, and staff are suitably vetted and supported by management. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27, 28, 29, 30. Staff rosters were seen and were in good order, giving the names of staff and the shifts they have worked, including night staff and ancillary staff. There is a low staff turnover, the majority of staff having worked in the home for several years. There was a vacancy for the post of full time cook, which had been advertised. A member of bank staff was covering the full time post and a part time permanent cook works two days a week. The managers’ hours are supernumerary to care hours and administration and maintenance staff are in post in addition to care and ancillary staff. Over 50 of staff who are employed in Cloisters have NVQ qualifications. Six members of staff have level 2, four members of staff have levels 2 and 3 and one currently undertaking level 3. One member of staff has NVQ4.
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 20 Cloisters has a training and development programme and all staff have had training in protection of vulnerable adults, raising concerns and “whistleblowing”, dementia, equality & diversity, managing challenging behaviour, medication administration, first aid, fire safety, food hygiene, infection control, manual handling. Training certificates were read and staff who commented said they are well supported and the training is relevant to their job roles. Cloisters has a recruitment procedures which includes advertising vacant posts, interviewing staff and taking up references and CRB and POVA clearances for appointed candidates. A sample of staff files was read and was in good order, containing application forms, two references, proof of CRB clearances. There was proof of training on record in staff files and staff said they have job descriptions, contracts of employment, appraisals and formal one-to-one sessions. There was also evidence of probationary periods and induction training for newly appointed staff. The staff files were secured in a locked cabinet in accordance with the policy on confidentiality followed in Cloisters. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Cloisters is managed in the best interests of residents and their health and safety is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31, 33, 35 and 38. Mrs. Hazel Welsh has been manager of Cloisters for 15 years and her qualifications include NVQ4, registered managers award and she is an NVQ work based assessor. There was evidence of Mrs. Welsh’s commitment to reviewing the quality of service through the setting up of “What we could do
Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 22 better” forms which have been created to identify possible improvements to the service, in addition to annual development plans, which are discussed regularly with the providers. There is a bi-annual quality assurance system in Cloisters, which is based on seeking the views of service users and/or their representatives through distributing questionnaires and the outcomes of questionnaires for March 07 were read. Mrs. Neale said that any problems identified in responses would be dealt with as part of the process. The outcomes, which were read, in a sample of quality assurance questionnaires, were predominantly positive. Mrs. Neale confirmed that Cloisters does not have any involvement in residents’ personal finances. If needed, residents have court of protection or access to advocates if they have no family to take responsibility. The charges for the service and who will pay them (eg. resident, Local Authority), is clearly set out in the individual’s contract of residence. Staff have received training in first aid, food hygiene and infection control. Certificates of training were seen in staff files and it was evident in the standards of hygiene observed that staff are following safety and infection control procedures. Staff said that management support them well, and confirmed that they have formal supervision (at least six times a year) and annual appraisals. Staff have received training in moving and handling and risk assessments are carried out to avoid accident/injury to residents. A report of accidents is maintained in Cloisters, and those which were read were satisfactory, and in suitable detail. Health and safety certificates and maintenance records and the fire book were read. Landlords Annual Gas Certificate 7/9/06, Electrical Certificate (3 or 5 yearly) January 07. Legionella certificate 2/5/07, submersible water tests carried out weekly and are set at 42 degrees, portable appliance tests are carried out annually. Emergency Lighting and Nurse Call tested February 07. Environmental Health visit, November 06. The fire book was satisfactorily maintained and the last fire drill was carried out on 11/5/07. The hoist was serviced 21/7/06, air conditioning was serviced in May 07, Employer’s Liability Insurance due January 08. Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 23 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 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 4 X 3 X 4 X X 4 Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 24 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 Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cloisters DS0000005410.V337177.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
