Inspection on 13/02/07 for Cloisters Nursing Home

This inspection was carried out on 13th February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cloisters Nursing Home 15/10/07

Cloisters Nursing Home 23/04/07

Cloisters Nursing Home 04/12/06

Cloisters Nursing Home 02/05/06

Cloisters Nursing Home 12/12/05

Cloisters Nursing Home 11/07/05

Cloisters Nursing Home 15/11/04

Cloisters Nursing Home 01/06/04

Cloisters Nursing Home 16/02/04

Cloisters Nursing Home 01/09/03

Cloisters Nursing Home 18/11/02

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:00 13 & 14th February 2007 th 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 Nursing Home DS0000010959.V326068.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 Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloisters Nursing Home Address 70 Bath Road Hounslow Middlesex TW3 3EQ 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) 020 8572 4131 020 8577 5358 Cloisters Care Limited Mary Elizabeth Horsfield Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61), Physical disability (61), Physical disability of places over 65 years of age (61) Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 61 beds for the elderly frail over the age of 60. All service users must be over 60 years of age at the time of their admission to the home. Five named service users with Dementia can be accommodated, as agreed by the NCSC on 6/5/04, for as long as there is no deterioration, which affects the well being of other service users. The rooms used for each of these service users will revert to the category of the unit once this service user no longer occupies it. 4th December 2006 Date of last inspection Brief Description of the Service: Cloisters Care Home is a sixty-one bedded care home giving nursing care to frail elderly service users. Twenty-eight of these beds are on the ground floor and thirty-three on the first floor. The purpose built building is situated on a busy thoroughfare close to the Hounslow Central underground station and bus transport links. There are fifty-one single bedrooms, thirteen with en suite washbasins and toilets. There are five double bedrooms, three with en-suites and two with bathrooms. There are six assisted bathrooms. There are two sitting rooms and one dining room on each floor. A stairway and two passenger lifts connect the ground and first floor. All areas of the home are wheelchair accessible. There is a large parking area to the side of the building and a garden to the rear. The fees range from £578.34 to £700 per week. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 27 hours was spent on the inspection process. A tour of each floor was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The CSCI pharmacist Inspector carried out a medication inspection on 13/02/07 and a separate report is available. The requirements and recommendations from the pharmacist inspection have been incorporated in this report. 9 service users, 10 visitors and 10 staff were spoken with as part of the inspection process. This report is a reflection of the findings at the time of inspection. Following the last inspection a meeting took place between CSCI and the Registered Manager and Area Manager for the home to discuss the shortfalls identified at that inspection. Following this inspection a further meeting has taken place between CSCI and the Responsible Individual and Area Manager for the home at which the shortfalls identified at the time of this inspection were discussed and assurances given to CSCI that prompt action would be taken to address them. What the service does well: What has improved since the last inspection? Staff training provision has improved to include dementia care, NVQ in care, topics relevant to the needs of the service users and also aspects of health & safety training. Overall the management and administration of medications has improved. Some shortfalls in this area were identified and must be addressed. The accessing of input from healthcare professionals for end of life care has improved, plus training in this area of care has been planned for staff. Staff had received training in POVA and representatives reported that any concerns are addressed. One incident was identified during the inspection that had not been addressed, and the Registered Manager said that she would ensure staff were fully aware to report any incidents. The home now has an auditing system in place for quality assurance, and the need to ensure audits are Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 6 carried out effectively was discussed. Information regarding the homes budgets has been provided to CSCI and the Registered Manager does have more information regarding this, although it is company policy not to provide the Registered Manager with copies of the budgets. 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 Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff had received training in dementia care, thus they did all have the specialist knowledge to care for service users fully with such a diagnosis. EVIDENCE: Pre-admission assessments were viewed. With one exception these had been fully completed and gave a clear picture of the service users needs. Social Services assessments were seen, including for the service user for whom the homes assessment was incomplete. The need to ensure all pre-admission assessments are complete was discussed with the Registered Manager. Several of the service users at the home have been assessed as having a dementia illness. Following the last inspection staff had received training in Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 9 dementia care. Further training has been planned in this area. Staff training records viewed confirmed that the training had taken place in January 2007. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the service user plan documentation was poorly completed and out of date, thus placing service users at risk of not having their needs identified and met. Although there had been an improvement in the medication management, shortfalls identified could potentially place service users at risk. Staff care for service users in a courteous and professional manner, thus respecting their privacy and dignity. Action is being taken to obtain professional input and to educate staff in the provision of end of life care, thus providing them with the knowledge to carry this out effectively. EVIDENCE: The Inspectors viewed 5 service user plans. The Inspectors were informed that new service user plan documentation had been introduced, however staff had not as yet received training in how to complete this. It was clear from some of the documents viewed that the lack of training had caused confusion in how the service user plans were to be implemented, and this included the Registered Manager. For one service user who had been in hospital the service user plan had not been reviewed on their return to the home. One new care Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 11 plan that had been completed was no longer relevant, but had not been concluded to reflect this. Some of the service user plans were very general and had not been personalised to the service user. Others had been personalised to give a good picture of each need. With the exception of signatures on some risk assessments, there was no evidence of input from service users and/or their representatives in the formulation and review of the service user plans. Risk assessments for falls had not always been completed in full, plus the new document being introduced had a ‘social situation’ section that included some information not relevant to service users living in a nursing home setting. Wound care documentation for 3 service users was viewed. Some information was out of date or incomplete and pressure sore risk assessments had not always been fully completed. The Inspectors expressed their concern and action was taken promptly to address the shortfalls identified. Moving & handling assessments were available, however the action plan page had not always been completed, and therefore the action to be taken when changing a service users position had not been identified. Bed rail risk assessments had been completed, however the document in use did not identify the risk to the service user and how this was to be minimised. Written consents for the use of bedrails had been obtained. Nutritional assessments were available and there was evidence that service users were being weighed monthly, with some being weighed weekly where a nutritional risk had been identified. Continence assessments had not always been completed and therefore the service users continence care needs had not been fully identified. There was evidence of input from GP’s and other healthcare professionals. The CSCI Pharmacist Inspectors carried out an inspection on 13/02/07 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for medication administration record. Staff were seen caring for service users in a courteous and professional manner. Overall service users and visitors spoken with expressed their satisfaction at the care provided at the home. Service users personal clothing is labelled, however some concern was expressed that items are not always returned to the correct service user. Some service users have their own telephones, either land line or mobile. Service users can bring in personal belongings in line with fire safety and several bedrooms viewed had been personalised. Following the last inspection action had been taken to improve the palliative care provision at the home. This includes accessing the Macmillan Nursing Service and also training for end of life care has been planned for staff. Some of the service user plans viewed did not contain information in respect of the wishes of service users and their representatives in relation to any deterioration in the service users health or their care in their final days. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provision within the home is good, and activities are planned to meet service users needs. More information is required to tailor the activities programme to meet service users individual needs. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, however service users are not offered assistance and thus may not always receive the nutritional input they require. EVIDENCE: The home has an activities co-ordinator who works hard to provide a varied activities programme for service users. Outings are planned although concern was expressed regarding the loss of a driver to take service users on outings. Service users were seen participating in arts & crafts to create decorations for Easter. On both days of inspection Pet Therapy was taking place and the service users enjoyed the company of the animals. The social and leisure care plans were still very general and in some cases little information about service users interests had been recorded. The home does have a comprehensive Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 13 document now in place to record service users social and life histories, however few had been completed. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home. Service users can receive visitors in their own rooms or in the communal rooms, to suit their preference. Details of Advocacy Services available in the local area are freely available in the main entrance of the home. This includes details for contacting Help the Aged and Age Concern. The kitchen was viewed. Shortfalls in cleanliness are discussed under Standard 26. Stocks of food were available and there was evidence of stock rotation. Fridge and freezer records were viewed and one fridge had not been included on the records. Some of the cleaning records were incomplete. A choice is provided for service users, however the daily choice forms had not been kept. For one service user with swallowing difficulties concerns were raised regarding lumps in the mashed potato. This was discussed with the cook who showed the Inspectors the small blender available for pureeing food. A satisfactory alternative to ensure food can be pureed fully must be provided. During the lunchtime meal the Inspectors noted that several service users being nursed in bed had their lunch meal placed on their bedside tables. It was clear that these service users needed some assistance in order to partake of the meal. One Inspector examined one plate of food and it was cold. One service user commented that this was a regular occurrence. The Inspectors did view some weight records for one service user in this situation and there was evidence that their weight had remained stable. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has procedures in place for the management of complaints, thus ensuring any concerns are investigated and responded to. Staff had received training in POVA and clear documentation is in place, however these had not always been followed, thus placing a service user at risk. EVIDENCE: The home has a clear complaints procedure with timescales for completion of any investigations into complaints. The Registered Manager reported that there had been no complaints received since the last inspection. The home has POVA documentation in place and also follows the Hounslow Safeguarding Adults procedures. Staff had received POVA training and those spoken with confirmed that they knew to report any concerns and were aware of the ‘Whistle Blowing’ procedure. Representatives spoken with said that they are kept informed of any concerns and any unexplained bruising is investigated and reported on. However, for one service user it was noted that bruising had occurred following an incident that had not been reported. Action had been taken to obtain medication for the bruising, however the service user had not been seen by the GP. On investigation it was clear that the correct care procedures had not been followed in this instance. This was discussed with the Registered Manager and with the Responsible Individual. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the décor in the home is generally of a good standard, there is a lack of necessary refurbishment in some areas plus shortfalls in the cleanliness of the home, thus the home is not being maintained at a good environmental standard for service users to live in. EVIDENCE: The Inspectors undertook a tour of the home. The Registered Manager reported that following the last inspection she had carried out a full environmental audit and this had been forwarded to head office. A copy was given to the Inspectors and identified areas for redecoration and refurbishment. Following this inspection a very brief document identifying timescales for the purchasing of some furnishings, subject to the financial wellbeing of the home, was forwarded to CSCI. A full redecoration and refurbishment programme, with timescales for completion must be available in Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 16 the home. Two of the automatic door closures on bedroom doors were not functioning and the doors were being held open by other means. The need to ensure the ‘dorguards’ are functioning at all times was discussed with the Registered Manager and the maintenance man. The home had not had a recent Environmental Health or Fire Safety inspection. In the communal areas some of the armchairs were damaged and exposing the foam filling underneath, which compromises the fire safety of the chairs and providing a poor standard of seating for those service users. The audit of furnishings carried out by the Registered Manager in December 2006 had identified the need for window restrictors to be checked in all areas, and it was not clear if this had been done. The laundry room was viewed. The flooring was very marked and lifting in places, especially where it butts up to the cupboard. This is a repeat finding. Laundry equipment is industrial and the washing machines have sluice programmes for disinfection purposes. Protective clothing to include gloves and aprons was available in the home. Sluice rooms with electronic disinfectors were seen on both floors. The general cleanliness within the home was inadequate, and dust and marks were seen on the tops of wardrobes, on carpets and on some surfaces. The visible areas had been cleaned and there were no malodours in the home. The Registered Manager reported that there had been a reduction in the hours available for cleaning duties. In one room the curtains, bedspread and lampshade were very dirty and it was clear these had not been washed for some time. The audit of furnishings carried out by the Registered Manager in December 2006 had identified all ‘drapes & blinds’ to be in need of laundering. Several service users have been experiencing unexplained skin irritations, and the CSCI Pharmacist Inspector has required that the cause for this be investigated. This must include cleanliness issues. The need to keep all areas of the home clean, to include regular laundering of linens, was discussed with the Registered Manager and the Responsible Individual. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are still not being calculated according to service users dependencies, plus hours for cleaning had been reduced, thus the needs of the service users and the home were not being fully met. Staff had received increased training to provide them with the knowledge to meet service users needs. Shortfalls were identified in recruitment practice, thus placing service users at risk. EVIDENCE: The staffing of the home is still being based on occupancy and not service users dependencies. The Registered Manager reported that she had requested an additional carer for the ground floor for the daytime hours. This has taken place for the morning shift, however not for the afternoon shift. At lunchtime the issue with a lack of staff to assist service users with their meals was identified. The Registered Manager reported that there had been a reduction in the number of hours for cleaning duties, and this was reflected in the shortfalls identified in the cleanliness of the home. The staffing must be reviewed to ensure there are sufficient numbers of staff on duty in all areas of the home for the needs of the service users and the home to be met at all times. The Registered Manager reported that 9 care staff have an NVQ in care qualification and 12 more care staff have been identified to undertake this Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 18 training. The Registered Manager is aware of the need to have 50 of care staff qualified to NVQ level 2 in care or the equivalent. Staff employment files were sampled. No ‘reason for leaving’ previous employment had been recorded and in one instance only one reference was available. It was not clear if the referees used had been the previous employer of the people concerned. Other information in these records did meet the Care Home Regulations 2001. The home has induction and foundation training based on the Skills for Care common induction standards. There had been an audit of all training files carried out and where shortfalls in training had been identified, action had been taken to arrange for training and updates. Staff spoken with confirmed that more training had been made available and undertaken. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is appropriately qualified to manage the home, however the home is not being fully effectively managed to ensure the needs of the service users and the home overall are met. The home has a programme in place for quality assurance, providing a system of audit and review for the home. Shortfalls in auditing were again identified, thus the process is not working effectively. Lack of financial investment in various areas of the home could place service users at risk. Service users personal monies handled by the home are being well managed and securely stored. Shortfalls identified in the management of aspects of health & safety at the home could place service users, visitors and staff at risk. EVIDENCE: Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 20 The Registered Manager is a first level registered nurse with a qualification in mental health, plus NVQ level 4 in management. Staff, service users and visitors spoken with said that the Registered Manager is approachable and supportive. The shortfalls identified during the inspection, to include repeat findings, give cause for concern, and it is essential that the Registered Manager manage the home effectively to address these shortfalls robustly and minimise the risk of re-occurrence. The company has introduced new auditing processes and documentation for quality assurance. There was evidence that audits to include medication and service user plans are carried out, however the standard of these audits, especially in respect of the service user plans, must improve to ensure service user plans are maintained to a good standard. Further areas for audit scheduled include health & safety, quality care, food safety and infection control. Staff meetings take place regularly. Following the last inspection the Responsible Individual provided CSCI with evidence of the homes financial position to include copies of the monthly budget. There is still a delay on expenditure within the home, and this needs to be addressed to ensure the home provides a good standard of accommodation for service users. The home holds small amounts of personal monies for service users and these are stored securely. Receipts are kept for all income and expenditure. Records viewed were up to date. Staff had undertaken training in health & safety topics. First Aid training had been planned. Risk assessments for equipment and safe working practices were in place. Since the last inspection the maintenance man had resigned and a new person employed. The new maintenance man had not received induction training specific to his role, and partly as a result of this some of the safety checks, for example, hot water temperature testing had not been continued. Servicing records viewed were up to date. In the kitchen no ‘deep clean’ had taken place for some time, and areas under the fridges, freezers and work areas, plus the wall tiles, were dirty. Following the inspection the Registered Manager has confirmed that a ‘deep clean’ has been carried out. The kitchenette on the first floor was viewed. The milk machine was being incorrectly used, and one section was very rusty. The fridge door was not shutting properly and the fridge was packed with foodstuffs, several of which were not fully labelled. The fridge had frosted up and the thermometer was frozen into the ice and debris. Bowls of food, covered with paper towels, were seen on shelves in the kitchenette. COSHH products were in the cupboard under the sink. These shortfalls were brought to the attention of the Registered Manager immediately and action was taken to address them. It was clear that no system was in place for regular checks of this area. COSHH products were also found in a bathroom on the first floor. The Inspectors were concern at the significant shortfalls identified in the health & safety at the home. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 21 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 3 X X 1 Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15, 17 Requirement Service user plans must be completed promptly and the information contained therein must be up to date and accurately reflect the needs of each individual and how these are to be met. Previous timescale of 31/01/07 not met. Staff must have the knowledge to complete any new service user plan documentation introduced accurately and in full. Input from the service user and/or their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. Assessments must be comprehensive and accurately reflect the status if the service user. Previous timescale of 31/01/07 not met. Wound care documentation must be complete and up to date. Previous timescale of 01/01/07 not met. Medicines must be recorded DS0000010959.V326068.R01.S.doc Timescale for action 16/03/07 2. OP7 18 16/03/07 3. OP7 15 01/04/07 4. OP8 15, 17 16/03/07 5. OP8 15, 17 16/03/07 6. OP9 13(2) 19/02/07 Page 23 Cloisters Nursing Home Version 5.2 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) 10. OP9 13 11. OP10 12 12. OP12 15, 16 13. 14. OP15 OP15 16(2)(g) 16(2)(i) 15. 16. OP18 OP19 13(4)&(6) 23(2)(b) & (d) accurately when received into the home. This includes the date. Staff must ensure that medicines are administered as per the homes policy- they are not left by the resident’s bed. Medicines must not be returned to the supplying pharmacist. Staff must adhere to the homes disposal policy. This must be reinforced. Medication must continue to be thoroughly audited regularly to maintain the good improvement in recording The home must try to establish a possible cause for the number of residents with a skin irritation in the home. Staff must be diligent and ensure that after laundering, clothing is returned to the correct service user. Individual information for each service user must be recorded to identify their social and leisure interests. There must be appropriate kitchen equipment available to puree food effectively. There must be robust systems in place to ensure that service users received their meals hot and staff are available to assist them with their meals. All staff must be aware to report any incidents affecting the welfare of service users. An action plan with timescales for completion must be drawn up to address the shortfalls identified in the environmental audit and any additional shortfalls identified at the time of inspection, to include redecoration, furniture and fittings. Previous timescales of DS0000010959.V326068.R01.S.doc 19/02/07 19/02/07 10/03/07 01/04/07 16/03/07 01/04/07 16/03/07 16/03/07 14/02/07 01/04/07 Cloisters Nursing Home Version 5.2 Page 24 17. 18. OP19 OP26 19. 20. OP26 OP27 21. OP29 22. 23. OP31 OP33 24. OP34 25. 26. OP38 OP38 01/06/06 and 01/01/07 not met. 23(4) Automatic door closures must be maintained in working order. Fire doors must not be wedged open. 13(3) The flooring in the laundry room must be made good to provide an impermeable floor surface throughout. 13(3), 18 The home must be maintained in a clean condition throughout at all times. 18 There must be appropriate numbers of staff on duty at all times to meet the assessed needs of the service users. This must be calculated according to service users dependencies, and not just based on occupancy levels. Previous timescales of 01/06/06 and 01/01/07 not met. 19 Staff employment records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. 10, 12, 13 The Registered Manager must ensure that the home is being managed effectively at all times. 24 The systems for auditing in place must be used effectively and prompt action taken to address any shortfalls identified. 12, 16, 23 There must be appropriate investment in the home to ensure it is fit for purpose at all times. An action plan to evidence this must be drawn up and forwarded to CSCI. Previous timescale of 05/01/07 not met. 13(4), 18 All staff must have the skills and knowledge to carry out their jobs safely and effectively. 13(3) A system for ensuring the kitchen receives a ‘deep clean’ at regular intervals to maintain the cleanliness throughout the DS0000010959.V326068.R01.S.doc 14/02/07 01/05/07 16/03/07 01/04/07 16/03/07 16/03/07 16/03/07 01/04/07 09/03/07 09/03/07 Cloisters Nursing Home Version 5.2 Page 25 27. OP38 13(3) 28. OP38 13(3) kitchen must be in place. Foodstuffs must be correctly and safely stored at all times. Daily checks of food storage facilities and areas must be carried out and prompt action taken to address any shortfalls identified. COSHH products must be securely stored in the home. 14/02/07 14/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations That the home reviews its ordering procedure with the community pharmacist and GP. The guidance of the Royal Pharmaceutical Society should be followed. Copies of original prescriptions should be kept in the home for reference. This would also reduce the number of discontinued items appearing on the MAR and reduce wastage. Cloisters Nursing Home DS0000010959.V326068.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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