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Inspection on 15/10/07 for Cloisters Nursing Home

Also see our care home review for Cloisters Nursing Home for more information

This inspection was carried out on 15th October 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Medications are being well managed at the home. The home has an open visiting policy and visitors are made welcome. The food provision is good and residents are offered a choice, which is respected. Also there is evidence that comments received from residents in respect of food quality have been responded to. The home has a clear complaints procedure and complaints had been appropriately responded to. The home was clean and fresh and infection control is being well managed at the home. Several CSCI comment cards received from residents indicated that they are being well cared for at the home and that action is taken to address issues raised.

What has improved since the last inspection?

There has been an improvement in the formulation and review of the service user plans, to include completion of assessments and wound care documentation. Medication management has improved to a good standard. Some information had been obtained regarding the provision of Advocacy Services, however this was limited and more information is required. There is evidence of redecoration and refurbishment, however the programme for this still does not identify the projected timescales for completion of each project. Risk assessments for fire, equipment and safe working practices had been reviewed and updated.

What the care home could do better:

It was clear from the fact that several residents with diagnoses outside the homes categories of registration had been admitted to the home that the preadmission assessment process had not been thoroughly conducted. Input fromresidents and/or their representatives in the formulation and review of the service user plans was not seen. A risk assessment had not been completed for the use of a wheelchair lap strap, thus there was no explanation or agreement for its` use. The wishes of residents and their relatives in respect of a deterioration in health and end of life care are still not being ascertained and recorded. Since the last inspection the activities co-ordinator has left and several comments have been received regarding the lack or limited activity provision in the home. There had been one POVA incident since the last inspection, and this was a result of the admission of residents outside the homes categories of registration and an apparent lack of understanding by staff regarding appropriate care provision in this case. Comment had been received regarding the home being short staffed at times and the rosters viewed evidenced this. In addition at the time of inspection there were occasions where staff were busy caring for residents with cognitive impairment, requiring significant supervision and input, and thus others were having to wait to have their care needs met. On some of the staff employment records viewed there was no explanation recorded for some gaps in employment, which needs to be addressed. The training provision needs to be reviewed. The company provides `mandatory training` to include health & safety topics, plus several staff had completed NVQ training. However, there is limited induction training, reflected by several comments regarding new staffs lack of knowledge about the care needs of individual residents. In addition, the training application form for additional training indicates that staff must undertake such training in their own time. The completion of the CSCI AQAA document was limited, with brief entries in some sections and a lack of comment regarding some of the key standards. Some of the records for the management of residents` monies were incomplete. Fire drill attendance information had not been completed in full. The shortfalls identified in various sections of this report evidence that not all the auditing systems in use are working effectively and prompt action is needed to address this.

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:20 15 & 16th October 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.V349200.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.V349200.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 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.V349200.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. 23rd April 2007 Date of last inspection Brief Description of the Service: Cloisters Care Home is a sixty-one bedded care home giving nursing care to older people. Twenty-eight of these beds are on the ground floor and thirtythree on the first floor. The purpose built building is situated on a busy thoroughfare close to the Hounslow Central shopping parade and transport links. There are fifty-one single bedrooms, nineteen with en suite washbasins and toilets. There are five double bedrooms, four with en-suite facilities and one without. There are six assisted bathrooms. 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. Alpha Health Care Limited, a private company owns the home. The fees range from £578.36 to £700 per week. Cloisters Nursing Home DS0000010959.V349200.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 28 hours was spent on the inspection process, and was carried out by 2 Inspectors. The Inspectors carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 18 residents, 20 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from service users, representatives/visitors and staff have also been used to inform this report. Comments received have been fed back to the Manager Designate in a general manner. What the service does well: What has improved since the last inspection? What they could do better: It was clear from the fact that several residents with diagnoses outside the homes categories of registration had been admitted to the home that the preadmission assessment process had not been thoroughly conducted. Input from Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 6 residents and/or their representatives in the formulation and review of the service user plans was not seen. A risk assessment had not been completed for the use of a wheelchair lap strap, thus there was no explanation or agreement for its’ use. The wishes of residents and their relatives in respect of a deterioration in health and end of life care are still not being ascertained and recorded. Since the last inspection the activities co-ordinator has left and several comments have been received regarding the lack or limited activity provision in the home. There had been one POVA incident since the last inspection, and this was a result of the admission of residents outside the homes categories of registration and an apparent lack of understanding by staff regarding appropriate care provision in this case. Comment had been received regarding the home being short staffed at times and the rosters viewed evidenced this. In addition at the time of inspection there were occasions where staff were busy caring for residents with cognitive impairment, requiring significant supervision and input, and thus others were having to wait to have their care needs met. On some of the staff employment records viewed there was no explanation recorded for some gaps in employment, which needs to be addressed. The training provision needs to be reviewed. The company provides ‘mandatory training’ to include health & safety topics, plus several staff had completed NVQ training. However, there is limited induction training, reflected by several comments regarding new staffs lack of knowledge about the care needs of individual residents. In addition, the training application form for additional training indicates that staff must undertake such training in their own time. The completion of the CSCI AQAA document was limited, with brief entries in some sections and a lack of comment regarding some of the key standards. Some of the records for the management of residents’ monies were incomplete. Fire drill attendance information had not been completed in full. The shortfalls identified in various sections of this report evidence that not all the auditing systems in use are working effectively and prompt action is needed to address this. 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.V349200.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.V349200.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has admitted residents with diagnoses outside the homes category of registration, therefore the assessment process has not been appropriate to ascertain the full needs of each prospective resident. EVIDENCE: In recent months the home has admitted some residents with diagnoses outside the categories of registration for the home. The home did have a condition of registration agreed in 2004 to permit 5 named residents with a diagnosis of dementia to continue to be accommodated at the home. On investigation it was found that none of these named residents were still living at the home and the Manager Designate and Area Manager had misunderstood this condition of registration, assuming it was acceptable to accommodate up to 5 residents with dementia at any one time. The admitting of residents with diagnoses outside the homes categories of registration has led to some disruptive behaviour and situations impacting on other residents. In turn this Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 9 has meant that the home has had to ask for residents to be found alternative suitable accommodation. The home must not admit residents outside its categories of registration and must ensure prospective residents are fully assessed prior to admission to the home. Cloisters Nursing Home DS0000010959.V349200.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. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Overall staff care for residents in a gentle and professional manner, however one shortfall identified could compromise privacy and dignity. Repeated shortfalls in identifying end of life care needs place residents at risk of not having there needs fully met. EVIDENCE: One inspector viewed 6 service user plans. Generally these were comprehensive and identified individual needs and how these are to be met. There was evidence that documentation had been reviewed monthly and more frequently if a change in a residents’ condition occurred. Residents and/or representatives had signed the care plan review form, however on discussion it was clear that people had not been given the opportunity to be part of the formulation and reviewing of the service user plan documentation, rather had just been asked to sign this document. The importance of involving the Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 11 residents in the formulation and review of the service user plans was discussed with the Manager Designate. Assessments for moving & handling, continence, nutrition, risk of falling and pressure sore risk assessment had been carried out and reviewed. Information regarding the moving & handling equipment in use for each person had been clearly recorded. Documentation for one wound was viewed. This was comprehensive and included details of the wound, the dressing regime in place and any involvement from the tissue viability nurse. Details of dressing changes were clearly recorded. The records viewed evidenced input from the General Practitioner, dietician, chiropodist and other healthcare professionals. Bedrails risk assessments and consents were viewed and found to be comprehensive. Some residents were seated in recliner chairs, plus one resident had a seatbelt in place for safety when seated in a wheelchair. Risk assessments had not been carried out and there was no documentation in place to explain the relevance and suitability of the use of this equipment in each case. A written consent for use of the seatbelt had been signed, however no explanation for the reason for use was given. Medications were viewed on both units. There was a clear list of nurse signatures in place. Medication administration records viewed were well completed and there were clear records when medication had been refused or omitted. The Controlled Drugs register on both floors was up to date and stock balances were correct. Liquid medications had been dated when opened. Receipts, administration and disposals had been clearly recorded. Fridge and room temperatures had been recorded and on the first floor an air conditioning unit is in place and used whenever required to ensure temperatures remain in safe range. Lancet devices for single use were being used for monitoring blood glucose levels. Records for residents on percutaneous endoscopic gastrostomy feeding (PEG) were clear and up to date, and any special instructions for all staff to observe for safety purposes were clearly displayed. Weekly medication audits are carried out and it was evident that these had contributed to the good improvement made in the management of medications in the home. Staff were seen caring for residents in a gentle and professional manner. In one double room where 2 residents were in bed the dividing curtain was not available. The Manager Designate said that this had previously been in place. The Manager Designate investigated the situation and has confirmed that it has been promptly addressed. Residents clothing is labelled and residents were well dressed, reflecting individuality. Residents can have their own telephones in their rooms, or a mobile phone. Residents receive their post unopened. The service user plans were examined for information regarding end of life care wishes. Only one contained some information regarding this. Whilst it is accepted that this can be a difficult subject to discuss, the importance of ascertaining and recording the wishes of residents and their representatives in Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 12 respect of deterioration in health and end of life care was discussed with the Manager Designate. Cloisters Nursing Home DS0000010959.V349200.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): 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 at the home is limited, thus residents interests and wishes are not being fully met. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was limited, thus peoples right to individual representation is not being fully respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: At the time of inspection the home did not have an activities co-ordinator. This post is being advertised and one of the care staff was working 30 hours per week to provide activities for the residents. Some comments received were in respect of the shortage or lack of activities and also the fact that outings were not being arranged. Plus comment was received regarding residents not being taken out in the garden. The Manager Designate explained that this was because of not having a member of staff available to sit out with the residents. This situation needs to be addressed as part of ensuring there are activities, outings and entertainments available to suit the individual needs and wishes of the residents. There was information regarding the interests of residents in Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 14 some of the service user plans viewed, and the individual interests and hobbies need to be ascertained and recorded for all residents. The home has an open visiting policy and visiting is encouraged. Refreshments are offered and visitors can have meals with residents if visiting at that time. The home has some advocacy information available for Care Aware, who provide advice on financial matters. The Manager Designate said that she had received information from Age Concern and said that she would display the advocacy information in the home. The Manager Designate said that all but one resident has a relative to represent them, however the need to provide information so that residents can access independent representation should they so wish was discussed. One Inspector viewed the kitchen. The area was clean and tidy and records were up to date. There was a good supply of fresh, frozen, tinned and dried foodstuffs, to include fresh fruit and vegetables. Comment had been received that there had been issues with the meal provision, however following a meeting with the chef and the management the menus had been reviewed and the food had improved. Mealtimes were viewed and staff were available to assist residents who required help, and the mealtime was a social occasion. There are snacks and drinks available throughout the 24 hour period. Meals to include liquidised food are attractively presented. Residents who wish can have a glass of sherry before their meal. Meal choices are offered and recorded. Cloisters Nursing Home DS0000010959.V349200.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): 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 a clear complaints procedure that is followed, thus ensuring that any complaints are addressed. The home has procedures in place for the protection of vulnerable adults, however lack of awareness in this area could place residents at risk. EVIDENCE: The home has a clear complaints procedure and this is displayed in the home and included in the Statement of Purpose and Service User Guide. The home has had 4 complaints since the last inspection, 2 responded to in writing and one verbally, with the outcome of the meeting with the complainant recorded. The fourth complaint has been dealt with under POVA (see below). The home has procedures in place for the protection of vulnerable adults and also has a copy of the Hounslow Safeguarding Adults procedures. A recent case came to light and had not been recognised by the home as a safeguarding adults situation. This was again in relation to admitting a resident outside category and the lack of knowledge of staff to manage such a situation appropriately. Such situations must not be permitted to arise in the future and staff must all have a clear understanding of adult protection procedures. It was also noted that some residents had minor injuries and in some cases no explanation had been recorded. The need to ensure all injuries are investigated and clear records maintained was discussed. Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, however evidence of planned works with timescales for completion is needed to show that work is being planned and completed in a timely manner. Infection control is being well managed, thus protecting residents, visitors and staff. EVIDENCE: One Inspector carried out a tour of the home. There was evidence of redecoration and refurbishment in areas to include new carpeting and décor in the lounges. New furniture includes profiling beds, armchairs and wardrobes. There was a redecoration and refurbishment list, however this was only dated following completion of work. A redecoration and refurbishment plan with dates for completion to evidence that work is to be completed in a timely fashion was still to be completed. Bedrooms had been personalised. The gardens were in need of attention. An Environmental Health Office Inspection had taken place Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 17 in July 2007 and the Manager Designate said that action had been taken to address the shortfalls identified. The laundry was viewed and was in good order. The washing machines have a sluice programme for the disinfecting of soiled items. The laundry person had received training in infection control and was able to explain this to one Inspector. The premises throughout were clean, tidy and fresh. Protective clothing to include gloves and aprons was available. Infection control was being well managed in the home. Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 18 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. Some shortfalls were noted with the staffing, thus residents needs were not being met at all times. Robust systems are in place for staff recruitment, however lack of information regarding gaps in employment could place residents at risk. Whilst NVQ in care training is ongoing, shortfalls in induction training and training in topics relevant to the diagnoses of the residents could lead to needs not being met. EVIDENCE: The staffing rosters were viewed. There was evidence that some weekend days where staff went off sick there was a shortage of staff, and comment regarding the shortage of staff on some weekends was received. In addition, with the admission of residents outside the homes categories of registration this has led to increased care needs overall, and it was clear from observing residents in one of the day rooms that staff are kept busy trying to care for and communicate with residents who are cognitively impaired and presenting some behavioural issues. In turn this has led to other residents having to wait for long periods of time when they need care, for example, to go to the toilet, and staff have been unable to attend to them promptly. The need to ensure that the staffing meets the assessed needs of all the residents at all times was discussed with the Manager Designate and the Area Manager. Some comments were received regarding the importance of trained and care staff working Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 19 together as a team and this was discussed with the Manager Designate. Staff spoken with commented that they did work as a team. 6 of the care staff had completed NVQ level 2 in care and 2 had completed level 3 in care. 9 care staff are currently undertaking NVQ level 2 in care. The administrator has completed NVQ level 3 in business administration and 2 of the ancillary staff are undertaking level 2 in housekeeping. The Manager Designate is aware of the importance of ensuring 50 or more of the care staff are qualified to NVQ level 2 or above in care. One Inspector viewed 3 sets of staff employment records. These contained all the information required under Schedule 2 of the Care Home Regulations 2001, with the exception that reasons for any gaps in employment histories had not been recorded. This was discussed with the Manager Designate, who said that she was aware of the reasons for the gaps in employment, however she had not recorded them. The need to ensure a full employment history is recorded, to include satisfactory explanations for any gaps in employment, was discussed. The home has an induction programme based on Skills for Care Common Induction Standards. Two booklets were viewed and complete, however a discrepancy in one was pointed out and the Manager Designate said that she would clarify this and record the outcome. The supernumerary induction period for staff consists of 2 shifts, one of which is for familiarisation with the premises and viewing of health & safety and associated video trainings, and the second day to work alongside another member of staff. Several comments received from visitors concerned the apparent lack of training for new staff and this had resulted in staff not being fully aware of the care needs of each individual. Staff undertake the company mandatory training that includes health & safety topics, POVA awareness and dementia care awareness. Several comments were received regarding the fact that training in other topics relevant to the diagnoses and care of the residents was no longer being approved unless staff undertook such training in their own time. This included any free training that was available. The Area Manager said that if training is deemed relevant then staff could apply on the company training application form to attend training. However, on this form it makes it clear that staff would be expected to attend any such training in their own time. The home must ensure that all staff are fully trained so that they have the skills and knowledge to carry out their work competently at all times. Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 20 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, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the experience to manage the home, however further training in topics relevant to her role and the needs of the residents is required as well as the planned management training to provide her with the skills and knowledge to manage the home effectively. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are securely stored, however shortfalls in recording were noted. Systems for the management of health and safety throughout the home are not always clear or complete, thus placing residents, staff and visitors at risk. EVIDENCE: Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 21 The Manager Designate is a first level registered nurse and has been working at the home for 7 years, to include 2 as Deputy Manager. She is booked to commence the Registered Managers Award, NVQ level 4 in management in 2008. The Manager Designate said that she had not undertaken any training courses such as care of the elderly or care of the dying and their families and the importance of undertaking training courses to include such topics was discussed. Staff said that the Manager Designate is approachable and does visits the floors to find out what is going on in the home, plus she acts on issues raised. The Manager Designate had completed the AQAA for CSCI, and some of the information was limited with not all key standards being commented upon. The Manager Designate does not yet have internet access at the home, and had therefore been unable to access the guidance information available from CSCI for the completion of the AQAA document. The fact that the Manager Designate does need more support to fulfil her role fully was discussed with the Manager Designate and the Area Manager, and both are aware of this need. Regulation 26 unannounced visits on behalf of the Responsible Individual are carried out monthly and a report completed. Alpha Care has a programme of audits to be carried out at stipulated intervals throughout the year. Information regarding moving & handling training was not accurately recorded, however a comment had been added to clarify the situation. The importance of ensuring that all information is accurate so that Alpha Care has a clear picture of any shortfalls identified in the audits and action taken to address this was discussed. Regular auditing of medications and service user plans had been effective in bringing about improvements in both areas. Regular meetings are arranged for registered nurses, for care staff, for housekeeping staff, for the health & safety group and for night staff. Relatives and residents meetings are arranged 2-3 monthly. Comment was received that the relatives meetings are held during the day when some people are at work and therefore cannot attend. The Manager Designate said that she had identified this and the next meeting would be an evening meeting. The home holds personal monies on behalf of residents. Monies are securely stored and receipts are given for income. Four sets of records were viewed. It was not always clear what the expenditure was for, and the need to ensure all expenditure is clearly identified was discussed. For one resident who had been discharged the monies being held on their behalf had not been sent home with them, and the administrator said that she was waiting for a relative to come and collect it. The Inspector recommended that a system be introduced to ensure all belongings, to include monies held, are sent home with the resident. Samples of servicing and maintenance records were viewed and these were up to date. However, the maintenance records did not identify individually which rooms/areas had been tested or checked, for example, water temperatures, emergency lighting points and wheelchairs. Also, in some instances it was recorded that some results were unsatisfactory, however it was not possible to Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 22 evidence where or what these referred to. The importance of clearly recording all checks so that any shortfalls and the areas concerned are clearly identified was discussed with the maintenance man. Following the last inspection the maintenance man had received some induction, but from the evidence viewed it did not appear that this induction had explained the full system of recording. The Inspector was told that the physiotherapist does carry out maintenance on the walking aids, however this was not recorded. Cold water temperatures were consistently being recorded as 20.4° centigrade, which is slightly above the recognised safe temperature. Some gaps were noted in the moving & handling training for staff and most of the care staff were yet to receive food safety training. The Manager Designate said that she had arranged sessions in both subjects for the near future. The fire risk assessment had been updated in May 2007. Fire drill records for the day staff were complete, however for the night staff the names of all the staff present had not been recorded, therefore it was not possible to ascertain if all night staff had been involved in fire drills every 3 months. Cloisters Nursing Home DS0000010959.V349200.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 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement Residents must only be admitted following a full pre-admission assessment and when this has identified that the home is able to meet the residents needs, so that they can be effectively cared for. The home must not admit residents with a diagnosis that is outside the homes categories of registration, as this breaches the Care Home Regulations 2001. Input from the resident 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. This will ensure the needs and wishes of the resident are clear and can be respected. There must be clear risk assessments in place for the use of wheelchair lap straps and also in any instances where practice could be seen as a restraint of a resident, in order to safeguard the resident. The wishes of service users must DS0000010959.V349200.R01.S.doc Timescale for action 09/11/07 2. OP3 14 23/10/07 3. OP7 15 01/01/08 4. OP8 13(4)&(7) 23/10/07 5. OP11 12 01/02/08 Page 25 Cloisters Nursing Home Version 5.2 6. OP12 15, 16 7. OP14 12 8. OP18 13(6) 9. OP19 23(2)(b) & (d) 10. OP27 18 11. OP29 19 be clearly recorded in respect of their care during their final days. This information must be updated should the service users wishes change. Previous timescale of 01/06/07 not met. The activities provision in the home must be reviewed to ensure that an activities programme is in place to meet the needs of the residents. Suitable arrangements must be in place to enable residents to sit out in the garden safely when they so wish. Information regarding advocacy services must be freely available to service users. Previous timescale of 01/05/07 partially met. Safeguarding adults procedures and training must be reviewed to ensure all staff are fully aware of what constitutes abuse of a resident so that residents are safeguarded at all times. Timescales for completion must be included on the redecoration and refurbishment plan to evidence that all areas of work are to be completed in a timely fashion. A copy of the completed document must be forwarded to CSCI. Previous timescale of 01/06/07 not met. There must be sufficient numbers of staff on duty at all times with the necessary skills and experience to meet the needs of all the residents. Staff employment records must include all the information required under Schedule 2 of the Care Home Regulations 2001. Any gaps in employment must have a satisfactory explanation and this must be recorded, in DS0000010959.V349200.R01.S.doc 01/01/08 01/12/07 09/11/07 01/02/08 09/11/07 09/11/07 Cloisters Nursing Home Version 5.2 Page 26 12. OP30 18 13. OP30 18 14. OP31 10(3) 15. OP31 24(3) 16. OP33 24 17. OP35 17(2) Schedule 4 23(4) 18. OP38 order to safeguard residents. The amount of time for induction training must be reviewed to ensure that all new staff have a working knowledge of the needs of each resident. Staff must receive training in topics relevant to the diagnoses and care needs of the residents to provide them with up to date skills and knowledge to care for them effectively. The Manager Designate must undertake training in topics relevant to the resident group, their diagnoses and also for her role as Manager, in order to provide her with up to date knowledge and skills. The CSCI Annual Quality Assurance Assessment must be completed in accordance with the available guidance in order to provide a comprehensive assessment of the home. The person responsible for completion of the AQAA must have a clear understanding of the process. The systems for auditing in place must be used effectively and prompt action taken to address any shortfalls identified. Previous timescale of 01/06/07 partially met. There must be clear records of all income and expenditure for monies held on behalf of residents. Fire drill records must clearly identify when the drills have taken place and who has attended, plus any action required to address shortfalls that may be identified. Fire drills for all day and night staff must take place at the required intervals. Previous timescale DS0000010959.V349200.R01.S.doc 01/01/08 01/01/08 01/02/08 01/01/08 01/01/08 23/10/07 01/01/08 Cloisters Nursing Home Version 5.2 Page 27 of 01/06/07 partially met. 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 OP31 Good Practice Recommendations It is strongly recommended that internet access be made available for the Registered Manager in order to keep up to date with changes in current legislation and guidance, and be able to access up to date CSCI information and documentation. There should be a system in place to ensure that any monies held by the home on behalf of a resident are available for collection at the time the resident leaves the home. 2. OP35 Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Cloisters Nursing Home DS0000010959.V349200.R01.S.doc Version 5.2 Page 29 - 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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