Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 02/05/06 for Cloisters Nursing Home

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

This inspection was carried out on 2nd May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Service users are assessed prior to admission to ensure the home is able to meet their needs and service users and/or their representatives are encouraged to visit the home to ascertain if it is suited to their wishes. Staff care for service users in a gentle and respectful manner. Information regarding advocacy services was available. The food provision is good and service users spoken with expressed their satisfaction with the meals. Service users finances are securely managed. Staff receive regular formal supervision. The maintenance man undertakes maintenance checks and clear records for these are kept.

What has improved since the last inspection?

No requirements were made at the last inspection.

What the care home could do better:

This inspection highlighted a number of shortfalls. These included the Statement of Purpose and Service User Guide being out of date and not including all the required information. Some of the wound care documentation needed reviewing and updating. Although generally well managed, there were some shortfalls in the management of medication noted. There were clear shortfalls in the provision of staff training, resulting in an immediate requirement being set in respect of moving & handling training. A robust training programme, to include NVQ in care, safeguarding adults, dementia care, induction & foundation training and all aspects of health & safety training,must be formulated and progressed. Areas of redecoration and refurbishment need to be addressed. Staffing provision must be in line with service users needs, and not just based on occupancy levels. A quality assurance programme was not in place. There was no business and financial plan available to view and it was not clear what budgets are available for the running of the home. Shortfalls in health & safety servicing were identified.

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 2nd May 2006 09:45 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.V288521.R01.S.doc Version 5.1 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.V288521.R01.S.doc Version 5.1 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 Mrs Carolyn Ann Butterworth 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.V288521.R01.S.doc Version 5.1 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. 12th December 2005 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 shopping parade and transport links. There are fifty-one single bedrooms, thirteen with en suite washbasins and toilets. There are five shared bedrooms, four en-suites and two with bathrooms. 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 Manager Designate commenced employment in January 2006. The home also has a deputy manager, an administrator, registered nurses, care staff, a chef and kitchen assistants, a maintenance person, a housekeeper and domestic staff and an activities organiser. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 18 hours was spent on the inspection process. One Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 13 service users, 12 staff, 9 visitors and a visiting healthcare professional were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: This inspection highlighted a number of shortfalls. These included the Statement of Purpose and Service User Guide being out of date and not including all the required information. Some of the wound care documentation needed reviewing and updating. Although generally well managed, there were some shortfalls in the management of medication noted. There were clear shortfalls in the provision of staff training, resulting in an immediate requirement being set in respect of moving & handling training. A robust training programme, to include NVQ in care, safeguarding adults, dementia care, induction & foundation training and all aspects of health & safety training, Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 6 must be formulated and progressed. Areas of redecoration and refurbishment need to be addressed. Staffing provision must be in line with service users needs, and not just based on occupancy levels. A quality assurance programme was not in place. There was no business and financial plan available to view and it was not clear what budgets are available for the running of the home. Shortfalls in health & safety servicing were identified. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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.V288521.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 Information available regarding the services offered by the home was incomplete, therefore not providing service users and their representatives with full information about the home. Pre-admission information was complete and provided a good picture of the service users needs. Prospective service users and their representatives are encouraged to visit the home, to enable them to make an informed choice. Staff have not received up to date training in dementia care, and are therefore not fully skilled to meet the specialist needs of some service users who have been admitted to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which are combined into one document. Neither details of the qualifications of the Responsible Individual and the Manager Designate, nor the number and relevant qualifications and experience of the staff were included in the document. Details of admission criteria to include emergency admissions were not included. There is no information as to where a copy of the most recent inspection report can be freely accessed. Details of involvement of service users and/or their representatives in the reviews of service user plans are not Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 9 included. Copies of this document were not seen in the service users bedrooms. Pre-admission assessments are carried out, and copies of the Social Services needs led assessments were seen in the service user plans viewed. This information provided a clear picture of the service user and their needs. Eight service users have been identified as having a diagnosis of dementia. The home is not registered to accommodate service users with this diagnosis. Staff had not received up to date training in dementia care. The Manager Designate said that the home is in the process of considering an application to accommodate service users with dementia on one floor of the home. This must be submitted to the CSCI. A representative spoken with confirmed that they had been able to visit the home prior to their relative being admitted. It is acknowledged that not all prospective service users are able to visit due to frailty, but visiting by their representatives is encouraged to help them to make an informed choice. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & aspects of 11 The service user plans were up to date and identified the needs of the service users, providing staff with clear information of how these are to be met. The management of medications has improved, and minor shortfalls should be easy to address. Staff were seen to treat service users with courtesy and respect. EVIDENCE: Service user plans were sampled on each floor. These were comprehensive and provided a good picture of the service users needs and how these are to be met. There was evidence of monthly reviews of the documentation, plus the formulation of new care plans for newly identified needs. Risk assessments for falls were in place. Risk assessments for other identified risks had been formulated. Some documentation had been signed by the service user or their representative, and the deputy manager said that work was being done to evidence service user and/or representative involvement in the service user plans. At the time of inspection 6 service users had pressure sores, the majority of which had developed at the home. Wound care documentation was viewed. Care plans for wound care had been formulated and reviewed weekly, and in most instances a wound assessment document, also reviewed weekly, was in Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 11 place. Consented photographic evidence, which showed an improvement in the wounds, was available. Dressing changes are recorded in the daily record, although some omissions in recording this information were noted. Pressure sore risk assessments had been completed, but in some instances these had not been correctly added up, thus providing inaccurate information. Some service users were identified as being at high risk of developing sores, and the need to formulate a care plan for skin integrity in such instances was discussed. Pressure relieving equipment was seen in use in the home, although the specific type of equipment in use was not always identified in the service users records. More attention to detail regarding the identifying and care of service users at risk of skin breakdown would heighten staff awareness in this area. Nutritional assessments were in place, plus care plans for nutritional needs, to include the feeding regimes in place for service users being fed artificially via a percutaneous endoscopic gastrostomy (PEG) tube. Monthly weights had been recorded, and where a concern was identified more frequent weight monitoring was being recorded. Moving & handling assessments were in place and care plans had also been formulated. Continence assessments and care plans were in place. The GP visits each week and there was evidence of input from other healthcare professionals. Samples of medication records were viewed on each floor. The home uses the NOMAD medication storage and administration system. Copies of medication policies to include instructions in respect of medication disposal plus good practice information were available. For each service user there is a comprehensive front sheet that includes a photograph and any allergy details. Lists of medications to include side effects are also drawn up for each service user, which is good practice. A separate ‘homely remedies’ form is completed for each service user and signed by the GP. Oxygen is securely stored in the home, and relevant signage is displayed. Individual finger pricking devices for checking service users blood sugar levels are clearly labelled with the service users name, as are the insulin pens in use. Medication stocks were at an acceptable level, with one medication only being prescribed on a bulk prescription. Receipts and disposals of medications are recorded. On the first floor, two gaps in signing for administration plus one receipt for a medication received mid–month was seen. Otherwise all medication administration record (MAR) charts viewed were fully signed. Overall medications are well managed within the home. The clinical rooms on both floors were quite warm, and the room temperature records evidenced that at times the temperature goes above 25° centigrade and therefore above the safe temperature for medication storage. In addition, the drugs fridges showed temperatures above the 2-8° centigrade safe storage level. The need for air conditioning to be introduced to these rooms was discussed, and this has been the subject of previous medication inspection findings. Staff were seen to converse with and treat service users in a gentle and respectful manner, and service users and visitors spoken with said that staff Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 12 are caring towards them. The visiting Healthcare Professional said that staff were approachable and helpful. Service users clothing is individually identified, and items viewed in the laundry evidenced this. Any unlabelled clothing is kept for service users or relatives to identify. Bedrooms viewed are personalised and service users are encouraged to bring in personal items, in line with fire safety. In the service user plans, ‘consent to treatment’ forms were viewed. These clearly identify the actions to be taken should the service users condition deteriorate. The service user or their representative had signed these, and it was clear that the information could be reviewed at any time. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15 & aspects of 12 The home provides an activities programme to keep the service users active and stimulated. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Information regarding advocacy services is available, thus ensuring service users rights and interests are upheld. The meal provision is good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The home has an activities co-ordinator. It was clear from the activities records viewed that activities are arranged and records are maintained for each service users involvement. At the time of inspection the activities co-ordinator was on holiday and no arrangements had been made to provide cover during her absence. Information of activities is available in the home. The home has an open visiting policy, with visitors encouraged to visit after 10am to allow for care to be given to service users, although should people wish to visit before 10am this is no problem. Service users can receive visitors in their bedrooms or in one of the communal lounges. Visitors spoken with said that they are made welcome at the home and that the service users representatives are kept informed of any issues. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 14 The home has access to Age Concern Advocacy services, and information is available to service users and their representatives. The kitchen was viewed and was clean and tidy. Food storage was appropriate, and there was evidence of stock rotation. Kitchen records to include food delivery, storage and serving temperatures and cleaning records were up to date. Fresh fruit and vegetables are delivered twice a week. Items in the fridges were dated. Service users spoken with generally said that the food provision was satisfactory, and that choices are offered. Service users were seen enjoying their lunch, and staff were seen assisting service users in a gentle manner. The chef said that there are new menus being introduced and the service users have had input into these. All but one of the kitchen staff had undergone certified food hygiene training, and this is being arranged for one kitchen assistant who currently has no involvement with food preparation or serving. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a satisfactory complaints system with evidence that service users and representatives concerns are listened to and acted upon. Staff have not all received training in adult protection, and therefore service users could potentially be at risk. EVIDENCE: Since the last inspection there had been 4 complaints received by the home. There were detailed written responses detailing the action taken to address the complaint made and any shortfalls identified. The telephone number for the CSCI local office was incorrect on the documentation viewed. There had been one safeguarding adults allegation since the last inspection, which has been investigated and is being addressed in conjunction with the safeguarding adults team. The staff training records viewed did not evidence that all staff had received POVA training. Staff spoken with said that they would report any concerns of this nature. They did not know about ‘whistle blowing’ procedures, and this was discussed. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 The home is generally clean and tidy and the environment is safe for service users. Some shortfalls in the environment need addressing in order to ensure décor and furnishings throughout are in good condition. Policies and procedures plus staff training for infection control is in place to safeguard service users from infection. EVIDENCE: One Inspector carried out a tour of the home. The home was clean and tidy and overall the décor was of an acceptable quality. There are some signs of wear & tear to include wheelchair damage to woodwork, doorframes and corridor walls. A copy of the redecoration and refurbishment programme was not available. A full environmental audit of the premises had been carried out, and an action plan to show how the shortfalls are to be addressed must be drawn up, with timescales for completion. There were no obvious fire safety or environmental health issues noted at the time of inspection. The grounds were being well maintained. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 17 Each floor has two lounges and a dining room. Some of the furnishings in the first floor dining room were noted to be worn and in need of replacement. This included dining tables where laminate strips had come off. Dining chairs previously identified for replacement were still in use. Some areas of the corridor carpets were marked, and these appeared to be stain marks as the areas were clean. One recliner chair in use in the first floor lounge was torn and in need of repair or replacement. One service user is awaiting provision of a specialist chair via Social Services, and for another service user the need for a new chair to meet their needs was identified and discussed with the Manager Designate. The assisted bathroom facilities are in good order. En suite facilities are available in most of the bedrooms. Toilet facilities are available near the lounge and dining areas. The bedrooms viewed were personalised and provide a homely environment for service users. The Manager Designate said that currently the double rooms were mainly vacant, and it is acknowledged that these rooms are hard to market as people want single rooms, with a few exceptions to this. The home was bright and airy and comfortably warm. Window restrictors are not in place on all windows, and some risk assessments for restrictors were viewed. This situation needs to be kept under review to ensure that service users safety is maintained. Hot water temperatures are recorded regularly, and any shortfalls are addressed. The laundry room was clean and tidy. Information in respect of infection control and laundering practices was on display. Protective clothing to include gloves and aprons was available, plus paper towels and liquid soap were available in all areas where service users, staff and visitors require to wash their hands. Following a recent outbreak of diarrhoea and vomiting in the home, training updates in infection control had been carried out, and the situation well managed. There is a sluice room on each floor, and these were clean and odour-free. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Changes in staffing levels had not been based on service users dependency levels, and could therefore pose a risk to service users. Systems for vetting and recruitment practices are in place and protect service users. Staff have not all received adequate levels of training in topics relevant to their work, thus service users needs may not always be met. EVIDENCE: It was apparent that there were some issues with changes in staffing levels that had been introduced, and there was no evidence to show that service users dependencies had been assessed prior to such changes being made. Whilst it is accepted that the home had 10 vacancies at the time of inspection, it is imperative that the ratio of staff to service users is determined according to the assessed needs and dependencies of the service users. Domestic and ancillary staff are employed in appropriate numbers to meet the needs of the service users and the home. Samples of staff employment files were viewed. With the exception of one photograph, these contained the information required under Schedule 2 of the Care Homes Regulations 2001. The Manager Designate said that this would be addressed. There was evidence that personal identification numbers for registered nurses had been verified. Evidence that Induction and Foundation Training in line with the Skills for Care core standards was not available. New staff undertake an in-house induction programme prior to working unsupervised, but this programme is not based on Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 19 the core standards. There was no staff training and development programme in place, and there was clear evidence that staff had not received a minimum of 3 paid training days in the last year. There appeared to have been a lack of investment in training in 2005. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37 & 38 The Manager Designate has the knowledge and experience to fulfil her role. Systems for quality assurance are in place, although a written plan for this needs formulating, thus providing an ongoing process of review and feedback. Financial documentation to include budgets for expenditure was not available, and therefore the management has no knowledge of the finances available to them. Systems for the management of service users monies are in place and secure facilities are available. Systems for health & safety within the home are in place, but the lack of staff training in some of these areas puts service users at risk. EVIDENCE: The Manager Designate is a first level registered nurse with a qualification in mental health. She has also undertaken the Registered Managers Award. The Manager Designate is in the process of applying to the CSCI for registration. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 21 Regulation 26 unannounced visits are carried out and copies of the reports forwarded to the CSCI. Service users and representatives meetings are held and minutes are kept. The Manager Designate said that satisfaction questionnaires are sent out every 6 months, and the need to forward the results of these to the CSCI was discussed. There was evidence of audits being carried out in several areas to include service user plans, medication and the environment. There was no annual development plan for quality assurance in place. Service users and visitors said that they are able to approach the Manager Designate with any issues and these are addressed. The home did not have a business and financial plan, and it was clear that the home did not have any information regarding budgets for expenditure. This needs to be addressed and a comprehensive budget to cover all areas of expenditure put in place. Records for service users monies were viewed, and these were up to date. Receipts are kept for all purchases made on behalf of the service users. Records of income and expenditure are maintained. Polices and procedures for the management of service users monies were not seen, and the need to ensure that one is in place was discussed. Staff supervision records were sampled and it was clear that staff do receive supervision regularly. The Manager Designate said that she was in the process of implementing a new system so that responsibility for staff supervision is cascaded down to the registered nurses, and training had been planned for this. Overall the records available in the home in relation to service users and staff employment were being well maintained. Shortfalls have been identified in other areas to include training, servicing, business, development and financial plans, and action must be taken to address any shortfalls identified. Requirements have been made under the relevant Standards. Servicing and maintenance records were viewed. Generally these were up to date, although it was noted that there had been a delay of 2 months in repairing some of the emergency lighting. A quote for this had been obtained on 12th April 2006 and forwarded to head office for approval. To date the repair has not been carried out. Documentation for safe working practices was in place. Staff training in health & safety topics was not up to date and an immediate requirement was given in relation to moving & handling training. The regular, thorough examination of the lift for insurance purposes was last undertaken on 14/04/05, and there was no up to date documentation available in relation to this. The fire risk assessment had been updated and regular fire safety checks carried out. Staff had received fire drill training, but it was not clear from the records if all the staff had undertaken this training, to include night staff. Records of checks undertaken by the maintenance man were well maintained. Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 22 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 2 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 X 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 3 3 2 1 Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 23 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. 1 Standard OP1 Regulation 4&6 Requirement The Statement of Purpose must be updated. This must be freely available in the home and a copy must be submitted to the CSCI. The Service Users Guide must updated. Copies must be provided to each service user and a copy submitted to the CSCI. All staff must have the knowledge and skill to care for the service users needs, to include those with dementia care needs, and training in this area of care must be arranged. Where service users have been identified as being at high risk of developing a pressure sore, a care plan for skin integrity must be formulated. Pressure sore risk assessments must contain accurate information. Medicines must be recorded accurately when administered. Medicines must be stored at the correct temperature in the clinical room. The clinical room must be maintained at less than DS0000010959.V288521.R01.S.doc Timescale for action 01/07/06 2 OP1 5&6 01/07/06 3 OP4 18(1) 01/08/06 4 OP8 15 01/06/06 5 6 7 OP8 OP9 OP9 17 13(2) 13(2) 01/06/06 02/05/06 01/06/06 Cloisters Nursing Home Version 5.1 Page 24 8 OP16 22(7)a 9 OP18 13(6) 10 OP19 OP20 23(2)(b) & (d) 11 OP27 18 12 OP30 18 13 OP30 18 14 OP30 18 15 16 OP33 OP34 24 25 25 degrees. The correct telephone number of the CSCI must be included on all copies of the complaints procedure. All staff must receive training in the Protection of Vulnerable Adults. Documentary evidence of this training must be available for inspection. 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. 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. Induction and Foundation training based on recognised standards must be formulated and implemented in the home. An action plan for training with timescales for completion must be formulated and a copy forwarded to the CSCI. All staff must receive a minimum of 3 paid days training per year, and there must be evidence available to support this. An Annual Development plan for quality assurance must be available for the home. A Business and Financial plan to include clear budgets must be available for the home. Thereafter this must be reviewed annually and whenever the needs of the home change. DS0000010959.V288521.R01.S.doc 19/05/06 01/07/06 01/06/06 01/06/06 01/07/06 01/06/06 01/08/06 01/07/06 01/07/06 Cloisters Nursing Home Version 5.1 Page 25 17 OP38 13(5) 18 OP38 23(2)(c) 19 OP38 23(4) 20 OP38 23(2)(c) All persons working at the home must receive training appropriate to the work they are to perform. A full audit of staff training records must be carried out and where shortfalls are identified in moving & handling training an action plan with timescales for completion of training must be drawn up. A copy of the action plan to include details of staff names and dates of planned training must be received by the CSCI by 12 midday 12/05/06. Immediate requirement issued. There must be evidence that all servicing and required checks for lift maintenance to include insurance requirements must be carried out and documentary evidence of this available for inspection. There must be evidence that fire drills for all staff to include night staff have been undertaken at the required intervals. The emergency lights that are out of order must be repaired. Thereafter the emergency lighting must be maintained in working condition. 12/05/06 01/06/06 01/06/06 01/06/06 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 Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cloisters Nursing Home DS0000010959.V288521.R01.S.doc Version 5.1 Page 27 - 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!