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Inspection on 23/04/07 for Cloisters Nursing Home

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

This inspection was carried out on 23rd April 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

People wishing to live at the home are comprehensively assessed prior to admission to ensure the home can meet their needs. Staff care for people in a caring and professional manner, respecting their privacy and dignity. Visiting is encouraged and visitors are made welcome at the home. The food provision is good, offering variety and choice. Complaints and adult protection issues are well managed and correct procedures are followed. Staff receive training in topics relevant to the care of the people living at the home. Monies held on behalf of the people living at the home are being robustly managed.

What has improved since the last inspection?

There has been an improvement in the overall formulation and review of the service user plans, with more work required in this area to bring all the service user plans up to a good standard and to include care plans for every identified need. There is evidence of more input from representatives in the service user plans. There have been some improvements in the area of medication management, however more work is required in this area to bring the management up to a good level and to maintain this. There has been an improvement in the systems for ensuring clothing is returned to people after laundering. New equipment has been provided in the kitchen and more robust processes for cleaning in this area have been implemented. People living at the home receive their meals hot and assistance is given promptly with mealtimes. Staff had received training in Safeguarding Adults. There had been some improvements in the environment, with more work required in this area to bring the home back to a good standard of accommodation. The laundry floor has been replaced and overall the cleanliness of the home has improved. Staffing levels have been reviewed and the Registered Manager reported that she has been given clearance to interview for more staff so that the staffing is in place should additional staffing be required to meet peoples` needs. There is evidence of more financial investment in the home to work towards ensuring it is `fit for purpose`. There has been an improvement in the health & safety management of the home, and the training matrix evidences increased staff training in these areas. However, shortfalls are still being identified in this area and updates in risk assessments must be carried out.

What the care home could do better:

It is acknowledged that the home has been working hard since the last inspection to address the shortfalls identified in that report, however work is still required to further improve. Shortfalls were again identified in wound care documentation, completion of assessments and some areas of medication management. A redecoration and refurbishment list has been drawn up, however the lack of timescales for completion mean that it is not possible to see when this work is going to be progressed, some of which needs to be prioritised. Shortfalls in the staff employment records were again identified. The Registered Manager has worked hard to improve the management of the home, and more work in this area to include training updates in management topics are required so that the style of management of the home becomes proactive, encompassing current good practice. Whilst there has been an improvement in auditing systems, shortfalls identified in the service user plans and medication management show that the audits are not currently thorough enough to pick up all the shortfalls.

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 23rd April 2007 10:15 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.V334923.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.V334923.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.V334923.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 sevice user no longer occupies it. 13th February 2007 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, 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. In addition to the Registered Manager, 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. The fees range from £578.36 to £700 per week. Cloisters Nursing Home DS0000010959.V334923.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 17 hours was spent on the inspection process and two CSCI Inspectors conducted the inspection. A tour of the home was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire has also been used to inform this report. 10 people living at the home, 6 visitors and 11 staff were spoken with as part of the inspection process. The term ‘service user’ refers to a person living at the home. What the service does well: What has improved since the last inspection? There has been an improvement in the overall formulation and review of the service user plans, with more work required in this area to bring all the service user plans up to a good standard and to include care plans for every identified need. There is evidence of more input from representatives in the service user plans. There have been some improvements in the area of medication management, however more work is required in this area to bring the management up to a good level and to maintain this. There has been an improvement in the systems for ensuring clothing is returned to people after laundering. New equipment has been provided in the kitchen and more robust processes for cleaning in this area have been implemented. People living at the home receive their meals hot and assistance is given promptly with mealtimes. Staff had received training in Safeguarding Adults. There had been some improvements in the environment, with more work required in this area to bring the home back to a good standard of accommodation. The laundry floor has been replaced and overall the cleanliness of the home has improved. Staffing levels have been reviewed and the Registered Manager reported that she has been given clearance to interview for more staff so that the staffing is in place should additional staffing be required to meet peoples’ needs. There is evidence of more financial investment in the home to work towards ensuring it is ‘fit for purpose’. There has been an improvement in the health & safety Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 6 management of the home, and the training matrix evidences increased staff training in these areas. However, shortfalls are still being identified in this area and updates in risk assessments must be carried out. 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.V334923.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.V334923.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to live at the home are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. The home does not provide intermediate care. EVIDENCE: Pre-admission assessments were sampled. Those viewed were comprehensive and gave a clear picture of each persons needs. Social Services or Primary Care Trust assessments were also seen on the files viewed. Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been an improvement in the formulation and review of the service user plans, however there were some shortfalls that could lead to peoples needs not being fully met. Overall medications are being managed, however shortfalls could place people living at the home at risk. Staff were seen caring for people in a caring and professional manner, thus respecting their privacy and dignity. More work is required in the area of end of life care to ensure the home identifies and meets individuals’ wishes for their final days. EVIDENCE: 5 service user plans were viewed in detail and 3 others were viewed for specific care needs. There had been a good improvement in the formulation and review of the service user plans. Staff confirmed that they had received extensive training on how to use the new service user plan documentation. There was evidence that people living at the home and their representatives had been consulted regarding their wish to be involved with the reviews of the service user plans, and documentation to reflect their wishes had been completed. Risk assessments for falls were in place, and the Registered Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 10 Manager reported that this document is in the process of being reviewed due to the inclusion of information more relevant to community living. For one person who had fallen twice recently, all the relevant documentation had been reviewed and updated promptly following the falls. The service user plan documentation had been reviewed monthly and also whenever the persons’ condition had changed. In 4 service user plans viewed some additional care plans for identified needs were required, to reflect all areas of need and how these are to be met. The Registered Manager and Deputy Manager do carry out regular audits and identify shortfalls in the service user plans for staff to correct. Wound care documentation was viewed. One pressure sore risk assessment did not accurately reflect all the persons’ risk factors. For another person a care plan to identify the treatment for a second area of wound care was required, to ensure all their needs in this area are identified and met. For another person the wound assessment documentation had not been fully completed. For people with multiple wounds the daily record did not identify which dressing had been renewed on what day and this needed clarification. Nutritional assessments had been carried out. Staff spoken with confirmed that for any people for whom there are weight concerns then a weekly weight record is maintained. This was not reflected in the care plans for nutrition, which did not state how often the weights were to be carried out. Continence assessments were in place, one being completed at the time of inspection. Care plans for continence care needs were available. Moving & handling assessments had been carried out, however the information did not always tally with the information contained in the mobility care plan, and it was not always clear how the person was to be moved. Assessments for bedrails were in place, however the document had not yet been updated to identify the actual risk to each person and how this risk is to be minimised, to include identifying if bedrails are appropriate for each individual. Written consents to include bedrails had been obtained. There was evidence of input from healthcare professionals to include GP, physiotherapist, chiropodist, speech therapist, opticians and tissue viability nurse specialist. The medication management was sampled on each floor. A staff specimen signature sheet was in place on both units, plus up to date policies and procedures and good practice guidance. A list of the nutritional supplements prescribed for each person is also available. The home uses the NOMAD system, and the dispensing pharmacist provides these weekly. All administration had been signed for, with clear entries on the back of the medication administration record (MAR) for any omissions. 10 MARs were viewed on each unit. Receipts had not always been signed for, and few entries had been dated. This is a repeat finding. Liquid medications had been dated when opened. Allergies are recorded in the MAR. Records for disposal are maintained and disposals are arranged via the clinical waste, in line with current legislation. There is a ‘homely remedy’ sheet for each person, and this has been completed and signed by the GP to give permission for homely Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 11 remedies to be used for a limited time. Following the last inspection the GP had reviewed all persons who were being treated for a skin irritation, and the majority of these conditions have been resolved. The fridge temperatures on the ground floor were within safe range, however on the first floor the minimum temperature had dropped below 2° centigrade, and the registered nurse said that the fridge would be adjusted. The room temperatures on both floors were 27.1 – 28.1° centigrade, and action must be taken to ensure medications are being stored at not more than 25° centigrade. The installation of air conditioning units has been previously discussed and action must be taken to address this without delay. The Registered Manager does carry out audits and the need to check the dating of receipts as part of this process was discussed. Single use lancing devices for professional use were being used for blood glucose monitoring. Care plans were in place with instructions for people on percutaneous endoscopic gastrostomy (PEG) feeding regimes. Staff were seen caring for people living at the home in a gentle, courteous and professional manner. Several bedrooms had landline telephones and one person also had a mobile telephone. Bedrooms had been personalised and people can bring in personal possessions in line with fire safety. Personal clothing viewed in the laundry had been labelled appropriately and people were dressed according to individual choice and cultural needs. Double rooms are only used for people who have chosen to share, for example, for married couples. There were no specific cultural or religious shortfalls identified at the inspection. In some of the service user plans viewed care plans for death & dying had been commenced, however the information was brief and did not clearly identify the wishes of the person or their representatives in this area. There is a separate document to identify if people wish to be taken to hospital in an emergency, plus their wishes regarding resuscitation. Some staff had received recent training in palliative care. Cloisters Nursing Home DS0000010959.V334923.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): 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 fair, however lack of information regarding peoples individual interests means that these are not being considered as part of the activities programme. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was not available, thus peoples right to individual representation is not being respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has an activities co-ordinator. Some of the service user plans viewed did contain some general information regarding the persons’ social and leisure interests, however the majority do not have such information recorded. This is a repeat finding. The need to ensure that peoples’ individual interests are ascertained, recorded and then the activities programme planned to incorporate those needs wherever possible was discussed. The Registered Manager did identify some documentation for this and said she would ensure this is addressed. A document entitled ‘Life History’ is currently being completed for each person, to give staff a picture of the person life before they Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 13 came to the home. The activities co-ordinator keeps a record of the activities undertaken with each person and a calendar is kept to record all planned events. An activities programme was on display and also a list of any entertainments planned. The activities co-ordinator said that she is a member of the National Association of Providers of Activities for Older People (NAPA) and she does access information from them, which is very useful and informative. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and that representatives are kept up to date with any issues. People can choose to receive visitors in their own rooms or in the communal areas, depending on their wishes. The Registered Manager could not find the contact information for Advocacy Services, which had previously been on display in the reception area. The Registered Manager said she would access this and re-display it. She said that the advocacy service is provided via Age Concern. One Inspector viewed the kitchen. This was clean and tidy and records were up to date. The cook reported that following the last inspection a ‘deep clean’ of the kitchen had taken place and that cleaning was being kept up to date. A new food processor had been purchased, and with the exception of occasional lumps in the mashed potato, the comments were that food that requires pureeing is now correctly done. The Registered Manager said that she would ensure the potato is properly creamed in future, to prevent lumps. Food stocks were low as a delivery was expected on the day of inspection, and there was evidence of stock rotation. Items viewed were in date. People spoken with expressed their satisfaction with the food and said that choices are offered. One person who enjoys Asian food as part of their diet confirmed that this choice is provided to them. The cook said that staff do provide a completed choice list and that she currently throws this away following each meal. The Inspector advised that this list be kept for a few days so that should there be any incident then it would be possible to identify who had eaten which meal option. Samples of each meal are kept for 3 days in line with food safety guidance. One Inspector observed the lunchtime meal on the ground floor and people were enjoying their meals. Staff were available to assist people with their meals in the dining room, and also to assist people in their rooms. Following the last inspection meals are not taken to the persons room until a member of staff is available to assist them, therefore meals are being served hot and not left at the bedside. Cloisters Nursing Home DS0000010959.V334923.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the people who live there. EVIDENCE: The home has a complaints procedure and this is on display in the home. There had been no complaints since the last inspection. People living at the home and visitors spoken with said that any concerns raised had been promptly addressed. The home has POVA documentation in place and also follows the Hounslow Safeguarding Adults procedures. Recent training from the Hounslow Safeguarding Adults team had recently taken place. There had been one POVA issue since the last inspection and this had been appropriately documented and reported. All incidents are now being reported promptly to CSCI and, where appropriate, other agencies. Cloisters Nursing Home DS0000010959.V334923.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home now has a redecoration and refurbishment plan, there are no timescales for completion, thus it is not possible to ascertain when all areas of the home will be brought back to a good standard of environment for people to live in. There had been a marked improvement in the cleanliness of the home and infection control procedures are adhered to, thus providing a safe environment for people to live in. EVIDENCE: One Inspector carried out a tour of the premises. An environmental audit had been carried out and a redecoration and refurbishment list formulated. However, no timescales for completion had been included, and the need to clearly identify these as part of the redecoration and refurbishment programme was discussed with the Registered Manager. One room has had the carpet replaced with flooring appropriate to the needs of the person living there. The Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 16 furniture in the first floor dining room had been replaced and the Registered Manager said that there were plans to redecorate the room in the near future. Several of the carpets both in bedrooms and in the corridors are old and worn and in need of replacement. Window restrictors had been identified as required for the bedroom windows. The Registered Manager said that these had been included in the environmental audit. The reception area of the home had been redecorated since the last inspection and was welcoming to visitors. The automatic door closures were in working order and no doors were seen wedged open at this inspection. The Registered Manager reported that one of the staff has commenced gardening duties. The home has a rear garden and flower borders at the front, which are overall being maintained and are to have more work done in the coming weeks. Some old furniture was seen in the rear garden and the Registered Manager reported that a skip had been ordered for the disposal of these items. Since the last inspection the laundry room floor has been replaced. The laundry was clean and tidy and a new washing machine has been installed. The second washing machine was out of order, and the Registered Manager explained that this was also being replaced. The home has two industrial dryers. Following the last inspection action had been taken to wash all the bedspreads and curtains, and several new sets of curtains had been ordered to replace those now looking shabby. Overall the home was clean and it was clear from speaking with staff that time is available not just for the ‘day to day’ cleaning, but also for more in depth cleaning throughout the home. The bath, shower and toilet facilities were clean and uncluttered. The kitchenette off the first floor dining room was clean and tidy and the Registered Manager reported that this is now cleaned and checked daily. Infection control training had been carried out with more planned in the near future. Policies and procedures for infection control are in place, plus protective clothing to include gloves and aprons were available. Cloisters Nursing Home DS0000010959.V334923.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing has been reviewed to provide appropriate levels of staffing for the assessed needs of the people living at the home. Training provision has improved, thus providing staff with the basic knowledge to care for people living at the home. Systems are in place for the vetting and recruitment of staff, however shortfalls identified could place people living at the home at risk. EVIDENCE: The Registered Manager reported that she has been given clearance to recruit more care staff with a view to ensuring enough staff are available to meet the needs of the people living at the home at all times. Dependency levels do change regularly, and the importance of having staff flexibility to cover shifts was discussed. Appropriate staffing for the home has also been discussed with the Regional Manager and Registered Provider for the home. The home has identified a shortfall in the numbers of care staff qualified to NVQ level 2 in care or the equivalent. Currently 26 of care staff have such a qualification, however the Registered Manager reported that 14 care staff have commenced NVQ level 2 in care training, plus 5 have commenced NVQ in care level 3 training. This will then bring the number qualified to over 50 . Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 18 One Inspector sampled 2 staff employment record files. Some of the employment history information was not complete in one file viewed, and no explanation had been given for not giving their current employer as a referee. The Registered Manager said that this would be addressed prior to the person commencing work. The importance of examining each application form and ensuring all the information is complete, up to date, and the correct referee given was discussed with the Registered Manager. Apart from this finding, all the information required under Schedule 2 of the Care Home Regulations 2001 was available. The home has an induction and foundation programme in place, which meets the Skills for Care Common Induction Standards. There is now a training plan in place and they have also completed a training matrix to identify easily who has undertaken each area of training and assists with keeping staff up to date with mandatory training. There was evidence of staff undertaking some training in topics relevant to the care of the people living at the home, and the importance of keeping all staff, to include the registered nurses, up to date with such training was discussed. Cloisters Nursing Home DS0000010959.V334923.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the overall management of the home since the last inspection, with further work in this area needed, working towards bringing the home to a good standard of management. Quality assurance processes have improved, thus the home is being better audited and reviewed on an ongoing basis and the majority of shortfalls are being identified for action, with some further work needed to ensure all shortfalls are identified. Money held on behalf of people living at the home is robustly managed, thus safeguarding peoples’ interests. Health & safety is being better managed however shortfalls identified could place people living, working and visiting the home at risk. EVIDENCE: Cloisters Nursing Home DS0000010959.V334923.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. People living at the home and visitors spoken with said that the Registered Manager is approachable and supportive. The importance of keeping up to date with current good practice in the management areas of the home was discussed with the Registered Manager and the possibility of further training to assist with this was discussed. The home does not have internet access and therefore the Registered Manager is not able to keep up to date with information provided on the CSCI website. The importance of this was discussed, as updates and new documentation is being published regularly on the website for the attention of Registered Managers and Registered Persons. Following the last inspection the Registered Manager said that she has been well supported by the Area Manager, who visits the home on a regular basis. The home has been subject to an audit by the Training Manager and the Systems and Procedures Area Manager for Alpha Care. However no audit report was available at the home from this visit. Systems are in place for auditing service user plans, medications and meal provision, plus other audits are to be introduced for health & safety topics. Shortfalls identified at the inspection with medications and service user plans show that the homes auditing processes need to be improved in these areas. Meetings take place for relatives and the people living at the home, plus staff meetings. Minutes of these meetings were available to view. One Inspector viewed the records for any monies held on behalf of people living at the home. The records were up to date and balances were correct. Receipts are given for all income, and receipts for expenditure are also kept. The pre-inspection questionnaire detailed that two people living at the home manage their own finances. Since the last inspection the maintenance man has received induction training specific to his role. He has also undertaken competency training in fire safety, enabling him to carry out training in this topic for other staff. Fire drill records viewed were not always clear and it appeared that the weekly fire alarm test was being used as a fire drill for staff. This was discussed and the need to carry out unannounced drills identified. The fire risk assessment and generic risk assessments had not been reviewed since 01/03/06 and the need to update these annually and whenever there is a relevant change to the home was discussed with the Registered Manager. Since the last inspection staff had received training in health & safety topics and further training in this area had been planned. It had been made clear to staff that they must attend annual mandatory training. The servicing and maintenance records were up to date with the exception of the Landlords Gas Safety Certificate. Evidence of servicing of the boilers in October 2006 has since been forwarded to CSCI. Some of the documentation was very old and required archiving, and this was again discussed with the Registered Manager. Policies and procedures for health & safety are in place. The Registered Provider has stated that more Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 21 health & safety reporting systems are to be introduced as part of the audits for the home. Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP7 OP8 Regulation 15 15, 17 Requirement The service user plan must include care plans for all identified needs. Assessments must be comprehensive and accurately reflect the status of the service user. Previous timescales of 31/01/07 & 16/03/07 not met. Wound care documentation must be complete and up to date. Previous timescales of 01/01/07 & 16/03/07 not met. The bedrail assessment document must be updated to clearly identify the risks and how these are to be minimised. Bedrails must only be used where they have been identified as appropriate for the safety needs of the service user. Medicines must be recorded accurately when received into the home. This includes the date. Previous timescale of 19/02/07 not met. Action must be taken to ensure the temperature in the clinic DS0000010959.V334923.R01.S.doc Timescale for action 01/06/07 01/06/07 3. OP8 15, 17 01/06/07 4. OP8 13(4)&(7) 01/05/07 5. OP9 13(2) 01/05/07 6. OP9 13(2) 01/06/07 Cloisters Nursing Home Version 5.2 Page 24 7. OP11 12 8. OP12 15, 16 9. 10. OP14 OP19 12 23(2)(b) & (d) 11. OP29 19 12. OP31 10(3) 13. OP33 24 14. OP38 13(4) rooms does not exceed 25° centigrade. The installation of air conditioning units or other method of temperature control must be implemented. The wishes of service users must be clearly recorded in respect of their care during their final days. This information must be updated should the service users wishes change. Individual information for each service user must be recorded to identify their social and leisure interests. Previous timescale 01/04/07 not met. Information regarding advocacy services must be freely available to service users. 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 Staff employment records must include all the information required under Schedule 2 of the Care Home Regulations 2001. Previous timescale of 16/03/07 not met. Application forms must be fully checked to ensure the information provided is correct and up to date. The Registered Manager must undertake periodic training in topics relevant to the management of the home. The systems for auditing in place must be used effectively and prompt action taken to address any shortfalls identified. Previous timescale of 16/03/07 not met. All risk assessments must be DS0000010959.V334923.R01.S.doc 01/06/07 01/06/07 01/05/07 01/06/07 04/05/07 01/08/07 01/06/07 18/05/07 Page 25 Cloisters Nursing Home Version 5.2 23(4) 15. OP38 23(4) updated annually and whenever there are any relevant changes in the home. This must include the fire and safe working practices risk assessments. 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. 01/06/07 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 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. Cloisters Nursing Home DS0000010959.V334923.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. Extracts may not be used or reproduced without the express permission of CSCI Cloisters Nursing Home DS0000010959.V334923.R01.S.doc Version 5.2 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. 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