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Inspection on 04/12/06 for Cloisters Nursing Home

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

This inspection was carried out on 4th December 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 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

Information about the home is freely available and is supplied to service users and their representatives. Prospective service users are fully assessed prior to admission to the home to ensure the home is able to meet their needs. Staff were seen to care for service users in a gentle, courteous and professional manner and service users spoken with expressed their satisfaction with the care provided at the home. The activity provision is good, with service users needs and abilities being planned for. The home has an open visiting policy and visiting is encouraged. Information on advocacy services is available in the home. The food provision is good and overall service users spoken with said the food is satisfactory and a choice is offered. Complaints are appropriately managed. Environmentally, the decoration is kept up to date, equipment for moving & handling is provided to meet the needs of the service users, plus the bedrooms viewed were homely and personalised. Robust recruitment practices are in place and are followed. Service users monies are securely managed.

What has improved since the last inspection?

The Statement of Purpose and Service User Guide documents have been updated since the last inspection and copies of the Service User Guide were available in each service users room. The frequency of night fire drills to include all staff had increased. The emergency lighting had been repaired and is being regularly checked and serviced.

What the care home could do better:

Several areas of training are still required, to include dementia care, palliative care, adult protection, increased numbers of staff qualified to NVQ level 2 or the equivalent and some areas of health & safety training, to include moving and handling training. The Inspectors were concerned about the number ofshortfalls identified with the formulation and review of the service user plans, and more work must be done to ensure this documentation is accurate and up to date, and that action is taken swiftly to address any shortfalls identified. Shortfalls were also identified in the management of medications, and robust action must be taken to address this. The lack of input from the palliative care team was of concern, and the importance of ensuring all service users needs are met in this area was discussed. The apparent lack of financial investment, both in staff training and in the environment, to include refurbishment where required, is a matter for concern. At the time of inspection the Registered Manager had still not been provided with a budget for the home, and therefore was not in a position to be able to manage the budget for the home effectively. On viewing past duty rosters, shortages in staffing had been noted, and it was clear that no review of service users dependency levels had been carried out to determine staffing levels, but rather the staffing was being purely based on occupancy levels. The home still did not have a development plan for quality assurance, or a business and financial plan in place. These points, with several of the other shortfalls identified have been discussed with the Responsible Individual for the home, and need to be addressed. The number of repeat requirements at this inspection gives cause for concern and the Responsible Individual and Registered Manager need to ensure action is taken to address them and put robust systems in place to minimise the risk of re-occurrence.

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 4th December 2006 10:00 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.V321519.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.V321519.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.V321519.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. 2nd May 2006 Date of last inspection Brief Description of the Service: Cloisters Care Home is a sixty-one bedded care home giving nursing care to frail elderly service users. Twenty-eight of these beds are on the ground floor and thirty-three on the first floor. The purpose built building is situated on a busy thoroughfare close to the Hounslow Central 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 Registered Manager has been in post since 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. The fees range from £573.36 to £700 per week, dependent on assessed need. Cloisters Nursing Home DS0000010959.V321519.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 21 hours was spent on the inspection process. 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 CSCI pharmacist Inspector carried out a medication inspection on 05/12/06 and a separate report is available. The requirements and recommendations from the pharmacist inspection have been incorporated in this report. 10 service users, 6 visitors and 12 staff were spoken with as part of the inspection process. The pre-inspection questionnaire completed by the home has also been used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: Several areas of training are still required, to include dementia care, palliative care, adult protection, increased numbers of staff qualified to NVQ level 2 or the equivalent and some areas of health & safety training, to include moving and handling training. The Inspectors were concerned about the number of Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 6 shortfalls identified with the formulation and review of the service user plans, and more work must be done to ensure this documentation is accurate and up to date, and that action is taken swiftly to address any shortfalls identified. Shortfalls were also identified in the management of medications, and robust action must be taken to address this. The lack of input from the palliative care team was of concern, and the importance of ensuring all service users needs are met in this area was discussed. The apparent lack of financial investment, both in staff training and in the environment, to include refurbishment where required, is a matter for concern. At the time of inspection the Registered Manager had still not been provided with a budget for the home, and therefore was not in a position to be able to manage the budget for the home effectively. On viewing past duty rosters, shortages in staffing had been noted, and it was clear that no review of service users dependency levels had been carried out to determine staffing levels, but rather the staffing was being purely based on occupancy levels. The home still did not have a development plan for quality assurance, or a business and financial plan in place. These points, with several of the other shortfalls identified have been discussed with the Responsible Individual for the home, and need to be addressed. The number of repeat requirements at this inspection gives cause for concern and the Responsible Individual and Registered Manager need to ensure action is taken to address them and put robust systems in place to minimise the risk of re-occurrence. 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.V321519.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.V321519.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): 1, 2, 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information they need to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff had not all received training in dementia care, thus they did not all have the specialist knowledge to care for service users fully with such a diagnosis. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Both documents are up to date and have been reviewed since the last inspection. Both documents are available in the main entrance. The Registered Manager stated that a copy of the Statement of Purpose and Service User Guide is given to the service user and their representative upon admission to the home. Some service users and representatives spoken with said that they were aware of the Service User Guide and had received a copy prior to admission. Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 9 There is a written contract/agreement with the Primary Care Trust and local Social Services for service users being funded by these departments. Contracts were available for service users funded privately. Some service users and representatives spoken with were clear about the contracts and had received copies. The home has a pre-admission assessment document and those viewed were comprehensive and provided information so that the home could ascertain if they are able to meet the service users needs. Copies of Social Services and Primary Care Trust assessments, plus hospital discharge information were also available. At the last key inspection several service users had been identified as having a dementia illness. The home is not registered to accommodate service users with dementia. A requirement was made at the last inspection that all staff must receive training and have the skills and knowledge to meet the needs of these service users. No training in dementia care has been planned since the last inspection. This is a repeat finding. Cloisters Nursing Home DS0000010959.V321519.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 poor. This judgement has been made using available evidence including a visit to this service. Service user plans were not always promptly completed or kept up to date and did not accurately reflect the condition and needs of the service user, thus placing service users at risk of not having their needs met. Shortfalls in the management of medications could place service users at risk. Staff care for service users in a gentle and courteous manner, thus respecting their privacy and dignity. Information and knowledge available for end of life care is limited, thus not fully providing for this area of need. EVIDENCE: Service user plans were sampled on each floor. The information provided in the service user plan was very general and not personalised to each service user. There was evidence that service user plans were being reviewed monthly. The daily records viewed were brief and did not detail the actual care provided. Risk assessments for falls had been formulated and the Registered Manager stated that there had been no falls in the last week. Correction fluid had been used on one service user plan and this is not in keeping with the Nursing & Midwifery Council guidance on records and record keeping. Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 11 Moving and handling assessments had been completed and detailed the equipment that was in use. Nutritional assessments viewed were not informative and did not fully assess the nutritional needs of the service user. Those viewed contained details of the service users body mass index and monthly weights. For two service users who had been recorded as having a significant weight loss, it had been two months before this weight loss had been referred to the GP. There was no explanation as to why there had been a delay. For one service user the BMI had been wrongly calculated. One service user plan viewed for eating and drinking indicated in the review that there had been no change with the service user and that the service users weight was stable, however the weight record indicated that there had been a marked weight loss. The need to ensure any weight loss is promptly brought to the attention of the Registered Manager and the GP was discussed. Where service users required bedrails consents were available, but there was no detailed assessment as to the appropriateness of their use. This is a repeat finding. Continence assessments viewed were those undertaken by Ealing Primary Care Trust in order to assess service users for continence products. No full continence assessment had been undertaken and there was no evidence as to how individual continence needs were to be addressed. Wound care documentation was viewed on both the first and ground floor. Wound photographs were available and consents had been obtained. For one service user the wound care plan indicated that the wound had healed, however the Waterlow assessment completed on the same day indicated that there was still a skin break. For one service user with two wounds, a wound assessment was not available for one wound. Dressing changes are recorded in the daily progress notes. Wound care plans detailed clearly the dressing regimes in use. Pressure relieving equipment in use was not always recorded on the care plan. Wound care audits were being undertaken. The CSCI Pharmacist Inspector carried out an inspection on 05/12/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were observed interacting with service users in a professional and caring manner. Staff knock on doors prior to entering service users bedrooms. Where service users require assistance with their meals this was done discreetly and sensitively. Service users and visitors spoken with said that the care provision in the home is a very good standard, and staff are approachable and helpful. Service users individual items of clothing are labelled. Service users can bring in personal possessions, subject to fire safety. Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 12 For one service user who required palliative care there was no service user plan to reflect end of life needs to include pain control, no referral had been made to the Macmillian Nursing services. With the exception of one member of staff no staff had received training in palliative care. Cloisters Nursing Home DS0000010959.V321519.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 good. This judgement has been made using available evidence including a visit to this service. The activities provision within the home is good, and activities are planned to meet service users individual expectations and preferences. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with service users choices being respected. EVIDENCE: One inspector spoke with the activities co-ordinator. Activities are arranged to encompass the abilities of all service users, and the activities co-ordinator said that everyone has a skill to be found. Recently service users had been involved in making Christmas decorations, with those able to actively participate doing so and others observing. A budget is available for activities and the activities co-ordinator arranges events and outings accordingly. Various in house activities were taking place at the time of inspection. Service users spoken with said that they enjoy the activities provided, but if they do not wish to join in then their wishes are respected. The home has a weekly activities schedule. Lunchtime outings have been arranged locally. A record of all activities is kept, to include service user input. Care plans for social and leisure activities are in Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 14 place, but the content is very general. The activities co-ordinator maintains a record of service user input into activities. The home has an open visiting policy, and details of this are available in the Statement of Purpose and Service User Guide. On both days of the inspection visitors were present and those spoken with said that they are made very welcome at the home. Service users can choose to receive their visitors in their own rooms, in one of the day rooms or in the garden, depending on their own wishes. Details of Advocacy Services available in the local area are freely available in the main entrance of the home. This includes details for contacting Help the Aged and Age Concern. A review of the menus has taken place in line with service users preferences. Menus are displayed in the dining areas with details of the choices available, to include specialist diet information. The lunchtime meal was sampled by both inspectors on the first day of the inspection. This was well presented and tasty. Service users spoken with expressed satisfaction with the food provision and confirmed that they are offered choices. The kitchen was clean and tidy and all records viewed were up to date. Meals are well presented and drinks and snacks are available throughout the 24 hour period. An environmental health officer visit had taken place in June 2006. The Registered Manager stated that the requirements from that visit had been addressed. Cloisters Nursing Home DS0000010959.V321519.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 clear complaints procedures in place to address any concerns raised by service users and their visitors. Procedures for the protection of vulnerable adults are in place, but staff training in this area needs to be progressed for the effective safeguarding of service users. EVIDENCE: The home has a clear complaints procedure, and this is on display in the main entrance, and is also in the Statement of Purpose and Service User Guide. Since the last inspection there have been 7 complaints. The complaint documentation was well recorded with details of the investigation undertaken and details of the outcome is recorded. The Registered Manager stated that she has an open door policy whereby she encourages service users and their representatives to raise any concerns so they can be promptly addressed. Service users and visitors spoken with expressed their satisfaction with the home and said that any concerns raised are promptly dealt with. The training records viewed detailed that not all staff had received training in the Protection of Vulnerable Adults. This is a repeat finding. Staff spoken with were not all fully clear on POVA procedures. Since the last inspection 1 POVA case has been identified, and appropriate action has been taken by the home in respect of this. Cloisters Nursing Home DS0000010959.V321519.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, 21, 22, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and there is a homely atmosphere, however repeated shortfalls in refurbishment indicate that the environment is not being fully maintained for the comfort of the service users. Bedrooms are personalised, thus providing service users with a homely environment to live in. Infection control procedures are in place and generally being adhered to, thus safeguarding service users. EVIDENCE: A tour of the home was carried out. At the last inspection a recent environmental audit had been carried out and it was required that a redecoration and refurbishment plan, with timescales for completion, be drawn up to address the findings of the audit. No action has been taken to address this. There was evidence that areas had been redecorated and the maintenance man works hard to keep the décor looking fresh. However items of furnishings to include dining room furniture, armchairs and corridor carpets are looking shabby and a programme of replacement is still outstanding. A copy of a quote for dining room chairs and tables was seen, but there was no Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 17 evidence that this had been progressed. A monthly audit of the linen provision in the home showed shortfalls in the amount of sheets, towels and face cloths available. The home has sufficient assisted bath, shower and toilet facilities to meet the needs of the service users. Some of the bedrooms have en suite facilities. Toilet facilities are situated near to the communal rooms. There are rails in the corridors and grab rails are provided in the assisted toilet facilities. Moving & handling equipment was available to meet the needs of the service users. A call bell system is in place throughout the home, and staff were heard to answer these promptly. Several of the bedrooms viewed were personalised and homely, and there had been input from the service users families. The home was clean and smelled fresh. The flooring in the laundry room was very marked and lifting in places, especially where it butts up to the cupboard. Laundry equipment is industrial and the washing machines have sluice programmes for disinfection purposes. Protective clothing to include gloves and aprons was available in the home. Sluice rooms with electronic disinfectors were seen on both floors. Information regarding infection control was on display in the laundry and staff had received training in this topic. Cloisters Nursing Home DS0000010959.V321519.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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are still not being calculated according to service users dependencies, plus there is evidence of some staff working excessive hours. These shortfalls place service users at risk of their needs not being effectively met. Staff still had not received adequate levels of training for induction purposes and also for ongoing training, in order to have the knowledge and skills to fully meet service users needs. EVIDENCE: The Registered Manager stated that there had been a recent increase in staffing in the home. Duty rotas examined indicated that staff were regularly working 12 to 15 days without a day off. On the 1st October one staff member worked an early shift, afternoon shift and a night shift. On one occasion 55 service users were accommodated at the home and there were 2 Registered Nurses and 3 care assistants on night duty. The rota also indicated that a student nurse from Thames Valley University worked a night shift. Students are supernumerary to the staff on duty. For two new care assistants the induction training consisted of one day and then they were rostered as part of the staffing numbers to work on the floor. Although a requirement was set at the last inspection that staffing levels be reviewed in line with service user dependencies, no formal staffing review had taken place for 5 months. The pre-inspection questionnaire detailed that 11 care staff have NVQ level 2 or equivalent. It is not clear from the information provided what plans are in Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 19 place for further care staff to be trained. The Registered Manager is aware of the need for 50 of all care staff to be qualified to NVQ level 2 or above, and this needs to be progressed. Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001, with the exception of one photograph, which was being addressed. Since the last inspection the home has obtained an induction booklet that meets the Skills for Care common induction standards. There was evidence of some staff had received periodic training in topics relevant to the needs of service users. All staff must be kept up to date with training to ensure they have the knowledge and skills to meet the service users needs. Cloisters Nursing Home DS0000010959.V321519.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, 34, 35 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Registered Manager is appropriately qualified to manage the home, and is approachable, thus listening to the needs of service users. The home does not have a programme in place for quality assurance, and auditing is not always effective, thus effective systems of audit and review are not in place. The home does not have a business and development plan or budget information, therefore the Registered Manager does not have the information in order to budget effectively for the home. Lack of financial investment in various areas could place service users at risk. Service users personal monies handled by the home are being well managed and securely stored. Shortfalls identified in the overall management of health & safety at the home could place service users, visitors and staff at risk. EVIDENCE: Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 21 The Registered Manager is a first level registered nurse with a qualification in mental health. She has also attained the Registered Managers Award, NVQ level 4 in management. Service users and visitors spoken with said that the Registered Manager is approachable and that any issues raised are addressed. A system of auditing various areas of care to include medications, service user plans, meals, infection control and audits of the floors are carried out randomly, but it was difficult to ascertain what action had been taken to address some of the shortfalls identified. Staff meetings and heads of department meetings take place and minutes are kept. Regulation 26 unannounced visits had not been taking place every month and this needs to be addressed. The home does not have a development plan for quality assurance, and this is a repeat finding. The home still does not have a business plan, and when asked the Registered Manager said that she still did not have sight of any budgets for the home. One Inspector discussed this with the Responsible Individual at the time of inspection, and was informed that the company is too small to warrant a business plan. This has been further discussed, together with the need to provide an annual budget for the home identifying the monthly monies available for each area of expenditure. Without this information it is not possible to effectively manage the expenditure for the home. A copy of the October 2006 budget and expenditure has since been provided, but it is not clear how the figures for expenditure have been reached, for example, for activities. The need to invest in the home, especially in respect of staffing, staff training and the environment was apparent at the time of inspection and needs to be addressed robustly. Small amounts of personal monies are managed by the home. Clear records of income and expenditure with receipts are maintained. The Registered Manager randomly audits records for service users monies. Training records viewed confirmed that not all staff had received health & safety training to include moving & handling. This is a repeat finding and an immediate requirement was set at the last inspection. At the time of inspection, the reason given for some staff not having been trained in this area was because there were not enough staff requiring training to warrant sending the trainer to the home. A recent incident involving poor practice with moving & handling has resulted in a service user injury. The Responsible Individual and Registered Manager need to ensure all staff are appropriately trained, receive training updates, and also are aware of the importance of adhering to the training they have received. Servicing and maintenance records were viewed at random and those viewed were up to date. Fire drills for all staff had been taking place at the required intervals. No progress had been made since the last inspection in having the lifts inspected for insurance purposes. The Registered Manager showed documentation that confirmed that a quotation had been obtained. The last inspection of the lift for insurance purposes was Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 22 carried out prior to November 2005. This is a repeat finding. Risk assessments for equipment and safe working practices were available and had been kept up to date. One cleaning fluid was found in a bathroom on the ground floor, and was removed at the time of inspection. Cloisters Nursing Home DS0000010959.V321519.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X 3 3 X 3 X 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 1 3 X X 1 Cloisters Nursing Home DS0000010959.V321519.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 OP4 Regulation 18(1) Requirement 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. Previous timescale of 01/08/06 not met Service user plans must be completed promptly and the information contained therein must be up to date and accurately reflect the needs of each individual and how these are to be met. The daily record must accurately reflect the care given to the service user. Correction fluid must never be used on legal documents. Assessments must be comprehensive and accurately reflect the status of the service user. Where a continence care need is identified a clear regime of continence management must be included in the service user plan. Where a service user is identified DS0000010959.V321519.R01.S.doc Timescale for action 31/01/07 2. OP7 15, 17 31/01/07 3. 4. 5. OP7 OP7 OP8 15, 17 17 15, 17 31/01/07 04/12/06 31/01/07 6. OP8 15, 17 31/01/07 7. OP8 15, 17 01/01/07 Page 25 Cloisters Nursing Home Version 5.2 8. 9. OP8 OP9 15, 17 13(2) 10. OP9 13(2) 11. OP9 13(2) 12. 13. 14. 15. 16. OP9 OP9 OP9 OP9 OP11 13(2) 13(2) 13(2) 13(2) 12, 18 17. OP11 12(1)(b) 18. OP18 13(6) as experiencing weight loss, prompt action must be taken to refer the service user to the GP. Wound care documentation must be complete and up to date. The home must ensure that medication is administered as prescribed by maintaining continuous supplies Medicines must be recorded accurately when received into the home and disposed of. Witness signatures must be obtained for disposals. Medicines must be recorded accurately when administered. Records must be clear particularly for changes in dosage, variable doses, reducing dosages and discontinued medicines The safe storage of medication requires review on the first floor Medication must be thoroughly audited at least weekly for the next 2 months Training needs of staff must be identified and met - by assessing competency The MHRA advice with regard to blood glucose testing must be followed Staff must have the skills and knowledge to care for service users with specialist needs, to include palliative care. Referrals to the appropriate healthcare professionals must be made promptly to meet service users needs. All staff must receive training in the Protection of Vulnerable Adults. Documentary evidence of this training must be available for inspection. Previous timescale of 01/07/06 not met DS0000010959.V321519.R01.S.doc 01/01/07 05/12/06 11/12/06 05/12/06 16/01/07 05/02/07 05/03/07 04/01/07 31/01/07 01/01/07 01/02/07 Cloisters Nursing Home Version 5.2 Page 26 19. OP19 23(2)(b) & (d) 20. 21. OP26 OP27 13(3) 18 22. OP28 18 23. OP30 18 24. OP33 24 25. OP34 25 26. OP34 12, 16, 18, 23 An action plan with timescales for completion must be drawn up to address the shortfalls identified in the environmental audit and any additional shortfalls identified at the time of inspection, to include redecoration, furniture and fittings. Previous timescale of 01/06/06 not met COSHH products must not be left unattended in service user areas. There must be appropriate numbers of staff on duty at all times to meet the assessed needs of the service users. This must be calculated according to service users dependencies, and not just based on occupancy levels. Previous timescale of 01/06/06 not met An action plan to evidence ongoing work to ensure 50 of care staff are trained to NVQ level 2 or the equivalent must be in place and adhered to. All staff must be trained appropriately to meet the needs of the service users accommodated at the home. An Annual Development plan for quality assurance must be available for the home. Previous timescale of 01/07/06 not met 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. Previous timescale of 01/07/06 not met There must be appropriate investment in the home to ensure it is fit for purpose at all times. An action plan to evidence this must be drawn up and DS0000010959.V321519.R01.S.doc 31/01/07 04/12/06 01/01/07 01/01/07 31/01/07 01/01/07 01/01/07 05/01/07 Cloisters Nursing Home Version 5.2 Page 27 27. OP38 13(5) 28. OP38 23(2)(c) forwarded to CSCI. 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. Previous timescale of 12/05/06 not fully met 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. Previous timescale of 01/06/06 not met 22/12/06 22/12/06 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.V321519.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Area 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.V321519.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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