Care Home: Cloisters Nursing Home

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What the care home does well The home is being effectively managed and this has led to marked improvements throughout the home. The management are approachable and proactive in their work and this is evident throughout the home. Staff care for residents in a gentle, caring and professional manner, respecting dignity, privacy and cultural and diversity needs. The home has an open visiting policy and visiting is encouraged. The food provision is good with good variety on the menu to meet personal and cultural preferences. Complaints are appropriately managed at the home. Infection control procedures are in place and are adhered to. Overall the comments received via the CSCI comment cards were positive. Examples of these are: `Cloisters care home looks after my relative in a kind and caring atmosphere`. `All the staff are helpful and friendly`. `The general cleanliness is very good as is personal cleanliness`. `The staff are kind, considerate, friendly and very caring`. What has improved since the last inspection? Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. The home is clear that they must not admit residents with a diagnosis that is outside the homes categories of registration. Overall the service user plans are well completed and healthcare needs are also being identified and met. There was evidence that where possible input had been sought from the resident and/or their representative in the formulation and review of the service user plans. Where this had not been possible this had been recorded. We were informed that risk assessments are in place for the use of wheelchair lap straps. There has been a significant improvement in the recording of residents wishes in the event of health deterioration and end of life care. The home has in place an activities programme to meet the individual needs and preferences of the residents. Information regarding advocacy services is freely available and detailed in the Statement of Purpose. Staff spoken with at the inspection confirmed that they are fully aware of safeguarding adults procedures and all staff had received training in this area. The environment is being well maintained with evidence of ongoing redecoration, refurbishment and maintenance. Shortages in staffing were not noted at this inspection. The management team is clear that staffing levels are based on the dependency needs of the resident s and not numbers of residents. Systems for the vetting and recruitment of staff are robust and are followed. The training provision is good and the NVQ in care training is being progressed. Kitchen and domestic staff are also undertaking relevant NVQ qualifications. The Acting Manager has also undertaken training relevant to her role and topics relevant to the care of the elderly. The AQAA submitted by the Area Manager on behalf of the home is clear and provides the information requested. The home now has systems in place for effectively reviewing the quality of care provided and for reviewing all aspects of the home for quality assurance purposes. Any monies held on behalf of residents are being appropriately managed, recorded and securely stored. CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:15 23 & 24th June 2008 rd 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.V364556.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.V364556.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 Manager post vacant 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.V364556.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. 15th & 16th October 2007 Date of last inspection Brief Description of the Service: Cloisters Care Home is a sixty-one bedded care home giving nursing care to older people. Twenty-eight of these beds are on the ground floor and thirtythree on the first floor. The purpose built building is situated on a busy thoroughfare close to the Hounslow Central shopping parade and transport links. There are fifty-one single bedrooms, nineteen with en suite washbasins and toilets. There are five double bedrooms, four with en-suite facilities and one without. There are six assisted bathrooms. A stairway and two passenger lifts connect the ground and first floor. All areas of the home are wheelchair accessible. There is a large parking area to the side of the building and a garden to the rear. Alpha Health Care Limited, a private company owns the home. The fees range from £500 to £835 per week. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 18 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 17 staff, 6 visitors and 1 healthcare professional were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and staff have also been used to inform this report. What the service does well: What has improved since the last inspection? Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. The home is clear that they must not admit residents with a diagnosis that is outside the homes categories of registration. Overall the service user plans are well completed and healthcare needs are also being identified and met. There was evidence that where possible input had been sought from the resident and/or their representative in the formulation and review of the service user plans. Where this had not been possible this had Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 6 been recorded. We were informed that risk assessments are in place for the use of wheelchair lap straps. There has been a significant improvement in the recording of residents wishes in the event of health deterioration and end of life care. The home has in place an activities programme to meet the individual needs and preferences of the residents. Information regarding advocacy services is freely available and detailed in the Statement of Purpose. Staff spoken with at the inspection confirmed that they are fully aware of safeguarding adults procedures and all staff had received training in this area. The environment is being well maintained with evidence of ongoing redecoration, refurbishment and maintenance. Shortages in staffing were not noted at this inspection. The management team is clear that staffing levels are based on the dependency needs of the resident s and not numbers of residents. Systems for the vetting and recruitment of staff are robust and are followed. The training provision is good and the NVQ in care training is being progressed. Kitchen and domestic staff are also undertaking relevant NVQ qualifications. The Acting Manager has also undertaken training relevant to her role and topics relevant to the care of the elderly. The AQAA submitted by the Area Manager on behalf of the home is clear and provides the information requested. The home now has systems in place for effectively reviewing the quality of care provided and for reviewing all aspects of the home for quality assurance purposes. Any monies held on behalf of residents are being appropriately managed, recorded and securely stored. 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.V364556.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.V364556.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 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. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Following the last inspection the home ensures that all residents come within the categories for which the home is registered. Cloisters Nursing Home DS0000010959.V364556.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): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is well completed to provide staff with the information to meet each resident’s needs. Medications are being well managed at the home, thus safeguarding residents. Shortfalls should be easy to address. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home now records the wishes of residents and their families in respect of end of life care, thus ensuring that their wishes and needs are discussed, recorded and met. EVIDENCE: 6 service user plans were viewed. There had been an improvement in the completion of the documentation to make it more personalised. Although some of the information was still quite general, registered nurses spoken with understood the need to make information more individualised to each resident and work in this area is being progressed, with service user plans being audited by the peripatetic manager. The service user plans had been reviewed monthly and whenever a residents’ condition changed. Full reviews had been carried out for residents on return from any hospital admissions. There was Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 10 evidence of input from representatives in the review of the service user plan. Risk assessments for falls were in place and had been updated following any changes in condition. Wound care documentation was viewed. This included care plans for each wound which recorded the dressing regime to be used, a wound chart and body mapping charts. The pressure sore documentation had been updated weekly and entries regarding dressing changes had been made in the daily record. Written consent for photography had been obtained, and wounds had been photographed to show the condition of each one. The wound care documentation was up to date and clearly showed the progress of each wound. Pressure relieving equipment was in use in the home and had been recorded in each persons service user plan. Assessments moving & handling were in place and equipment to be used for each moving & handling need had been identified. Assessments for continence, nutrition and dependency were in place and were up to date. Risk assessments for the use of bedrails had been carried out and written consents for their use obtained. There was evidence of input from healthcare professionals to include GP, community matron, dietician, chiropodist and care managers. Medication management was viewed on both floors. Lists of registered nurse signatures were available on each floor. A homely remedy sheet had been completed for each resident. There were clear records of receipts and administration, and with the exception of one medication all administration records had been signed. On investigation the medication had recently been discontinued, however the home had not been informed of this. For one medication the coding ‘o’ had been used, but no explanation as to why the medication had been omitted had been recorded. Receipts to include medications received mid-month had been recorded, and stock checks were accurate for medications audited. Liquid medications, creams and eye drops had been dated when opened. Approved lancing devices for professional use were available for blood glucose monitoring. The temperature records for the fridges in the clinical rooms indicated that the temperatures were regularly outside the safe range of 2-8° centigrade. The clinical rooms were showing a temperature above 25° centigrade. The Area Manager said that these shortfalls had already been identified and new fridges are to be purchased plus the ventilation system was to be reviewed throughout the home. The home uses the weekly NOMAD system for medications. The medication information available on the back of each box was incomplete, as no description of tablets had been included. For one medication where there had been a dose change, this had been altered by hand. The home also confirmed that they do not see the prescriptions and that the dispensing pharmacist deals directly with the GP. The importance of ensuring the home has a copy of the prescription for the current medication in use for each resident was discussed. Controlled drugs had been recorded and were being securely stored. Staff were using initials instead of their full signature when signing the CD book and the need to sign in full was discussed. For residents being fed via a percutaneous endoscopic Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 11 gastrostomy (PEG) tube, the daily feeds had been recorded on the medication administration record (MAR) chart and also on the daily fluid balance chart. Medications are being correctly disposed of by the home. The British National Formulary book available was dated September 2006 and it is strongly recommended that an up to date copy be obtained. Where residents were receiving oxygen therapy this had been appropriately recorded and safety signage was in place. It was noted that in the ‘allergy’ section on each of the MAR charts the wording ‘none known’ had been printed, however staff had changed this where necessary to identify the allergies for residents. This needs discussing with the dispensing pharmacist to ensure any allergies are clearly printed on the MAR. The Management arranged to meet with the dispensing pharmacist to discuss issues identified as part of this inspection, and has provided feedback to us from this meeting. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Staff were seen communicating with residents in a respectful manner. Bedrooms had been personalised and there was a homely feel throughout. Residents can have their own telephones, either mobile or landline. Residents spoken with said that they were being well cared for, and they looked well groomed and dressed to reflect individuality. Since the last inspection there has been a marked improvement in the information available in the event of deterioration in a residents’ health, plus ‘end of life’ information. It was clear that this had been discussed with residents where able and representatives, and information recorded to ensure the wishes of the resident and their families was known and could be respected. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision has improved, and each residents’ right to choose to join in is respected, thus meeting their individual needs and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The activities co-ordinator has been in post for 5 months, and it was clear from speaking with her that she has wide experience of working with the elderly and understands the importance of providing activities that are appropriate and that meet their individual interests and needs. She ensures she meets with each resident on a daily basis. Care plans for social and leisure interests were in place. Some of the information was quite general, however ‘Life History’ documents had been completed and gave a good picture of each persons past, to include previous hobbies and interests. A weekly activities programme is displayed and the activities co-ordinator keeps a record of each persons Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 13 involvement, to include one to one sessions. Some local outings have taken place. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and refreshments are offered. Visitors commented about the homely atmosphere throughout, and one relative said that ‘it is like my second family here’. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was displayed in the main entrance of the home. The home has information from Age Concern and various advocacy services to provide financial advice. We viewed the kitchen. This was clean and tidy and all the records were up to date. Residents are offered a choice of meals and documentation to evidence this was available. There are three main meal choices for lunchtime, to include a vegetarian curry option, and where a resident would like another alternative this is also provided. A 4 week menu is available and is displayed in the foyer. Residents spoken with said that overall they do enjoy the food. Soft diet and Pureed meals are well presented. We sampled the lunchtime meal on the first day of inspection and the food was well presented and tasty. Visitors are also able to partake in meals should they wish to. Staff were available to assist residents with their meals as needed, and did so in a gentle manner. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. 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 residents and their visitors. There is a clear system in place for safeguarding adults, to protect residents from abuse. EVIDENCE: The home has a clear complaints procedure and this is displayed and is available in the recently updated Statement of Purpose, which has been given out to residents. One resident was able to produce this document and was knowledgeable of its content. Visitors spoken with were aware of the complaints procedure also. There had been 2 complaints since the last inspection and these had been investigated and responded to. There have been 5 safeguarding adults referrals since the last inspection. These have been investigated and where letters of concern had been received by the home they also have responded to these under their complaints procedure. The home has also contacted the Hounslow Safeguarding Adults team and arranged Safeguarding Adults training which has recently taken place. Staff spoken with were very clear to report any concerns and understood the Whistle Blowing procedures. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Equipment is in place to ensure the moving & handling needs of the residents can be met. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: A tour of the home was carried out. Overall the home has been maintained, and the Area Manager stated that a full redecoration and refurbishment programme is commencing on 07/07/08, and this was evidenced by documentation provided. New furniture had been purchased for some of the rooms and some new reclining chairs to meet residents specific needs. The Area Manager explained that as part of the refurbishment programme the central heating system is to be upgraded. The home now employs a gardener for 8 hours per week and it was evident that much work had taken place to Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 16 improve the external grounds, to include the garden area accessible to residents. There are rails in each corridor and also in the toilet facilities. Staff reported that new hoists have been purchased to ensure the moving & handling needs of all the residents can be met. The home is also due to receive a hoist with an integrated facility for weighing residents. We viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. Good practice notices and laundering guidelines were on display. The washing machines have sluice programmes for infection control and there are 2 washing and 2 drying machines, all industrial standard. Protective clothing to include gloves and aprons was available throughout the home. We spoke with some staff seen using gloves when not providing personal care and the importance of ensuring gloves are only used in line with procedures. Infection control procedures are in place and were being followed. The home was clean, bright and fresh throughout. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and protect residents. There has been an improvement in the training programme, providing staff with training in topics to enhance their care of the residents. More work is needed on the induction programme training to ensure new staff are provided with the knowledge and skills to care for residents effectively. EVIDENCE: At the time of inspection the home had 45 residents. Despite the vacancies the staffing had been maintained at the level for when the home is fully occupied. We did receive some comments regarding the home being short of staff, particularly at the weekends, and this was discussed with the Management. They explained that there has been an improvement in the weekend staffing and the home has also been recruiting new care staff to ensure they have enough staff on duty. Staff spoken with confirmed that the numbers of staff on duty are appropriate to meet the residents needs. The home employs administration, catering, domestic, activities, maintenance and gardening staff so that all the needs of the residents and the home in general can be met. Over 60 of care staff are qualified to NVQ level 2 in care or above or are currently undertaking the course. As well as care staff, ancillary staff are also given the opportunity to study for an NVQ. The training matrix shows that all Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 18 staff now receive regular training in topics relevant to the diagnoses and needs of the residents. Staff are also now paid to attend training and staff spoken with were enjoying the training and the registered nurses felt that they were now being more valued and that training was being provided to ensure they fulfil the training requirements of the Nursing and Midwifery Council. Some of the care staff explained that they are undertaking English classes at the home, to improve their communication skills. Three sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has an induction programme based on Skills for Care Common Induction Standards. Staff spoken with said that they have 3 days induction, one of which is watching various care and health & safety videos and then 2 days working shifts alongside experienced staff. The Perapatetic Manager explained that Alpha Care does allow 5 days for induction, and this information had not been cascaded to the Manager. The importance of ensuring all staff have a full induction so that they have the skills and knowledge to care for residents effectively was discussed. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team in place are effective and ensure that the home is being well managed, and processes are open and transparent. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are in place, however shortfalls could present a risk to residents, staff and visitors. EVIDENCE: Currently the Deputy Manager is the Acting Manager and the home is in the process of recruiting a new Manager. This has been an ongiong process for several months. In addition the home has regular input from the Area Manager and a peripatetic Manager, who is providing training input in areas such as care planning. It is also clear that there has been an increase in investment in Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 20 the home and this has brought about improvements to the management as resources are more freely available. The Area Manager is very clear that the home needs to be effectively managed so that improvements can be maintained. The home has commenced the completion of the Alpha Care monthly audits, which cover all aspects of the home. One had been completed for June 2008 and provided a good picture of areas of strength plus the areas where shortfalls had been identified. Action plans to address the shortfalls are drawn up. There was also a health & safety audit that had been recently completed and this is a similar document with an action plan for shortfalls. The management said that a medication audit was due to be carried out in the near future, and thereafter regular audits of all areas would be carried out. Regulation 26 visits on behalf of the Registered Provider are carried out and reports are available. Minutes of staff meetings, residents meetings and health & safety meetings were available. A meeting for relatives was being advertised for 25/06/08 and a schedule of meetings will be planned thereafter. Residents and relatives can discuss any issues with the Acting Manager on an individual basis at any time. Surveys for residents and relatives had been carried out in January 2008 and results were included in the recently updated Statement of Purpose. The home holds personal monies on behalf of some residents. Monies are securely stored and receipts are given for income. Four sets of records and were viewed and audited against monies held. These were accurate and all income and expenditure had been clearly recorded, with receipts available for all expenditure. Samples of servicing and maintenance records were viewed and these were up to date. It was noted that the weekly wheelchair checks had been recorded as now being carried out by the staff on the floors, however there was no record of this, and in one instance a wheelchair had one footplate from another chair on it. This was discussed with the Area Manager as it is important that the wheelchairs are checked regularly and any problems addressed. The training matrix identifies some shortfalls in the completion and update of mandatory training to include moving & handling, and the importance of including moving & handling practical training as part of the induction process was discussed. It is noted that the health & safety audit had identified the shortfall in this training. A fire risk assessment had been completed in May 2008 and several areas had been identified as needing work. The Area Manager said that this was already being planned and that all the areas identified would be addressed. Daytime fire drills are carried out on a weekly basis, but the importance of implementing night fire drills was discussed, as the staff do not do day and night rotation. In the light of a recent incident keypads have now been installed on the doors leading to the staircases, to minimise the risk of accident. Overall health & safety was being reasonably well managed at the Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 21 home, however the shortfalls identified need to be addressed to ensure the home provides a safe environment throughout. Cloisters Nursing Home DS0000010959.V364556.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 3 8 3 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 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Cloisters Nursing Home DS0000010959.V364556.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. Standard OP9 Regulation 13(2) Requirement Clinic room temperatures and medication fridge temperatures must be within the safe range for storage of medication. Medication information on the back of each dosette box must be clear and include description of the tablets contained in the box, in order to safeguard the resident. Induction training timescales must be reviewed to ensure all staff receive appropriate induction training to provide them with the skills and knowledge to care for residents effectively. Fire drills for all night staff must take place at the required intervals to ensure that residents are safeguarded. All staff working in the home must receive health and safety training to include moving and handling training, to ensure that residents are safeguarded. There must be evidence that the wheechairs are being appropriately checked and DS0000010959.V364556.R01.S.doc Timescale for action 01/08/08 2. OP9 13(2) 01/07/08 3. OP30 18 01/08/08 4. OP38 23(4) 01/07/08 5. OP38 18 01/08/08 6. OP38 12 01/07/08 Cloisters Nursing Home Version 5.2 Page 24 maintained, to ensure that the residents are safeguarded. 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. 2. Refer to Standard OP9 OP9 Good Practice Recommendations Registered nurses should use their full signature when signing the Controlled Drugs register. The home should continue to work with the pharmacist and GP to ensure that the ordering process allows the home to have sight of the original prescription, in order to check for accuracy and evidence of the current medication. Cloisters Nursing Home DS0000010959.V364556.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V364556.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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