Background to this inspection
Updated
11 January 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.
The inspection took place on 22 and 23 November, 2017 and was unannounced
The inspection team consisted of one adult social care inspector, an assistant adult social care inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before the inspection visit we reviewed the information which was held on Cloisters Care Home. This included notifications we had received from the registered provider such as incidents which had occurred in relation to the people who lived at the home. A notification is information about important events which the service is required to send to us by law.
A Provider Information Return (PIR) was also submitted and reviewed prior to the inspection. We used information the provider sent us in the PIR. We require providers to send us at least once annually to give us key information about the service, what the service does well and improvements they plan to make. We also contacted the commissioners of the service and the local authority safeguarding team. We used all of this information to plan how the inspection should be conducted.
During the inspection we spoke with the registered manager, four members of staff, maintenance co-ordinator, seven people who lived at the home, the chef and two relatives.
In addition, a Short Observational Framework for Inspection tool (SOFI) was used. SOFI provides a framework to enhance observations during the inspection; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at the home who could not express their experiences for themselves.
During the inspection we also spent time reviewing specific records and documents. These included four care records of people who lived at the home, four staff personnel files, recruitment practices, staff training records, medication administration records and audits, complaints, accidents and incidents, infection control procedures and other records relating to the management of the service.
We undertook general observations over the course of the inspection, including the general environment, décor and furnishings, the bedrooms and bathrooms of some of the people who lived in the home, the dining/lounge areas and garden area.
Updated
11 January 2018
This inspection took place on 22 and 23 November 2017 and was unannounced.
Cloisters EMI is a ‘care home’ and is registered to provide care and support for up to 20 older people and people living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
At the time of the inspection there were 20 people living at the home. Accommodation is provided across three floors and facilities included one dining room, two large TV rooms, a garden area to the rear of the building as well as a small car park at the front.
At the time of the inspection there was a registered manager in post. A ‘registered manager’ is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the previous comprehensive inspection which took place in October 2016, the home was rated as ‘Requires Improvement’. We found the registered provider was not meeting legal requirements in relation to ‘good governance’.
Following the previous comprehensive inspection the registered provider submitted an action plan which outlined how they were improving the standards of care and quality of service. We then conducted a ‘focused’ inspection in February 2017 to check the provider had made enough improvements to meet their legal requirements.
During the focused inspection we found that a number of improvements had been made and the registered provider had met the breach in regulation.
During this inspection we found the registered provider was delivering a ‘good’ service although we have made a number of suggestions to the registered provider in relation to the on-going assessment and monitoring of people living at the home and quality assurance systems.
We reviewed a number of care records and risk assessments which were in place for the people who lived at Cloisters. Care plans and risk assessments were being regularly reviewed and staff were familiar with people's support needs. However, audits and checks were not identifying some areas of concern we raised during the inspection.
We have recommended that the registered provider reviews their quality assurance processes
Accidents and incidents were being recorded and monthly audits were conducted. However, we found evidence to suggest that accidents/incidents were not being thoroughly investigated. This meant that some of the records were not up to date and important information was not being recorded.
We have recommended that the registered provider reviews their processes in relation to accident and incidents.
During this inspection we found the home was operating in line with the principles of the Mental Capacity Act, 2005 (MCA). People were appropriately assessed, mental capacity assessments were decision specific and there was best interest processes in place for people who lacked capacity.
We found the environment to be clean, well maintained and free from any odour. There was an effective cleaning rota in place and infection control policies were being adhered to.
Health and Safety audit tools were in place to monitor, assess and improve the quality and standards of the home. This meant that people were living in a safe environment.
Supervisions and appraisals were taking place. Staff were receiving the necessary training to support them in their roles and staff expressed that they felt supported on a daily basis.
During this inspection we found that care records contained person centred information and staff were able to provide person centred care. The environment itself had been adapted to support people living with dementia although we did discuss some further improvements which could be made with the registered manager.
We reviewed the recruitment processes and found these were safely managed. This meant that staff who were working at the home had suitable and sufficient references and the appropriate criminal record checks had been carried out.
Medication processes and systems were safely managed. During the inspection we found that routine monthly medications audits were being conducted, medication administration records (MARs) were being appropriately completed and only staff who had received the appropriate training were administering medication. This meant that people were receiving a safe level of care in relation to the medications which they were being prescribed.
The day to day support needs of people living in the home was being met. We reviewed a number of files which demonstrated that the appropriate referrals were taking place and the relevant guidance and advice which was provided by professionals was being followed accordingly.
Privacy and dignity was preserved and respected. Staff were observed providing dignified care and there was evidence to show how people were provided with ‘choice’ and supported to remain as independent as possible.
There wasn’t an activities co-ordinator at the time of the inspection. We were informed that each staff member was responsible for arranging activities as part of a scheduled rota. The feedback we received about activities was positive. People we spoke with said they enjoyed the activities which were organised and people were observed taking part in the activities. .
People told us they were happy with the quality and standard of food they received. We observed good quality, nutritious food being offered during the inspection. People were offered a variety of choices and preferences, likes and dislikes were also recorded in people’s care records.
We reviewed the complaints policy and processes which were in place. People and relatives we spoke with were familiar with the complaints process. At the time of the inspection there were no formal complaints being investigated.
Staff morale was positive. Staff expressed how there was an open and supportive culture within the home and expressed that it was a ‘lovely’ home to work in.
The registered manager was aware of their responsibilities and had notified the CQC of events and incidents that occurred in the home in accordance with the CQC’s statutory notifications procedures. The registered provider ensured that the ratings from the previous inspection were on display within the home.
We reviewed the range of policies and procedures which were in place. Policies and procedures were available to all staff and staff were able to discuss specific procedures and processes with us during the inspection.