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Inspection on 12/12/05 for Cloisters Nursing Home

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

This inspection was carried out on 12th December 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has maintained a permanent staff group of several years and those who spoke to the Inspector expressed satisfaction with the support they received within the team and also from the Acting Manager. The service users appeared appropriately dressed, well cared for and content. They reported being happy with the standard of care they received at the home and were observed to relate in a friendly manner with members of staff who were on duty during the inspection. The records and documents viewed were satisfactory, up to date and indicated that the safety and welfare of the service users were being protected. Overall the home was found to be clean, hygienic and well maintained . The environment was pleasant and homely.

What has improved since the last inspection?

All twenty-one requirements that were met at the last inspection had been complied with.

What the care home could do better:

No requirements were identified at this inspection.

CARE HOMES FOR OLDER PEOPLE Cloisters Nursing Home 70 Bath Road Hounslow Middlesex TW3 3EQ Lead Inspector Ms Jean Bovell Unannounced Inspection 10:30 12 and 22 December 2005 th nd 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.V271811.R01.S.doc Version 5.0 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.V271811.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cloisters Nursing Home Address 70 Bath Road Hounslow Middlesex TW3 3EQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8572 4131 020 8577 5358 Cloisters Care Limited Mrs Carolyn Ann Butterworth Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61), Physical disability (61), Physical disability of places over 65 years of age (61) Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 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. 4th May 2005 Date of last inspection Brief Description of the Service: Cloisters Care Home is a sixty-one bedded care home giving nursing care to frail elderly service users. Twenty-eight of these beds are on the ground floor and thirty-three on the first floor. The purpose built building is situated on a busy thoroughfare close to the Hounslow Central shopping parade and transport links. There are fifty-one single bedrooms, thirteen with en suite washbasins and toilets. There are five shared bedrooms, four en-suites and two with bathrooms. There are six assisted bathrooms. A stairway and two passenger lifts connect the ground and first floor. All areas of the home are wheelchair accessible. There is a large parking area to the side of the building and a garden to the rear. Alpha Health Care Limited, a private company owns the home. The Head of Nursing was Acting Manager on the day of the inspection. The home also has an administrator, registered nurses, care staff, chef and kitchen assistants, a maintenance person who has supervisory responsibilities for a team of domestic staff and an Activities Organiser. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 10.30 am and 3.30 pm on 12th December 2005 with a follow up visit on 22nd December 2005. The Acting Manager, four Registered General Nurses, eight care assistants, ancillary staff and 56 service users were present. A number of relatives and/or friends visited the home at various times during the inspection. The Inspector was advised that one service user had been admitted to hospital and that there were four service user vacancies at the time of the inspection. A new Registered Manager had been appointed and was expected to be in post in January 2006. During the course of the inspection, discussions were held with seven service users, two visiting relatives, two Registered General Nurses and one care assistant. A tour of the building was undertaken and records, policies and procedures were viewed. The Acting Manager was co-operative and provided appropriate assistance throughout the inspection. What the service does well: The home has maintained a permanent staff group of several years and those who spoke to the Inspector expressed satisfaction with the support they received within the team and also from the Acting Manager. The service users appeared appropriately dressed, well cared for and content. They reported being happy with the standard of care they received at the home and were observed to relate in a friendly manner with members of staff who were on duty during the inspection. The records and documents viewed were satisfactory, up to date and indicated that the safety and welfare of the service users were being protected. Overall the home was found to be clean, hygienic and well maintained . The environment was pleasant and homely. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 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.V271811.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4. Standards 1, 2, 3, 4 and 5 were examained at the last inspection. The requirements that were made under standards 1 and 4 at the last inspection had been complied with. EVIDENCE: The home’s statement of purpose and service users guide had been updated and copies were submitted to the CSCI. This complied with the requirement that was made under standard 1, at the last inspection. The records indicated training on dementia had been delivered to Registered General Nurses and care assistants on 13th September 2005. This was in compliance with the requirement that was made under standard 6, at the last inspection. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 11. Standards 7, 8, 9 and 10 were examined at the last inspection. The home’s policy and procedures relating to the death of service user is satisfactory. The requirements made under Standards 7, 8 and 9 at the last inspection had been met. EVIDENCE: The home’s policy and procedures relating to the death of a service user were in place and specific wishes, where appropriate, were documented on care plans. A number of care plans were examined at random. All had been satisfactorily undertaken and were regularly reviewed. This complied with a requirement made on standard 7, at the last inspection. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 10 It was evidenced on records seen that training on manual handling was delivered members of the care staff on 17th November 2005. This requirement was made under standaard 8, at the last inspection. Medication kept at the home was appropriately stored, recorded and administered. The proper procedure for the disposal of medicines was in operation. Feeding regimes for those on peg feeds were displayed. These requirements were made under standard 9, at the last inspection and had been met. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. The service users at the home are enabled choice in relation to their daily living routines. Standards 12, 13 and 15 were examined at the last Inspection and there were no requirements. EVIDENCE: The Inspector was advised by the Acting Manager that service users were able to make decisions regarding choice of clothing, activities and when they got up on mornings or retired at night. Service users also received choice in relation to meals and whether or not they wished to be served in their bedrooms. Service users were observed meeting with visitors, watching television, reading or sitting quietly in their bedrooms. Others sat in groups within the communal areas listening to music, watching television or moving freely within the home. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. The home’s policy and procedures relating to complaints are within the minimum standards required. The legal rights of the service users are approriately protected at the home. Standard 18 was examined at the last inspection and no requirements were identified. EVIDENCE: The home’s policy and procedures regarding complaints were clearly stated and accessible to service users and their relatives. Two complaints were made by one relative following the last inspection. One complaint was satisfactorily investigated and resolved. The other is currently being investigated. The Acting Manager confirmed that postal voting were made available to all the service users at the home. Service users who required representatives or legal advice were referred to the social workers and a meeting, relating to these requests, would be convened at the home. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 and 25. A safe and well maintained environment is being provided for the service users and there are sufficient toilet and bathroom facilities to meet their needs. Appropriate specialist equipment are in place. Standards 19 and 26 were examined at the last inspection. A requirements made under standard 19 at the last inspection had been complied with. EVIDENCE: The communal areas within the home are spacious, comfortably furnished and suitable for shared activities or individual use. The bathroom and toilet facilities are sufficient in numbers for meeting the private and personal needs of the service users. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 14 Various aids and adaptations were in place for assisting and maximising the independence of the service users. These include a passenger lift, wheelchairs, zimmer frames, hoists, grab rails, raised toilets and nurse call systems. Pressure relieving equipment including cushions and mattresses were also in place. The service users bedrooms were attractively decorated and suitably fitted and furnished. Each reflected personal choices and interests, and service users said that they felt settled and comfortable with their allocated bedrooms. Overall, the home was found to be hygiencially clean and well maintained. The atmosphere was calm and homely and the safety and welfare of the service users was being protected. Ristrictors were fitted on windows in all service users bedrooms and environmental risk assessments had been undertaken. This was in keeping with requirements that were made at the last inspection. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. Standards 27, 28 29 and 30 were examined at the last inspection. A requirement made under standard 29, at the last inspection had been complied with. EVIDENCE: A number of personal files were viewed at random and they were found to contain all the necessary documents including CRB or Pova First certificates. This complied with the requirement made at the last inspection. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 36, 37 and 38. The Acting Manager is competent in her role and a friendly and open atmosphere is being promoted at the home. Regular supervision is being delivered to all members of the care staff and records, policies and procedures are satisfactory. Standards 33, 35 and 38 were examined at the last inspection. A requirement made under Standard 38 at the last inspection had been complied with. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 17 EVIDENCE: The Head of Nursing is appropriately qualified and was Acting Manager at the time of the inspection. The Acting Manager confirmed that the home aimed to promote a friendly, open and respectful environment in which good qualty care was provided. The Inspector was advised by the Acting Manager that the accounting and financial affairs of the home were handled at Head Office. All members of the care staff were regularly supervised. This was reflected on records seen and confirmed by staff members who spoke to the Inspector during the inspection. All records, policies and procedures viewed were satisfactory, up to date and indicated that the best interests of the service users were being safeguarded. Environmental risk assessments had been appropriately undertaken. This complied with a requirement made under standard 38, at the last inspection. Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 18 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 3 3 3 3 3 3 X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X 3 3 3 Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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.V271811.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cloisters Nursing Home DS0000010959.V271811.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!