Inspection on 18/07/05 for The Cloisters

This inspection was carried out on 18th July 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.

Other inspections for this house

The Cloisters 05/06/07

The Cloisters 06/12/05

The Cloisters 01/12/04

The Cloisters 02/08/04

The Cloisters 17/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE THE CLOISTERS 1 The Cloisters Rectory Road Rushden NN10 0HA Lead Inspector Pat Harte Unannounced 18th July 2005 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 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. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Cloisters Address 1 The Cloisters Rectory Road Rushden Northampton NN10 0HA 01933 356423 01933 397446 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Rex Smith, Mutual Homes Limited, The Cloisters, Rectory Road, Rushden, Northampton, NN10 0HA Mrs Christine Chambers CRH 13 Category(ies) of OP - Old Age - 13 places registration, with number of places THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The Home will limit its services to the following service user categories: No person falling within the category Older Persons (OP) can be admitted where there are 13 persons of category OP already in the home. The total number of service users in the Home must not exceed 13. Date of last inspection 2nd August 2005 Brief Description of the Service: The Cloisters is a care Home providing personal care and support for up to 13 Older People including one older person with mental health needs. The Cloisters Residential Care Home is owned by Mutual Homes and is managed by Mrs. Christine Chambers. The Home is located in close proximity to the town centre of Rushden and its amenities. The premises consist of a listed building set in pleasant well-maintained grounds, which also accommodate retirement flats and bungalows. The retirement flats and bungalows are managed separately from the Home and do not form part of the registration. The Home comprises of five single bedrooms and four double shared bedrooms, though currently one of the double rooms is being used as a single room. One of the double rooms is located on the ground floor. A stair lift aids access to bedrooms on the first floor however it is necessary to negotiate a few steps for access to four of the single bedrooms. Communal accommodation comprises a dining room, large lounge and conservatory. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Preparation for the Inspection took two hours and consisted of the review of the Home’s service history, the last two Inspection reports, the pre-Inspection Questionnaire and the comment cards received from nine Residents, thirteen Relatives and two visiting Clergy. The comments received were all very positive. The primary method of inspection used was ‘case tracking’ which involved selecting three Residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. In addition discussions were held with the Deputy Manager, two staff and six other Residents. A partial tour of the premises took place and a selection of records was inspected. The Inspection was unannounced and took place during the morning and lunchtime over a period of four hours. What the service does well: Senior staff from the Home carry out a through assessment of all prospective Residents and only those people who’s needs can be met in full are admitted to the Home. The Home has a stable, committed and caring staff group who work together as a team. Staff turnover is low and this provides Residents with continuity and consistency of care. Residents spoken with felt that their relationships with staff were good and that staff provided them with good care, support and encouragement. Residents are given choice in the daily menu and they felt that their likes and dislikes and special dietary needs were known and respected by the catering staff. Routines in the Home are relaxed and flexible and Residents confirmed that they were free to choose how and where they wished to spend their time. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 6 Residents are encouraged, supported and enabled to be as independent as possible and staff take care to protect their privacy and dignity when caring out personal care tasks. The general and domestic maintenance of the Home was good providing the Residents with comfortable and homely surroundings. 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. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 standard(s) 3, 4 & 5 Prospective Residents are provided with information on the Home to enable them to make informed choices regarding their placement. The pre-admission assessment is thorough and effective EVIDENCE: Individual records are kept for each of the Residents and inspection of the records showed that the assessment process was thorough with senior staff visiting all prospective Residents in order to make a preliminary assessment of their needs. Where it is assessed that needs can be met Prospective Residents and their Relatives are then asked to visit the Home, where possible, to view the potential accommodation, meet with staff and other Residents and discuss further their individual requirements. A Resident spoken with felt that he had been given good information on the Home’s services and facilities and the pre-admission visit to the Home had really helped him to make to make up his mind as to whether he wished to move into the Home. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 9 The records of the assessments are made available to staff in order that they were prepared to receive and care for them. Specific assessment tools were used to identify any risk factors such as the risks from falls or pressure care. Assessments were carefully documented and showed that Residents had been consulted on their preferred routines and that their wishes had been respected. Residents’ contracts were not accessible on the day of Inspection due to the Manager’s absence. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Residents’ physical and health care needs are met although further development is needed to ensure that emotional and any psychological needs are identified and guidance is given to staff on how to support their Residents. EVIDENCE: Residents spoken with stated that care staff took account of their personal preferences for the timings of the care routines and how they wished the care to be carried out and the preferences were documented on the individual care plans. They commented that they felt staff respected them as individuals and enabled them to retain or develop their independence as much as possible by allowing them to do things for themselves. They were satisfied in the way they were cared for and confirmed that staff protected their dignity and privacy when carrying out personal care tasks. Three care plans were inspected and it is acknowledged that action has been taken to develop the plans. The plans showed that Residents had been consulted, had agreed the routines and care delivery and had signed the plans. The plans identified Residents physical and health care needs and provided THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 11 guidance to staff on the how the care was to be provided. The timings for some of the routines were not always stated although it was clear that staff were fully aware of these. Some instructions were unclear for example a plan referred to “applying cream where needed” but did not provide guidance as to how staff were to determine the need. There were also references to the need to monitor the use of the stair lift by some Residents but no specific instructions were provided. There was little reference to Residents emotional care needs or of how staff were to emotionally support their Residents particularly through the settling in process. Records showed that staff monitor and record Residents health care needs carefully and are quick to refer any concerns to the Community Medical services. Arrangements are made for Residents to undertake routine screening and health checks. Monthly reviews are carried out and documented with changes made to the plans accordingly. The Home’s Medication system was generally in good order with medication securely held and the required records maintained. However an unsafe and inappropriate practice was noted during the midday medication round. The medication for one Resident was dispensed early; the Resident did not take the medication at the time, the practice being that she took it to her room to take later at the prescribed time of 2pm. The staff member signed the records as the medication having been administered without witnessing that this was the case. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14 & 15 Residents are enabled to control their own lives and continue to pursue their interests and hobbies. Care is taken to provide Residents with a good range of meals giving them choice and alternatives and ensuring that their likes and dislikes are respected. EVIDENCE: Residents stated that account was taken of their personal lifestyle preferences and that they could spend their time as they wished. They said that staff provided them with support and encouragement but respected their rights to exercise choice and control over their own lives. They stated that the Home had an activities programme with daily activities such as Bingo, Quizzes, Videos, Music, Exercise sessions as well as visits from external entertainers. They felt that they were supported in pursuing their individual interests. Residents confirmed that they were enabled to fulfil their religious needs if they wish. Visiting Clergy conduct Church services at the Home and some Residents attend local Churches. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 13 The Home has an open visiting policy and Residents stated they were enabled to receive their Visitors in private if they wished. Residents were positive in their comments on the food provision. They felt that their likes and dislikes were known to and respected by staff. They were provided with choices and further alternatives were made available if requested. Prior to the midday meal Residents were offered a drink of their choice from the Bar menu. The serving of the mid day meal was efficient and the food was nicely presented with the tables tastefully laid with napkins and flowers. Residents are encouraged to eat in the dining room to promote social interaction but may take their meals in the lounges or their rooms. The Kitchen was in good order. Records are maintained of the food provided. Discussions with the Cook showed that there is an emphasis on providing fresh food and vegetables and care is taken to ensure good quality meat from a family Butcher in a near by village. The Home can provide for special diets and discussions with the Cook showed that every effort had been made to provide suitable vegetarian meals for one Resident. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents are informed how to complain and processes are in place to ensure that any complaints will be listened to and acted upon. Staff were not fully familiar with the procedures for reporting abuse. EVIDENCE: Residents confirmed that they had received information on how to complain and felt that they were able to raise any issues with the staff or Manager. The Commission has not received any complaints in the last year and no complaints have been recorded by the Home. Discussions with the Deputy Manager on duty showed that she was not fully familiar with the reporting procedures for allegations of abuse although she was able to access the Home’s procedural documentation. There is a risk that allegations may not be promptly reported to the relevant Authorities. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 The Home was safely maintained, clean and comfortable and suitable for the needs of the Residents. EVIDENCE: Standards of domestic and hygiene maintenance were viewed as good throughout the Home including the bathroom and toilet areas. Residents stated that domestic routines were carefully carried through to prevent any disruption to them. The general upkeep of the building was viewed as good. Standards of décor and furnishings were of good quality, homely and comfortable. Whilst it is acknowledged that the Hall and corridor carpets on the ground and first floor are noted for replacement on the refurbishment programme this is yet to be carried through. Currently the appearance of the old and badly marked though THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 16 clean carpets detracts from the overall well maintained appearance of the Home. Specialist equipment, such as mobility aids can be obtained for Residents where necessary. Residents confirmed that their rooms were suitable for their needs and they were enabled to personalise them and have their belongings and furniture around them. Residents have access to substantial, pleasant and safely maintained garden areas and a conservatory. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Procedures for the recruitment of staff were robust and provided safeguards to offer protection to people living in the Home. Staffing levels were sufficient to meet the needs of the Residents. EVIDENCE: Residents praised the staff group highly and stated that they were sensitive and caring and responded promptly to their needs. . Discussions with the Deputy Manager and Residents confirmed that current staffing levels are sufficient to meet Residents needs, as the dependency levels are generally low. There are 2 care staff, including one of the Deputy Managers, on each daytime shift and night care is provided by1 waking night staff. The Home also employs catering, housekeeping and maintenance staff. The records relating to 2 staff members were inspected and showed that the appropriate checks and references had been obtained prior to their employment. Staff training records confirmed that new staff receive induction and on going training is provided to all staff on both core and specialist areas. 2 care staff hold National Vocational Qualifications in care at level 2, the Deputy Managers are in the process of completing their Level 3 training and 3 further carers are to undertake level 2 in September. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36, 37 & 38 The Management of the Home is overall effective, accessible and responsive to the needs of both the Residents and staff. EVIDENCE: The Manager was away on Holiday at the time of Inspection. Staff spoken with felt that both the Owner’s Representative and the Manager were easily accessible to them and that the Manager was willing to discuss any issues and guide them in practice. Supervisions and appraisal systems were in place to ensure that staff receive guidance and support. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 19 Residents felt the Manager was readily available to them and that their opinions were listened to, valued and acted upon. They stated that they had trust and confidence in the staff group as a whole. A Quality assurance policy has been developed but due to the Manager’s absence this are was not reviewed on this Inspection. The Home does not currently hold any Residents monies or valuables for safekeeping. The overall approach to the health and safety of Residents and staff was good. Records showed that staff receive regular updates in core training areas such as Fire Safety and Movement and Handling Training. There are systems in place for the reporting and addressing of any health and safety issues or risk areas. Fire records showed that the fire safety equipment and fire alarm were tested at the intervals advised by the Fire Officer and fire drills were conducted. Records were safely stored. The storage of the stair lift chairs was noted as a potential hazard. Some Residents use the stair lifts independently and several times during the Inspection the lift chairs were left at the top of the stairs. The way past the chairs is narrow and there is a potential risk of falls to Residents negotiating their way past. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x 3 3 3 2 THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 9 9 Regulation 13 (2) 13(2) Requirement All Medication must be dispensed at the prescribed times. Staff administering medication must sign the record sheet only after giving and witnessing that the medication has been taken. Further training must be provided for all care staff on the Protection of Vulnerable Adults reporting procedures. Written confirmation that this has been undertaken must be forwarded to the Commission. The Manager is to carry out a risk assessment on the siting of the stair lift chairs when not in use to eliminate the risk of falls from the narrow passageway. A copy of the assessment is to be forwarded to the Commission including the action taken. Timescale for action 25.7.2005 25.7.05 3. 18 13 (6) 16.8.2005 4. 38 13.5 30.7.05 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 C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 22 THE CLOISTERS 1. 7 2. 20 The on-going development of the care plans should include references to Residents Emotional and, where necessary, Psychological care needs giving detailed guidance to staff on how these needs are to be met. It is recommended that the hall stair and corridor carpets are replaced as soon as practicable. THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Newland House, First Floor Campbell Square Northampton NN1 3EB 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 THE CLOISTERS C51 S34509 The Cloisters V223475 180705 stage 4.doc Version 1.30 Page 24 - 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. 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