Inspection on 05/06/07 for The Cloisters

This inspection was carried out on 5th June 2007.

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 06/12/05

The Cloisters 18/07/05

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 Northants NN10 0HA Lead Inspector Mrs Bhavna Keane-Rao Unannounced Inspection 5th June 2007 10:30 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 The Cloisters DS0000034509.V337862.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. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cloisters Address 1 The Cloisters Rectory Road Rushden Northants NN10 0HA 01933 356423 01933 397446 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) Mutual Homes Limited Mrs Christine Alexander Chambers Care Home 12 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (11) The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of beds registered in the home must not exceed 12. Eleven service users who have care needs of Old Age (OP) and one named service user with care needs in the category of Mental Disorder and aged over 65 years (MD (E) 20th April 2006 Date of last inspection Brief Description of the Service: The Cloisters is a care home providing personal care and support for up to 12 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 six single bedrooms and three double bedrooms. 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 manager provides, upon a request or enquiry, an information pack, which includes residents guide and statement of purpose. On 5th June 2007 The Registered Manager confirmed that the fees had been increased to £389.00 per week person. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the last Inspection Report, reviewing of the pre-inspection questionnaire, the service history of significant events since the last inspection and Comment Cards sent to residents from the Commission for Social Care Inspection. The unannounced site visit commenced on the 5th June 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the residents. The method of inspection was ‘case tracking’. This method involves identifying individuals who currently live at the home and tracking the experiences of the care and support they received during the time they have lived there. Three residents were selected and discussions were held with them. The method of case tracking included the review of residents’ individual care records, discussions with staff with various responsibilities within the home and reviewing the records, training records and the minutes of team meetings. The inspection was also used to check that information provided by the manager matched the individual experiences of residents. This was achieved by speaking with residents, manager and care staff who were on duty whilst observing day to day care practice. Other residents were spoken with and observed although they were not part of the ‘case tracking’ process. Commission for Social Care Inspection sent out ten Comment Cards called “Have your Say about…” to residents and also to their relatives. This is a way of collecting views from people who use the services. Of the ten cards 2 residents and 3 relatives returned them to CSCI. All the responses were generally positive about the care provided at The Cloisters and the home environment. What the service does well: The residents are provided with individually tailored care. All the people who were spoken with were very positive about the home and the staff who help provide the care. The food provided at the home is freshly prepared daily. All the people at the home stated that the food was ‘very good’ and were full of praise for the cook. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 6 One person stated, “ When I moved to The Cloisters home I thought I would miss my home terribly, but I don’t miss it as much as I thought, as this so much like my own home” Another person stated, “We have a choice of male/female care staff, although they are all ever so discreet and sensitive” Comments incorporated within Relatives Comment Cards and direct comments included: “When I first came here and saw that at the front it said ‘Rushdens finest’ I thought how big headed. But having lived here and received the quality of care I would have to agree with this statement of fact” “I feel the care home looks after the welfare and medical needs of the residents very well” “They have good staff who provide good standard to care” “The home is just like my home” What has improved since the last inspection? What they could do better: All the residents who were spoken with were asked this question and they all said, ‘nothing.’ Relatives were also asked this in the Comment Cards, they responded with: “Do not think they can as they do a very good job” “Transport could be arranged with no fuss made” The manager stated that this has never been raised as an issue by anyone but that she will monitor and review if needed. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 7 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. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 8 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 The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Standard 6 is not applicable. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager and her staff ensure that new residents’ care needs and aspirations are assessed before admission to the home. EVIDENCE: “ We were given a lot of information about the home and what we should expect when we got there” People who are considering whether to move to The Cloisters are provided with relevant information such as a brochure and a Service User Guide. The initial three months of stay or a ‘period of mutual assessments’ are used to see if both the resident and the home are happy and to review any changes in care needs. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 10 The manager carries out an assessment. One resident stated “the manager visited me at the hospital before I came to live here” If the home is able to provide care for the person then an initial action and routine plan is drawn up. Two people spoken with stated that this was the procedure followed by the staff when they moved to the home. Records demonstrated this to be the case. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are well cared for, their health and daily care needs are met through improved care planning. There is an efficient medication system in place. EVIDENCE: The care plans and records of three residents were well written and presented to a good standard and have significantly improved, to guide staff to provide the care needs. Residents now sign these care plans when they are reviewed and or up dated. All the resident spoken with were aware of their care plans however one person stated that he did not like this but realised that it was necessary. The care plans were personal to the resident, setting out some history and background of the resident, the level of assistance required, specific dietary The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 12 needs, observance of religious or spiritual practices, social interests and choice of male or female carer and involvement of family. The medication Records Sheets were viewed and staff were observed giving out medication to the residents. This was satisfactory. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good 12, 13, 14 and 15. This judgement has been made using available evidence including a visit to this service. Residents benefit from a flexibly run home, which enables them to make a positive choice about daily living. They are offered a variety of meals and social activities of interest to suit them. EVIDENCE: All the residents spoken with stated that they can generally do what they want when they want. The care plans provides staff with information as to resident’s preferences, hobbies, religious beliefs and interests, which are then incorporated into their daily social activities. Resident’s relatives are always welcomed into the home. One resident stated, “As my son enters the home there is a coffee that follows him and is there as he sits down” The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 14 All the residents were full of praise for the cook. One person said, “The food is absolutely fantastic. Do you know they don’t even have a food budget?” The manager confirmed this to be the case and stated that what residents wanted to eat they got. Residents confirmed that drinks and snacks are available upon request. The meal observed was a relaxed informal gathering where there was light banter and discussion of daily news. Tables were set with glasses of wine, juice, water and sherry. Residents were observed going into Rushden during the day and coming back for lunch. The residents received other visitors. Records are kept of resident’s involvement in activities, which was consistent with the programme of activities and information received directly from the residents and staff. Staff were aware of their duties in relation to key-working and doing specific activities with the residents. There are regular meeting to obtain the views of residents regarding activities, held in January 2007, and Food preference meeting, held December 2006. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff who are trained in safe guarding adult processes. EVIDENCE: Residents who were spoken with were confident that should they have any concerns, whom they should speak with, in addition there is a written complaints procedure. The home has not received any complaints since the last key inspection in April 2006. The Commission has received one anonymous complaint in January 2007. This was regarding staffing levels. The manager refuted this. On the day of the site visit Staff rotas were checked and the number of staff on duty demonstrated there were always at least two care staff and the manager. They were able to provide for the care needs of the residents at the home. Residents who were spoken with also stated that there were enough staff on duty to meet their care needs. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 16 Staff demonstrated a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff files examined contained evidence to show that they have received training in safe guarding adults. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: A resident said: “This is the most loveliest homely place. It is a home from home” All the residents who were spoken with were very positive about the home and the surrounding environment. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 18 The hallway has recently been re-carpeted and redecorated. Some of the communal areas have been decorated, as were some of the bedrooms. They were all found to be clean and well maintained. A member of staff was observed ensuring that the lounge and the dining area were ready for use after breakfast. All the bedrooms viewed, with permission from the residents, were personalised to reflect their interests and personal history. Residents were observed moving around the home and coming and going out of the home without any restrictions. The Registered Manager said further refurbishment of the home is planned. The laundry room is on the ground floor, away from resident’s bedrooms, lounges and kitchen area. A member of staff is responsible for the cleanliness of the home and the laundry. One resident said that all her “delicate and woollen clothes are always hand washed.” Another person stated, “I take my clothes off at night and in the morning they are back all nice and clean.” The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment processes and are trained to ensure the care needs are met sensitively and safely. EVIDENCE: The residents spoken with stated: “The girls are so lovely here” “They can’t do enough for us” The Cloisters employs sufficient staff to meet the needs of residents. The staffing ratio is that there are always two care staff all day time hours. In addition the manager and the providers work at the home. There is a domestic person on duty during the day. Observations made during the site visit indicated that there were sufficient staff on duty to support and interact with residents. One complaint was received about staffing levels within the home. This is included in the Complaints section. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 20 The recruitment and selection procedure in place is robust The files of three staff were viewed and all files contained thorough pre-employment checks including mandatory safety checks, a completed application form and two written references. The Registered Manager submitted to the CSCI information as to the staff training before the site visit, in addition training records were viewed on the day of the site visit. The details demonstrated a good skill-mix of staff to meet the needs of the residents at The Cloisters. Staff were aware of their roles and responsibilities, where to find the home’s procedures and who to report any concerns to. Staff said they felt totally supported by the Registered Manager. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents benefit from a well managed home with good leadership, having opportunity to shape and improve the service, whilst ensuring their health; safety and welfare are promoted. EVIDENCE: Residents spoken with were aware who the manager was and what her role and responsibilities were along with the roles and responsibilities of staff and providers in the home. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 22 The residents were very confident about the management of the home and having a say in the way it is run. Residents were adamant that there is nothing in the home that they don’t know about and have a view on. Residents and the manager stated that people at this home ensure their views are heard and acted on. Quality system is in place and results of the these are made available during the site visit. This is in form of questionnaires to residents and their relatives and the Activities Meeting and Food Questionnaire. Reviews of number of falls in the home are also undertaken at a regular period to ensure that residents are safe and only acceptable risks are taken. For example during September 2006 and January 2007 there were four falls recorded as a result of an ‘error on residents part.’ A number of ‘thank you’ cards were viewed during this visit, evidencing residents’ and relative satisfaction in the care The Cloisters provides. Residents and staff records viewed were kept in good order, comprehensive, up to date, stored securely and were available for the purpose of the site visit. Staff were aware of where information, incident and accident record, policies, and procedures are kept. Assessments of risk for falls and moving and handling were carried out and in the care files for all the residents. The Pre Inspection Questionnaire detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, central heating systems and emergency call systems. Almost all the Requirements and recommendations from the last key inspection were met. However on the day of the site visit the testing of electrical equipment was still outstanding. The manager was able to contact an electrician and was able to arrange for a visit during the week beginning 25th June 2007. The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 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 3 3 3 X 3 3 3 3 The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 24 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 The Cloisters DS0000034509.V337862.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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