Inspection on 06/12/05 for The Cloisters

This inspection was carried out on 6th 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.

Other inspections for this house

The Cloisters 05/06/07

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 Judith Sansom Unannounced Inspection 6th December 2005 12:00 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.V271893.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. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 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.V271893.R01.S.doc Version 5.0 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 (`JW`) with care needs in the category of Mental Disorder and aged over 65 years (MD (E)). 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 five single bedrooms and four double shared bedrooms, though currently .the use of the double rooms is being reviewed with the result of offering these double rooms as singles. 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 DS0000034509.V271893.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for residents and their views of the service provided. The methodology of case tracking is used to find out if the care being provided to the residents is of an acceptable standard and meets their individual needs. ‘Case tracking’ involves the review of resident’s records, meeting with them and talking with the care staff that provide the personal care to the selected residents. The inspection also includes a review of the homes’ procedures and processes to ensure that all practices carried out by the staff protect the residents. The inspection process includes the collation of information from residents, relatives and visitors to the home. The manager submits a completed preinspection questionnaire. From these information sources an inspection plan is developed. The inspection in the home was carried out on an unannounced basis during the late morning and early afternoon. The inspection process that included the preparation and inspection took approximately four hours. Compliance by the manager to action previous requirements placed at the inspection 18th July 2005 was reviewed as part of the inspection process. What the service does well: Staff and residents were welcoming, which resulted in a homely atmosphere. People living in their own flats and bungalows within the complex are invited to join with the residents for their mid-day meal. Both the residents and visitors expressed how they enjoyed this sharing of a meal, and how they also enjoyed being able to join in any other activities if they chose. The home and surrounding gardens continues to be maintained to a good standard. The staff group is committed with very few changes giving continuity and consistency to the care of the residents living in the home. The interaction between the staff and residents was friendly and open, and residents spoke of ‘how marvellous all the girls were’. All staff are expected to be committed to training, with a high number having achieved or working toward an NVQ (National Vocational Qualification). Routines in the home are flexible and built around the needs of the residents. Residents spoke of their on going interests and how the staff in the home help The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 6 them to decide how they want to spend their time. One resident spoke of attending church groups, the Womens’ Guild and the library. One resident stated, “The home is marvellous, I have never been happier.” 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 DS0000034509.V271893.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 The Cloisters DS0000034509.V271893.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): 3 & 4. Standard 6 does not apply to this home. The home has a pre-admission process that involves in meeting with the potential residents to provide them with the opportunity of gaining information about the home. This enables each prospective resident to be able to make informed choices about the home. The pre-admission process of all potential residents to the home is well managed. EVIDENCE: Written information in the resident’s files confirms that the admission process is taken seriously. Meetings are arranged including visits to the home and residents are provided with essential information about what they can expect if they decide to live in the home. Residents confirmed that they had been involved in this process, and that they were happy to have made this choice. The Cloisters DS0000034509.V271893.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, & 11 Although care records require some additional development the current practices in the home ensures that health care needs of the people living there being met. EVIDENCE: The care plans have been further developed since the last inspection with the addition of pertinent information relating to residents’ emotional and psychological needs. Contained in the front of the care plan is a record of the personal care needs of the resident and the times they prefer these needs to be met. Information recorded on one file identified that a male carer was preferred when personal care was being given. Steps must be taken to ensure that the records identify how the resident chooses their care to be provided and their personal preferences and choices. For example if personal care in the form of bathing is to be provided, how this activity is to be undertaken that maintains the resident’s personal routines. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 10 One resident spoke of how the manager will take them to the doctors’ whenever necessary, and to any other appointments that have been made, for example to the hospital. Since the last inspection one resident who was terminally ill has died. During the last few weeks of this resident’s life the family and the resident requested to remain at the home to be looked after. All care was provided to the resident to make their last days as comfortable and dignified as possible. Correspondence from the bereaved family confirm the way in which the staff in the home cared for this resident, that it was provided in a sensitive, dignified and personal manner. The Cloisters DS0000034509.V271893.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): 12, 13, 14 & 15 Resident’s views are sought and acted upon in respect of their daily lives, and residents are provided with a variety of choices to empower them to make choices about maintaining contact with families, friends and the wider community. This action promotes the independence and freedom of choice for all residents. EVIDENCE: Residents talked freely about their experiences whilst living in the home. All residents were very positive and constructive in their comments. Their comments ranged from the way in which their individual likes and dislikes are taken into account with the meals provided in the home to the activities they are involved in both inside and outside of the home. One resident who enjoys walking down to the town to see old friends and acquaintances and ‘having a gamble when I want’ described how the staff help him to remain as independent as possible. One resident talked about having made friends with a person who lives in the flats in the same complex and how they meet up. This starts at the beginning of the day by them shining their torches to each other out of the window to The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 12 make sure that each of them is ok. Staff are proactively encouraging this friendship and the friend is invited into the home whenever she chooses. The registered manager is encouraged to extend the range of activities that are offered to ensure that they are person centred and where possible to provide the opportunities for these residents to either learn new skills and interests or to maintain past hobbies and interests. All residents were very positive in their comments about the food in the home, including the quantities and the variation of menu. The menu provides a wide choice and a daily alternative for the residents. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 13 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): 17 & 18 Residents’ prerogative to pursue their legal rights is facilitated within the homes’ management structure. EVIDENCE: The commission has not received any complaints regarding this home since the last inspection. Within the residents’ files was information relating to their right to vote. Further information is available regarding independent advocacy. One resident said that if they wanted to see anybody, like a solicitor, they would be able to meet with them in the privacy of their own room. Review of the homes’ policies and procedures in relation to the reporting of an allegation or suspicion of abuse identified that the home is in receipt of the locally agreed strategies with the Northamptonshires’ Protection of Vulnerable Adults team. However the homes own policies and procedures would benefit from the inclusion of additional information and clarification of the steps to take in the event of an allegation of abuse being made. There is detailed information relating to the identification of abuse, but it is insufficiently clear in instructing the staff how to initiate the necessary steps and what would be expected of them if the manager were unavailable. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 14 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): 20, 23 & 26 The environment provides safe comfortable surroundings and is maintained to an acceptable standard. EVIDENCE: Residents’ rooms were individually designed to maintain the personal choices of the residents. Where double rooms are being used as single rooms, these have a room divider in place with the result that the resident his provided with two separate areas within their room. The residents spoken with clearly enjoyed this layout and felt that they had a living room as well as a bedroom. All areas in the home were pleasant, clean and hygienic. Clearly the domestic staff take their duties seriously, and maintain a very high standard. Residents commented on the way in which the staff look after their bedrooms, and how pleased they were. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 15 The registered person is continually reviewing the condition of the home to identify any areas that are in need of redecoration or replacement. As a consequence ongoing maintenance is in place both externally and internally with bedrooms and communal areas being redecorated as needed. The registered person is strongly encouraged to review the condition of the carpet on the stairs and hallways of the home. Where these have received frequent cleaning there are areas of carpet that are bubbling, this could be a potential trip hazard. One join in the first floor hallway carpet needs to be reassessed to ensure that it will not cause a trip hazard. The condition of the carpet on the stairs and hallways has been spoilt by bleach spillage, and tar being walked in from the driveway. Enquiries from carpet specialists should be made to ascertain whether any action could be taken to make improvements to these areas. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 16 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): 27, 28, 29 & 30 Staff morale is high resulting in an enthusiastic workforce that works positively with the residents to improve their whole quality of life. EVIDENCE: Residents spoke very highly of the staff, making comments like ‘all the staff really care for us’, ‘they give us anything that we want’, ‘staff are marvellous’. The staff group are committed to caring for the residents and have a good rapport between the residents and themselves. Training is ongoing with a detailed induction for any new members of staff. There is little change in the staff group that maintains a stability and consistency in care towards the residents. The manager who identifies any training needs ensures that the necessary training is provided. A high number of the staff have attained an NVQ (National Vocational Qualification). Currently there are only 7 residents living in the home. However there has been no decrease in the staffing levels. This has resulted in the staff being able to spend more time with the residents meeting their individual needs. Records confirm that the manager prior to new staff commencing work at the home has undertaken the necessary employment checks. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 17 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, & 38 There is good leadership, guidance and direction to staff from the Registered Manager that ensures the residents receive consistent quality care. EVIDENCE: The manager has been in post for a number of years and has substantial experience and knowledge in the running of a care home. Staff and residents confirmed that the manager was approachable and that they could discuss any issues with her, confident that she would take appropriate action to address any concerns. The home does not undertake the responsibility of managing any of the residents’ monies. One resident talked of how their friend has taken on their The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 18 responsibility, and how this has made him feel very independent and in control. Through the managers’ oversight all staff receives the appropriate health and safety training, and staff accept that it is everybody’s responsibility to identify and issues and make the situation safe if necessary. The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 19 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 2 8 3 9 X 10 X 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 X 17 3 18 2 X 3 X X 3 X X 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 X X X X X X 3 The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 20 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. 1. Refer to Standard OP7 Good Practice Recommendations The on-going development of the care plans should ensure that where care is provided there is sufficient detail that instructs and guides staff in the manner that the resident wishes the care to be provided. All policies and procedures should be reviewed to ensure that they contain sufficient and instruction for all staff to take in the event of an allegation or suspicion of abuse occurring. It is recommended that carpet specialists are contacted to give advice on the way in which the hall stair and corridor carpets could be improved, taking into consideration the bubbling, the joining of two carpets and the staining. 2 OP18 2. OP20 The Cloisters DS0000034509.V271893.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House 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 DS0000034509.V271893.R01.S.doc Version 5.0 Page 22 - 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. 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