Inspection on 01/02/07 for Nazareth House

This inspection was carried out on 1st February 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

Nazareth House 10/06/10

Nazareth House 21/08/07

Nazareth House 12/10/05

Nazareth House 05/05/05

Nazareth House 28/02/05

Nazareth House 22/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nazareth House 162 East End Road East Finchley London N2 0RU Lead Inspector Karen M Malcolm Key Unannounced Inspection 1st February 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 Nazareth House DS0000010519.V313322.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. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address 162 East End Road East Finchley London N2 0RU 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 8883 1104 020 8444 3691 The Congregation of the Sisters of Nazareth Mrs Anne Fenlon Care Home 89 Category(ies) of Old age, not falling within any other category registration, with number (89) of places Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Fifteen specified service users who have dementia may remain accommodated in the home. The home must advise the regulating authority at such times as any of the specified service users vacate the home. 12th October 2005 Date of last inspection Brief Description of the Service: Nazareth House is a long established residential care home providing a home for eighty-nine people over the age of 65. It is owned and operated by a Roman Catholic order of nuns The Congregation of the Sisters of Nazareth who are the registered providers. There is a very strong Catholic ethos in the home, including a chapel where Mass is celebrated daily. Service users from other religious and cultural groups are admitted and assisted to maintain contact with their religious and/ or community groups. Nazareth House is a large home split into a number of annexes named after Saints. There are a number of bedrooms with en-suite facilities and those bedrooms without en-suite facilities have bathrooms facilities close by. Nazareth House with its spacious grounds offers peace and tranquillity and it is practically situated with ready access to shops, post office and local transport. Ample space is available in the grounds for a leisurely stroll along specially made pavements around the garden, providing an atmosphere where independence is encouraged. The home is light and bright with appropriate adaptations and equipment. The home is divided into a number of separate units. Staff generally work on the same unit so service users receive care from the same staff. Each unit has a separate dining area and lounge. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The cost of placements is £536 to £589 per week. Additional cost are for: Hairdressing, chiropody and nail care Following “Inspecting for better lives” the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 1st February 2007 as part of the annual key inspection programme to identify progress with previous requirements and to check standards of care against the key standards. The CSCI Pharmacist Vashti Mahajah inspector accompanied the lead inspector. The inspection took approximately seven hours to complete. The inspection involved sampling care plans, examining policies and procedures and completing a tour of the building. The inspector spoke to four service users independently, seventeen staff members in a group and observed staff interaction with service users. The manager assisted the inspector throughout the inspection; this was found to be positive and open. The inspectors were very impressed by the home and the high standards of care provided. This was reflected in the care practices seen by the inspectors, record keeping, and comments from the service users and staff spoken to on the day of the inspection. The feedback comment cards received from the service users and relatives and friends showed a majority of positive comments relating to the excellent care received. A number of Standards in this report receive a grading of excellent and the service is commended for this. The inspectors would like to thank all the manager, staff and service users for their time and co-operation during the inspection process. What the service does well: The home has a comprehensive pictorial statement of purpose and service guide to enable prospective service users to make decisions about the home. The service users benefits from having detailed assessments of need in place, individual plans are reviewed monthly. These are comprehensive providing a holistic view of the individual that staff are able to follow and provide continuity in care. This is supported by service users who said ‘the staff are very kind, caring and know what I like’. Risk management strategies are detailed ensuring the safety of service users. Social and personal health care needs are met by a variety of health care professionals. The food provided in the home is fresh, hot and well balanced to meet the needs and preferences of service users. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 6 Service users know how to complain and have been given the relevant contact information to enable them to complain both internally and externally. Quality assurance audits ensure service users views are listened to and acted upon. Staff morale is good which promotes good positive team working and consistent practice for service users. The environmental conditions are calm and serene. The health, welfare and safety of service users are protected through regular health and safety checks. Service users benefit from a competent organised manager and staff team 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. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 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 Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is assessed prior to admission and express confidently that their needs are met. Intermediate care is not provided in the home. EVIDENCE: Full assessments undertaken by the social workers were in place alongside the home’s own assessment of care needs for each individual service users. It was evident that assessments seen by the inspectors were very impressive, clear; detailing individuals care and support needs and ensuring that the information gathered was cross-referenced into individuals’ care plans. The care plans also include specialised services offered by the home with clinical guidance for care staff to follow regarding a users care. This demonstrates good care practice. The inspectors commended the manager on the care plans. Service users confirmed the receipt of the service user guide and statement of purpose stating that they ‘gave a clear indication of what is provided in the home, what the rooms look like, where they can eat, activities provided and the staff provided. It is the opinion of the inspector that the home ensures Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 9 that the admission procedures are followed through consistently with each admission to the home. This is seen as good practice and commended by the inspectors on the day. At present the home is supporting seventy-nine service users and carrying ten vacancies. The discussion of sexuality was raised with the manager, regarding meeting prospective service users needs and how this is completed in a sensitive way. It was recommended that sexuality training for all staff is needed to address this matter sensitively. The home does not provide immediate care. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9,10 &11 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The home has a strong ethos of involving service user in all aspect of their life. All service users have a robust care plan. The home has effective systems in place to ensure the care plan is reviewed and updated monthly and arranges additional reviews when changes take place. However, monitoring and reviewing of care plans have not been consistent therefore information may be either out of date or needs updating to ensure service user obtain the best care package. Procedures are in place and being followed for all aspects of medication handling, all medicines were in stock, records of receipt, administration and returns were accurate, staff have had appropriate medicines training, including yearly refresher training, and residents have regular access to their GPs. EVIDENCE: The inspectors requested seven care plans. However, four care plans were examined carefully. Care plans were very well presented and demonstrated that service users benefit from the home having a clear, consistent understanding of their health, personal and social care needs. Individual plans Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 11 were excellent, they were detailed, reviewed monthly and intervention had been sought from multidisciplinary teams. Appropriate detailed risk assessments were in place to safeguard service users, for example risk of falls, nutrition, mobility, pressure care and water-low assessments. The manager stated they have been in contact with Barnet Health Authority regards managing falls’ in the home. A copy of the ‘falls’ registered for December and January was shown to the inspector. One service user had a number of falls over the past two months. On the 28th January 2007 a specific service user had another fall resulting being taken to hospital. The manager stated that since the service user’s returned, the falls register and risk assessment had been updated. This was evident. However, the action taken by the home is that the specific service user now needs constant supervision and one to one support at all times. This was not addressed fully on the specific service user’s care plan examined. It was advised that this specific service user’s care plan must be updated fully to reflect their current changes and support needed. There was evidence that the privacy and dignity of service users is taught during induction and given a high priority. Staff were observed to knock before entering private rooms, offer choice before helping a service user and interact with service users in a friendly and professional way. Examinations by health professionals and discussions with other advisers are carried out in the service user’s own room. The service users have access to a number of support agencies such as district nurses, pharmacist, occupational therapist when needed, chiropodist who visits monthly, optician who visits twice annually and dentist. The daily reports are written on A4 lined paper, although some were had the service users name at the top of the sheet others did not. It was the opinion of the inspector that the registered manager should review the format to ensure that the information pertaining to daily information could be more precise and clear. Risk assessments are undertaken. A number of care plans risk assessments seen related to health issues. This was discussed and it was advised that risk assessments must also include activities undertaken by service users such as going on the mini bus, going shopping and any activity participated by individuals’ inside or outside the home. This is to include how service users are supported. The risk assessment format had a scoring system displayed on the left side of the form. However, this was not being used. This was also discussed and it was suggested that the manager should review the format as to whether or not this section is useful. Weight charts are completed monthly. On the charts examined two service users had lost or gained weight within a couple of months. The information recorded was ‘satisfactory’. The manager stated that she has addressed this with the staff team and on that occasion a specific service user weight records showed that the individual had lost 12lbs in one month. The manager reNazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 12 weighted the service user. It was found that the specific service user had not sat properly on the scale. The inspectors’ case tracking this specific service user’s care and health notes, no information with regards to this information was recorded. It was advised that the information recorded on the weight charts and health care notes must be specific as to why an individual may have lost or gained weight and what action is/are to be taken to support individual. Key workers undertake monthly reviews. However, these were found to have the same information recorded month after month. Therefore it was not evident whether the service users’ needs were being appropriately supported each month. This was especially worrying as the specific service user who had lost weight, and another had a number of falls. This was discussed with the manager who stated that she is going to review the monthly report with the staff team. Supplies of all medicines listed on the medication administration charts were available. All records of administration, receipt and returns of medicines were inspected and were accurate. The district nurse keeps separate records at the home for injections given/dressings applied. The GP visits weekly and all residents have a review every 8 weeks. The supplying pharmacist provides a good service and training for staff. Storage facilities are good and temperature-monitoring records show that medicines are stored at the correct temperatures. The home makes safe provision for supplying medicines to residents when away from the home e.g. on holiday. Staff have received external and in-house medication training. From inspection of records and discussions with staff, this training has been effective. One person signs for administration although a second member of staff witnesses it. Witnessing is only necessary for controlled drugs, and shouldn’t be necessary for regular medicines if staff are appropriately trained and feel confident to administer medicines alone, however the home is free to implement any extra checks they feel are necessary as long as two members of staff are always available, to avoid any delays in administration. One resident has their medicines crushed to aid swallowing. This has been authorised by the prescriber and next of kin. There are medication profiles in place for some residents listing the medicines each resident is on and the start date. It is good practise for medication profiles to also list the stop dates and dates any changes are made as well as what each medicine is for and common side effects. This is necessary Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 13 so that staff are aware of what all medicines they are administering are for and also to be able to spot any potential side effects. Those residents who have the capacity are encouraged to keep and take their own medicines. Secure storage is provided in their rooms although it was noted that some items are not kept locked e.g. creams, inhalers. Risk assessments are in place for these residents and are reviewed monthly to ensure residents are still able to manage. One resident had a medicine in their room dated October 2006. Although this had not expired, it is recommended that all medicines are replaced on a regular basis even if not used. Some items with a finite shelf life after opening (eye-drops) did not have the date of opening added. This must be added to ensure stocks are replaced on time to avoid bacterial contamination. A requirement has not been left as all other items did have dates of opening however this should be checked as part of the homes regular medication audits. There is separate secure storage for controlled drugs and all current records of administration were accurate. Some historic records of returns were not accurate; as staff/pharmacist had not signed when controlled drugs were returned. This is needed to provide a complete audit trail. It is recommended that a note is made in the register that these medicines were returned. It is also recommended that the index is used at the front of the CD register to record all of the CDs currently kept, the residents name, and the relevant page numbers. The wishes of service users in connection with spiritual rites and functions including funeral arrangements were detailed on service user plans. A number of care plans have a Resuscitation consent form on file, which is either signed by the service user or their next of kin. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is excellent. This judgement has been made using evidence gathered both during and before the visit to this service. Service users benefit from the provision of good entertainment and have a satisfactory social life within the home. Service users maintain family contact and participate in various planned activities in house and in the community on a weekly basis. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The home has a number of activities planned. A copy of the timetable was displayed on each service users notice board in the home. The home has an activity co-ordinator and an activity room, where service users can participate in arts and craft sessions. The manager stated that the home now produces a monthly newsletter of activities planned within the month. The newsletter also gives brief information on service users who had recently past away, staffing information and birthdays. A copy is given to each service users. Service users are asked whether or not they would like their birthday or other information published. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 15 Service users are able to exercise their choice as much as they are able. Most service users manage their own money. None of the service users are subject to ‘Power of Attorney’ or ‘Guardianship Order’. Service users receive visitors in their room or in a choice of lounges scattered around the home. Information regarding visiting is given to service users and their representatives on admission and is included in the service user guide. Service users’ decisions not to receive visitors are recorded as necessary. The service users are encouraged to maintain links with the local community, including visits to local shops, cafes and pubs. There was evidence that family and friends visit service users. The inspector saw a number of visitors visiting on the day. There was evidence that service users receive a varied and nutritious diet. Snacks and drinks are available throughout. Special therapeutic diets, e.g. diabetic and low fat are provided. No service users currently accommodated require culturally specific food though this would be provided on request. Meal times were unhurried and staff were observed providing assistance in a sensitive and appropriate manner. Service users spoken to confirmed this. Service users also said the food at the home was excellent and that they had a choice of menu. Staff in the kitchen areas wear appropriate protective clothing. Copies of the menus were sent to the inspector prior to the inspection. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Service users know that their views are listened to and acted on. Service users are protected and safeguarded by care staff that are aware of how to recognise the different forms of abuse. Therefore the service users are confident and feel safe in their needs will be protected by the home. EVIDENCE: Since the last inspection there has been no complaints recorded. The inspector saw evidence that service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self- harm. An appropriate procedure for recording complaints, and a complaints book were available within the home. Prior to this inspection the Commission had not received any complaints. A detailed adult protection policy, including guidelines on whistle blowing, alongside the local authority’s adult protection policy were available. Staffing records show that all support workers have undertaken adult protection training. Nazareth House DS0000010519.V313322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a safe well-maintained environment; bedrooms are spacious and personalised to meet individual needs a place they can call home. The home is warm, comfortable, clean, pleasant and hygienic. EVIDENCE: Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 18 The home is a large home divided into nine areas, all named after Saints. The home has a number of dining areas, large and small lounges and small quiet rooms for service users to sit at their own leisure. There is a large hall at the front of the home, which is used for large meetings and other entertainment. The home also has access to a Catholic church that holds daily mass. The home is situated in a residential area close to a small group of shops and accessible by public transport. All parts of the home are well maintained, decorated and furnished to a high standard. There is a large, accessible and well-kept grounds. CCTV is not in use. A number of the bedrooms have en-suite facilities and those that don’t have en-suite facilities, shared facilities are nearby. All bedrooms are spacious. There is a main kitchen area, which caters for the whole of the building, based on the ground floor. The gas, emergency lighting, electrical installation and portable appliance testing and legionalla certificates were in place. The home is warm and inviting, service users spoken to express their delight in living in the home and felt their needs are addressed well. One service user stated that they were able to bring to the home a number of their personal items and this has made their bedroom feel and look homely. Since the last inspection new fitted cupboards in three dining rooms have been fitted and new windows in the Chapel. There are written infection, cleaning, laundry and hand washing policies and procedures. Washing machines have a sluice facility and heat water to the required temperature. The home was very clean, hygienic and free from offensive odours throughout. Nazareth House DS0000010519.V313322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Staff morale is high, resulting in an enthusiastic workforce that works positively with the service users. Service users are supported and protected by the home’s recruitment policy and practices. Therefore service users benefit from a well support, competent and trained staff team. EVIDENCE: The home supports a large staff team consisting of the a manager, senior care workers, care assistants, receptionists, administrators, cooks, kitchen assistants, dining assistants, domestics, laundry assistants and handy persons There were sufficient numbers of staff working at the home on the day of the inspection. The staffing numbers and skills mix of qualified/unqualified staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home at all times. The home is divided into separate units and staff generally work on the same unit to ensure consistency of care. The home operates a key-worker system. At the last inspection it was required that the registered person must ensure that one member of staff who had a transported their Crinminal Record Bureau certificate (CRB) from their previous employer, reapply for a CRB. Prior to this inspection a copy of the staff list which included each staff CRB number was submitted to the Commission along with a copy of the CRB completed from the specfic staff members who CRB was undertaken by their previous employer. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 20 The Pre-Inspection questionnarire included a list of all staff and volunteers CRB. It was reccomended that the home should undertake CRB checks every three years as this is good practice. Four staffing records were examined. All personnel records had the appropriate information as required under Regulation 19 Schedule 2. The home has a clear policy and procedures in place with regards to training. A list of all staff training undertaken was on listed. The inspector was able to interview approximately seventeen staff on the day. It was evident from the discussion that the staff spoken to were very positive about the home, the service users and the their roles and responsibilities. Staff spoke very highly of the manager. Staff were also positive about the training they had received, this included NVQ training and on-going training. The manager showed the inspector the induction-training format, which meets with the Skills for Care requirements. It is evident that over 50 of the staff team have undertaken NVQ level 2 and above, the inspector commended this. Nazareth House DS0000010519.V313322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using evidence gathered both during and before the visit to this service. Service users continue to benefit from living in a home, which is run in an organised and open manner by a competent manager. Service users are consulted regularly to ensure that the home is run in their best interests. Additional feedback from external stakeholders and a summary of the audits is benefiting service development. Staff are appropriately supervised. The health, safety and welfare of service users is promoted and protected. EVIDENCE: Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 22 The registered manager is competent and experienced and has created a very well run and organised home, for the best interests of the service users. The manager has been in post for approximately three years, however has worked in the home for over twenty years. The inspector observed during the tour of the building that the registered manager displayed an open and positive approach this was reflected in the general atmosphere within the home. Discussions with staff and service users indicated that the manager was seen as approachable and supportive. Seventeen staff spoken they all expressed that the registered manager and their direct line managers were open, approachable and always welcomed discussion about the service provision. Staff stated ‘ I like working here, it’s a bit like being in a family’. ‘We work in a friendly atmosphere and any issues get addressed quickly’. Staff felt the training they received was good and they have undertaken a number of training courses. Newly employed staff also expressed this too. All stated they receive regular supervision and regular team meetings. The service users were a joy to work with and staff morale was good as they all worked well as a team. The ethos of the home is service user centred and that the staff approach is in keep with this, when they are assisting a service user with their personal care and daily support needs. Four service users were also spoken to individually. One service user quoted ‘that Nazareth House is a ‘Home’. All service users spoke positively about the comfort of the home, staff, the manager and the overall support and services they received, which they all had the highest praise for. The home has a file of all the compliment cards received and quality assurance questionnaires undertaken. The outcomes were very positive. The home is commended on the upkeep of the quality of the care provided to the service users on a daily basis. This has been reiterated to the inspector by staff and service users each time an inspection is made. Nazareth House DS0000010519.V313322.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 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 3 17 X 18 3 4 X X X X 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 3 X 3 X X 3 Nazareth House DS0000010519.V313322.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. 1. Standard OP7 Regulation 15(2)(b) Requirement Timescale for action 28/03/07 2. OP8 17(1)(a) Sch 3.3(m) 3. OP8 17(1)(a) Sch 3.3(o) 13(4) The registered person must ensure that the information recorded on the monthly reports is accurately reflected in the individual service users overall care needs support for that particular month. The registered person must 28/03/07 ensure that service users monthly weight charts, accurately reflect why the individual may have lost or gained weight during that period. The registered person must 20/03/07 ensure that the specific service user who recently returned from hospital after a fall, their risk assessment must be updated to reflect what the changes have occurred and what action/s is/are being supported by the home on a daily basis to ensure the individual is safe. Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 25 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. 2. 3. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations It is recommended that the registered person should provide sexuality training for all staff. It is reccomended that the registered person should review the risk assessment scoring section and the daily report format. The registered person should ensure that medication profiles are available for all service users, are up to date, and include start/stop dates, dates any changes are made, what each medication is used for and common side effects. The registered person should ensure that the index is used in the controlled drugs register listing all the controlled drugs kept, the names of the residents, and the relevant page numbers, and that a note is made in the register regarding historic returns which were not signed for by the pharmacist. The registered person should ensure that medicines kept in service users rooms are replaced on a regular basis if not used. It is good practice to undertake CRB for each staff member approimately every three years 4. OP9 5. 6. OP9 OP29 Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Nazareth House DS0000010519.V313322.R01.S.doc Version 5.2 Page 27 - 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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