Inspection on 01/10/07 for Nazareth House

This inspection was carried out on 1st October 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 12/08/08

Nazareth House 31/05/06

Nazareth House 13/03/06

Nazareth House 13/09/05

Nazareth House 10/03/05

Nazareth House 23/11/04

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 Hammersmith Road London W6 8DB Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 1st October 2007 09:00 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 Nazareth House DS0000010917.V341263.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 DS0000010917.V341263.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address Hammersmith Road London W6 8DB 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 8748 3549 020 8563 7421 srcelinemarie@yahoo.co.uk The Congregation of the Sisters of Nazareth Sister Celine Marie Donnelly Care Home 95 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (65), Terminally ill (5) of places Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 65 beds for elderly medical patients over the age of 60 years of which 5 patients may be received for palliative care for a terminal illness and 25 patients may have a diagnosis of Alzheimer’s Disease. 30th August 2006 Date of last inspection Brief Description of the Service: Nazareth House is registered to care for a total of 95 people of either gender. The home is owned and run by The Sisters of Nazareth. There are currently 92 people living in the home. Care is provided by a staff team comprising nurses, care assistants, domestic, catering, administrative and maintenance staff. The fees at the home range from £607.70 to £781.30. The home is situated over three floors and accommodation is provided both in single and double rooms. There is lift access to all floors. The home has a very large garden that residents use on a daily basis. Inside the home there is a small library, chapel, hairdressers and a shop. The home owns a specially adapted vehicle for local trips outside of the home. The home is situated in Hammersmith and is close to public transport links and local amenities. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 1st and Tuesday 2nd October 2007. A total of 13 hours was spent talking with residents, relatives and other visitors, Managers the Administration Officer, the new Responsible Individual and staff. The Inspector spent time looking at four residents records, four staff records, medication records on all three floors, residents finances and touring the premises. The inspector spent time with the maintenance team checking all relevant safe working practices and looking at maintenance records that were seen to be well recorded. Looking at menus and checking the kitchen with the Sister in charge, the Inspector was told that they had an environmental Health check on the 24/08/07 that had no recommendations. The Inspector spent time with two of the activity coordinators who were assisting residents to bake cakes and painting in the art class, music was playing and the residents were singing along. Residents told the Inspector they enjoyed the activities provided. The Inspector spent time looking at the training programme with one of the training coordinators, the training provided is linked into the Skills for Care programme. On day two of the Inspection an Inspector spent time on the 1st floor using the Short Observation Framework for Inspection (SOFI) methodology, tracking the residents state of being and their level of engagement with others. The outcome of the (SOFI) will be included throughout this report. All of the nine requirements made at the last inspection have been met. There are two new requirements from this visit. What the service does well: The care provided by all staff working at Nazareth House is good; residents, family members and visitors told the Inspector that they were happy with the care. The understanding and care seen to be given to residents that have dementia was good, working at a level and pace that suited each individual and the communication from staff to residents was appropriate for each individuals understanding. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 6 The training provided to all staff has improved and all staff has a training plan to meet mandatory training and also specialised training if required. All staff spoken to told the Inspector that the training was good and they attend a lot of different courses that assists them to do their job to a good standard. Activities are improving looking at individual’s needs as well as groups, the provision of activities to people who have dementia is improving and the Manager told the Inspector that she is looking at different activity programmes to be used in Nazareth House. Some residents are escorted to their chosen place of worship when requested, as Nazareth House does understand the diverse needs of all residents living there. What has improved since the last inspection? All staff are now trained in providing care to people who have dementia. Staff are required to follow the care plan of individuals to provide stimulation and also provide relevant activities to suit their needs. The care plans have improved and a lot of information is recorded, work is continuing to show how the staff are working towards person centred planning looking at individuals needs, goals and aspirations. There are adequate qualified staff to meet the needs of residents that have dementia. The Manager told the Inspector the ratio of staff is led by the needs of the residents. All staff are employed in accordance with the (GSCC) General Social Care Council and have signed and agreed to show that they understand the Code of conduct. All staff have a training analysis that shows what training they have completed and what training they are required to attend, with also training requests form the individual in specialised areas. The daily records have improved and are now linked into the care plans; activity participation is also now recorded. Developmental work is now part of the training to ensure that staff put the training into practice and ensure residents are respected, that their individual needs are understood, that they are included and that they are facilitated choice. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Nazareth House DS0000010917.V341263.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 Nazareth House DS0000010917.V341263.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): Standards 1,2,3, and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. For people whom are self-funding and without care Management Assessment the assessment is always undertaken by a skilled and experienced member of staff. EVIDENCE: The Inspector looked at the Statement of Purpose and Service User Guide that has been bought up to date with the new Responsible Individual information in place and the documents also reflect changes that have occurred at the home. The information is very informative and can be provided in different formats, all residents are given a copy of each document that is kept in their bedroom. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 10 The inspector looked at four residents files and records of assessments were in each file. The home has a designated registered nurse assessor who is responsible for the pre-admission assessments. These assessments are carried out in the residents usual place of residency that can either be in the residents own home, another care home or hospital. There are sixty residents living at Nazareth house that are self-funding at present. When a resident is referred through Care Management, a copy of their assessment is received and the home will later undertake their own assessment. The four residents files looked at had contracts in place that had been signed and agreed by residents, a family member and the Manager. The Inspector was told by the registered Manager that they do not provided intermediate care. Nazareth House DS0000010917.V341263.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): All of the above Standards were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is responsive to the varied and individual needs and preferences of the people who use the services. Staff respects privacy and dignity and are sensitive to changing needs. EVIDENCE: The Inspector checked four residents files and in each file had an up to date care plan with all of the residents’ health and social care needs recorded. The information in each file was informative and a lot of work has been done by staff to make sure the information is as accurate and informative on each individual as possible. In discussion with the Management team the Inspector discussed person centred care plans linking into the aims, goals and aspirations of all people receiving care from them. The Manager told the Inspector that they are looking at ways to include this information in care plans, linking this into activity plans and training staff to compile life books with some residents. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 12 Risk assessments linked into the four residents care plans showing how risk assessments minimise any risk areas with actions for staff to follow. The Inspector spent time meeting with staff who stated that they do follow care plans and risk assessments when assisting a resident. All of the risk assessments had been regularly reviewed. The care plans records are kept in the resident’s own bedrooms. There is a GP who visits the home every week for 2 days all residents are seen by the GP. The home has access to two physiotherapists, who visit the home three times a week; they have new treatment rooms that were shown to the Inspector that are very comfortable with all relevant equipment in place. Questionnaires returned to the CSCI stated that physiotherapy was an excellent service provided by the home. An optician is available locally or home visits can be arranged, and residents have access to a local dentist as required. Referrals can also be made to speech therapist, dietician, audiologist, community nurses and occupational therapist through the GP, records were seen to be in files to show that this does happen on a regular basis. In discussion with the Manager the Inspector was told that residents with cognitive impairment and showing signs of distress are referred to a psychologist. The inspector checked the medication records for nine residents. The homes medication recording has improved immensely since the last inspection. The inspector looked at the medication procedures for safe storage and controlled drugs all records were seen to be well recorded and up to date. One Inspector spent time on the 1st floor using the Short Observation Framework for Inspection (SOFI) methodology, tracking the resident’s state of being and their level of engagement with others. The outcome from this observation and spending time with five residents was very positive showing that staff interacted well and are providing a good level of care to residents who are diagnosed as having dementia. The Inspector looked at staff training records and the training programme, all staff has completed dementia awareness training and assisting people who have Alzheimer’s. Nazareth House DS0000010917.V341263.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): All of the above Standards were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. EVIDENCE: The inspector checked the files of four residents and assessment records and care plans were in place to show how the home would meet their needs. The home holds a number of events including opening evening’s birthday celebrations and lunches for family and friends of residents. In discussion with the Manager the Inspector was told that there are residents that have different cultural and religious needs that staff are aware of and endeavouring to meet, one lady attends a different church weekly, another lady has specific clothes that are worn at all times as part of her cultural heritage and beliefs. The activity co-ordinators facilitates the planning of group activities and one– to–one activities in the home, these include bingo, singsong, teddy bear tea parties, jigsaws, reminiscent chats, painting, baking and listening to classical and traditional music. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 14 The inspector checked the activity plans in the resident’s files and looked at daily records that are now completed by the training coordinators for all residents. Activities are now being provided that are suitable to meet the needs of people with dementia, in discussion with the Manager this is an area that they are endeavouring to improve upon and the Manager was in contact with Skills For Care to look at the training available for staff. The home has a mini bus for residents to go on outings. The Inspector saw a lot of people visiting Nazareth House on the two days of this inspection. Family and friends of residents spoken with at the time of the inspection stated that they were always made very welcome by staff when they visited the home. Residents are able to bring personal possessions including furniture into the home with them and resident’s rooms seen by the Inspector were personalised with pictures, photographs and other personal items. The Inspector spent time with the Manager looking at the financial transactions of residents; all records seen had the correct information in place. Some of residents chose to look after their own finances. The Inspector spent time looking at menus and discussing them with the Catering Manager. There are three options for each meal and special diets and cultural dishes are provided when requested. The home is now using calculation records to check the Body mass Index of all residents (BMI) if the (BMI) is below 20 the Manager told the Inspector that an intense four day observation of food and drink will take place with ongoing monitoring for individuals that are seen to be not eating or drinking sufficiently. Records were shown to the Inspector for one resident who had lost weight, there were records from the GP, weekly weight records and food and drink records. Hot food is served three times a day with snacks in between, residents are prompted to drink regularly and in some instances records were in place to monitor fluid in take. Nutrition information was seen in all files and all staff have training in nutrition as part of the homes induction training. Nazareth House DS0000010917.V341263.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in different formats to help anyone living at the home complain or make suggestions for improvement. EVIDENCE: The inspector looked at the one complaint record that have been made in the last 12 months, the record had the relevant action plan attached to show how the complaint had been investigated and what actions had been taken. The complaint procedure is written in the Statement of Purpose and the Service User Guide. The complaints procedure and forms were seen by the Inspector in all parts of the home. Residents, family members and visitors spoken with stated they would speak to a member of staff or to the Manager if they were not happy with something. The Inspector spent time discussing Safeguarding Adults procedures with the Manager, the procedure for the Protection of Adults is in place. The Manager told the Inspector that all staff have now completed Protection of Vulnerable Adults (POVA) training. The home has had no incidents in the last 12 months. Residents told the Inspector that they would speak to the Manager or a member of staff if there were any issues. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 16 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): Standards 19,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy; they seek expert advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. EVIDENCE: The inspector had a full tour of the home and six residents bedrooms were seen. The bedrooms had a lot of personal possessions in them including photographs, pictures and other personal items, the bedrooms were seen to be comfortable, clean and tidy. Communal areas were comfortable with lounge/dinning areas on all floors. The home employs domestic staff to do all the cleaning; all 3 floors were seen to be clean and tidy. The home has a main reception area and access is via an entry phone. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All of the above Standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is enough qualified, competent and experienced staff to meet the health and welfare needs of people using the service. EVIDENCE: The inspector looked at the staff rotas for all 3 floors; all 3 floors had adequate staff on each shift to meet the needs of all residents. Residents, family members and visitors all stated that they were happy with the staffing levels. In discussion with the Manager the levels of staffing on each floor is calculated by the needs of the residents and more staff will be used if required. The Manager and Administration Officer have to make sure that all staff have a Criminal Records Bureau (CRB) Disclosure completed by the home. The Administration Officer looked at all staff CRB records and there are 3 staff who’s CRB is not valid. The staff have worked at the home for a long period of time and all other recruitment checks were seen to be in place. On the second day of this Inspection the Administration Officer had completed POVA first checks on the three individuals and the CRB documentation had been completed. The Inspector checked the recruitment records of a nurse and their pin number was not in date, the Manager liaised with the member of staff who bought in their up to date pin information. The Manager must check that all nurses’ registration is up to date and have the relevant information in place. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 18 All staff employed has a code of conduct that is in accordance with the (GSCC) General Social Care Council. The Inspector met with care staff, nurses, domestic staff and kitchen staff all of the staff told the Inspector they were happy working at Nazareth House and the training they received was good. All of the staff have completed mandatory training and had also completed refresher training specifically moving and handling, health and safety, food hygiene and (POVA) Protection of Vulnerable Adults. All staff has had a training analysis completed, the Inspector looked at four staff files and each had an up to date training analysis in place. 49 of care staff has NVQ’s or equivalent, the home will have over 75 of staff having completed an NVQ by the end of 2007. All nursing staff are up to date on training. All staff have completed dementia training and in discussion with the Manager a more intensive training on Alzheimer’s is now being provided to all staff. Using the Short Observation Framework for Inspection (SOFI) methodology the Inspectors saw a great improvement in the way staff are now providing assistance to people who have dementia or any cognitive impairment. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 19 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): Standards 31,33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the required qualification and experience, is highly competent to run the home and meet its stated aims and objectives. EVIDENCE: The Registered Manager has a Diploma in Management and a BSc (Hons) in Health and social care of older people. The Manager has also studied courses in palliative care and dementia care. As well as the above courses, the Manager attends periodic in-house training sessions. In discussions with the Manager and staff it was apparent that the Manager is very knowledgeable about the needs of all residents and also staff development. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 20 Four staff files were checked and records for supervision meetings were seen to be in place. In discussion with the Manager the Inspector was told that all staff have an annual appraisal. The Inspector met with staff who confirmed they have regular two-monthly supervision and an annual appraisal, where they are able to discuss training and development and any issues they may have. The Inspector checked the finances of five residents, all financial transactions were recorded and the relevant balance was in place for each resident. The Manager told the Inspector that the Responsible Individual also checks the resident’s finances on a regular basis. The Inspector spent time with the Maintenance team checking all relevant health and safety records including weekly fire alarm checks. The London Fire Emergency Planning Authority (LFEPA) had visited the home in April 2006 and was happy with the risk assessment in place, no recommendations came form the visit. The health and safety records looked at were well written and up to date. The Maintenance team do a weekly health and safety check of the whole building the Inspector told the team this was good practice. The Manager told the Inspector that they have recently started residents monthly meetings again where an agenda will be in place as specified by residents. The outcome of these meetings will be linked into the Quality Assurance monitoring of the home. Questionnaires are also given to residents to complete and their families, friends, advocates and social services placement officers. Forms were seen in place around the home for anyone visiting to complete. Residents have regular reviews and issues can be taken from them for the Manager to look at improving in any area. There are monthly Person in Control visit records were all areas are looked at any actions are recorded and monitored, a record of these records is sent to the CSCI. All of the information has been collated into an annual quality assurance summary with a copy being sent to the CSCI. Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 21 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 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 3 29 2 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 DS0000010917.V341263.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 18 Requirement The Manager must make sure that all staff have a (CRB) disclosure completed by them as the employer. The Manager must make sure that up to date information on all nurses pin numbers from the (NMC) is in place in each nurses file. Timescale for action 01/12/07 2 OP29 18 01/11/07 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 Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Nazareth House DS0000010917.V341263.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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