Inspection on 12/08/08 for Nazareth House

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Excellent service.

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 01/10/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Nazareth House Hammersmith Road London W6 8DB Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 12th August 2008 10:00 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.V366990.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.V366990.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 (95), Old age, not falling within any registration, with number other category (95) of places Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 95 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 93 people living in the home, 35 being privately funded. Care is provided by a staff team comprising nurses, care assistants, domestic, catering, administrative and maintenance staff. The home is situated over three floors and accommodation is provided both in single and double rooms. Nazareth House is 150 years old and there are restrictions on adapting the premises, as it is a listed building. 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. There is currently 64 care staff, 28 nursing staff and 48 domestic/ kitchen staff employed at Nazareth House. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Tuesday 12th and Wednesday 13th August 2008; we spent 15.00 hours visiting the home. We were assisted by an expert by experience who is a person because of their shared experience of using services, visits a service with an inspector to help them get a picture of what it is like to live there. We spent time talking to the registered manager, administration Officer, the Responsible Individual, staff, residents and people visiting Nazareth House. We spent time with the maintenance team checking all relevant safe working practices and looking at maintenance records that were up to date and well recorded. Looking at menus and checking the kitchen with the Sister in charge. We checked the care records of four people; all medication and finance records were looked at and were well recorded. 12 of the bedrooms were looked at and all communal parts of the home including the kitchen, laundry, gardens and dining areas on all floors. The home provides a good standard of accommodation; the home was seen to be clean and tidy. There were 93 residents living at Nazareth house at the time of this inspection. We received 6 relatives’ surveys, 13 residents’ surveys and 1 professional survey; comments from the surveys will be included throughout this report. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly charge for Nazareth House is from £640.00 to £781.00 this will vary depending on the level of care required. What the service does well: People that live at Nazareth House have access to a multi-professional health care team on-site. There is a physiotherapist now on site with a GP who visits the home twice a week and available 24 hours a day if necessary. Medication records were checked on the three floors and all records were completed correctly with all controlled drugs stored appropriately with the relevant information in place. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 6 We spent time on all three floors talking to residents and relatives, all comments received were very positive about the care provided at Nazareth House. Relatives spoken to, all stated that they visit at different times and days however they are always made very welcome by staff. We discussed this with the registered manager who stated that they are a home that values family, friends and other stakeholders visiting. There is a room also available for any residents’ family that travel long distances or wish to stay when their relative living at the home is ill. All staff spoken to on the days of this inspection were very positive about their roles, we spoke to the registered manager, administration officer, nurses, care staff, physiotherapists, domestic staff, kitchen staff and the activities coordinator. The food provided is of a good standard; we spent time with residents at lunchtime and tried a sample of the meals being offered that was a choice of soup, three main hot options with different deserts available. If a resident did not want what was being offered salads or sandwiches of their choice were offered. Menus looked at are varied, nutritiously balanced and were of a high standard. There were a lot of positive comments made by residents. We also spent time with the sister in charge/chef in the kitchen discussing religious and cultural meals that are available when required. We looked at the activities programme; activities are improving looking at individual’s needs as well as groups. The provision of activities to people who have dementia is improving and we were told by the registered manager she is continually looking at different activity programmes with the two activity coordinators 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. We looked at the training and development programme for all staff. Training is now predominantly done by two training officers employed by the home. We discussed the training with one of the training officers who was very positive about her role and we were told that the registered manager was very supportive and agreed with the commitment to provide a continual programme for all staff to make sure they are all fully skilled and competent in the role they provide at Nazareth House. All residents and relatives spoken to told us that staff is competent and experienced in providing care. All staff spoken to was very happy with the training provided. 48 staff has an NVQ qualification with 11 care staff currently working to achieve the qualification. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Nazareth House DS0000010917.V366990.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.V366990.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. For people who are self funding and without a Care Management Assessment the assessment is always undertaken by a skilled and experienced member of staff. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the designated registered nurse assessor will still visit the individual and complete the homes assessment record. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘My relative moved into Nazareth House from another care home, since moving into Nazareth House she is a different person, she is happy, eating and drinking and now is able to walk again they have done so much to get her mobile and independent again’. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 10 ‘We have waited for a place to be made available for our mother and we were so glad we did as she is so well looked after’. ‘I am so happy living at Nazareth House all of the sisters and staff look after me so well’. We looked at the home’s statement of purpose that is very informative and reflects the care that is provided to all residents. There is also a lot of information on how care will be provided to residents with complex needs such as dementia. The documents can be made available in different formats and languages If required. We looked at four residents files one of which was a privately funded resident and all included a contract with the home covering the terms and conditions of the organisation. The manager stated that any resident who was not able to fully understand the contract would be referred to an advocate if no other relatives were known. Information received within the Annual Quality Assurance Assessment (AQQA) completed by the registered manager, indicated that there is a designated registered nurse assessor who completes all initial assessments at Nazareth House. The registered manager and deputy manager is also very involved in all admissions into the home. We looked at four residents files and all included a full needs assessment using standard assessment tools, including the initial referral, Barthel and Waterlow. The assessments were very informative with all of the relevant information in place. There is an issue that two of the four clients files has records that had not been signed by the individual who had updated them. Nazareth House does not provide an intermediate service at this present time. In discussion with the registered manager this is an area that the organisation are considering putting in place and will liaise with the Commission if they decide to go ahead with the plan. Nazareth House DS0000010917.V366990.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): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are trained and competent in health care matters particularly in the care of individuals who remain immobile for long periods of time. The home arranges training on health care topics that relate to the health care needs of residents. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘I have all of my needs taken care of by the staff at the home’. ‘I am aware how busy staff are and I do sometimes have to wait a bit for what I want’. ‘Staff here provide the best possible care to my father, they are all wonderful’. ‘Everything is total commitment’. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 12 ‘ My mother has been cared for so gently by all of the staff at Nazareth House, she is so fragile’. ‘This is a nice place to live and staff were kind and helpful’. Comments made by a professional. ‘Always seen residents being treated with respect, and dignity high on the agenda. People are treated as individuals’. We looked at 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. Night care plans were seen on each file setting out the residents care at night, including preferred time for going to bed, and for getting up. The care plans are up dated on a monthly basis or when there is a change to the care plan, we saw updates in all four residents files. We looked at the risk assessments and all of the information corresponded with the initial assessment and care plan. All risk areas do work in conjunction with the care plan showing how a risk has been identified with a relevant action plan showing what actions staff must follow to minimise the risk to ensure the safety of the resident and staff. Looking at the healthcare records of the four residents all are registered with the resident GP. We were told by the registered manager that all of the residents are registered with the GP but can stay registered with their own GP if they wish to, however all chose to change as the resident GP visits the home twice a week and is available at any time for visits to the home or in an emergency. We saw copies of residents monitoring records including weight charts, blood pressure readings, fluid and food intake, BMI records, the staff monitor residents health and liaise with the GP if they are concerned about any aspect of the residents health and well being. We looked at the medication procedures on the three floors; all Medication Administration Records (MAR) were well recorded. The storage of medication was good with the medication rooms having the temperature recorded daily and medication fridges were also checked daily, all records show that the medication is stored at a safe temperature. We looked at the controlled drugs currently stored in the home. There was only three residents currently prescribed controlled drugs, we checked the amount against the record and the information recorded was correct. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 13 Staff was observed to speak respectfully to residents, using their preferred form of address. The residents privacy is respected, for example staff were seen to knock on the doors of residents before entering and all personal care was attended to in the privacy of the residents own room or in one of the communal bathrooms. In discussion with residents and there relatives we were told that staff are always very polite and treated the residents with respect at all times. We discussed end of life care with the registered manager who stated that the policy and procedure of the home states that a resident will be cared for with dignity and respect. All of the relevant care will be provided to make sure a resident is kept comfortable. We looked at a lot of letters and correspondence sent from relatives to the registered manager and staff that were very detailed thanking staff for the assistance given to family and relatives during this difficult time. Nazareth House DS0000010917.V366990.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘I do enjoy doing activities and join in the group activities when I want to as sometimes I do not feel up to it. The staff never force me to do anything they only try to encourage us to join in’. ‘There should be more funding for the activities as a relative I would like my aunt to go out more into the community’. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 15 ‘My mother enjoys the activities and joins in the cookery classes as she was a very good cook’. ‘I have lived in three other homes and this is far and away the best, having much higher standards than the others’. We looked at four residents files and care needs assessments. All of the files contained a lot of information regarding the resident’s likes, dislikes, hobbies and leisure interests. In discussion with the registered manager we were told that they are trying to be more person centred providing a lot of different activities to individuals on a one to one basis. We looked at daily records for the four residents and there was information written daily about what activities an individual had done including going for walks, art, cooking, poetry reading and attending any community activities. The activity coordinators make sure that all residents are supported to participate in activities they enjoy. On the first day of this site visit the coordinators had organised a day trip in the mini bus to Brighton, unfortunately the weather was very bad with rain and storms so the trip was cancelled. Activities provided over the two days were cooking, art, singing, book reading, walking in the garden, listening to music and staff were seen providing a lot of one to one activities with residents. We looked at a plan of all of the activities that are planned in August 2008; the registered manager and an activity coordinator stated that this does change to suit residents. Photographs were looked at showing residents doing a lot of activities including attending parties at the home. The expert by experience spent time with residents that were doing activities There is an issue that residents with dementia may not be able to join in some of the group activities and more suitable activity plans should be put in place to suit their individual abilities. We were told by the manager that family and visitors are welcome at Nazareth House, on the day of the two days we were at the home residents’ families were seen on each floor. We spoke to six relatives who were very positive about the care provided to their relative and stated that the registered manager and staff made them feel very welcome. Night care plans indicate that residents are assisted to go to bed at whatever time they wish to, there is no set time. Meals are prepared in the main kitchen and transported to the floors in trolleys. A hot choice is available at breakfast, lunch and supper when a range of dishes are available. All of the residents spoken with confirmed that they were happy with the food provided. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 16 We spent time on each of the three floors and the expert by experience had lunch on one of the floors and all of the choices were tried, the food was very tastefully served and all was of a good quality. We looked at the menus that were varied, nutritiously balanced and were of a high standard. We spent time with the sister in charge of the kitchen and kitchen staff that are all very passionate about what food is provided to residents. The food was served by care staff; staff that had to assist residents to eat did so with encouragement and patience. A relative informed the expert by experience that the registered manager gave permission for family members of a relative to prepare and serve cultural food for their Polish mother and have a Christmas Eve party. In discussion with the sister in charge of the kitchen she stated that any resident that required a special diet or had religious or cultural food requirements would be provided with whatever they wanted. The four files looked at contained a copy of a dietary assessment, with action taken where concerns were identified. We were told by the manager that food and fluid intake is recorded for all residents, we saw records of fluid and food intake in the four files looked at. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 17 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 on request in a number of formats, to help anyone living at, or involved with, the service to complain or make suggestions for improvement. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘I do not have any issues and I would speak to one of the staff if I had a problem’. ‘There is a copy of the complaints procedure in my dads room, I would follow that if there was anything I had to report’. ‘I would speak to one of the sisters if I was not happy about my care or if there was something I was not happy about’. We looked at the homes complaint procedure that is given to all residents when they move into Nazareth House. The complaints procedure is easy to follow and give clear information and timescales for dealing with a complaint. There have been no complaints in the last twelve months. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 18 We looked at the homes safeguarding policy and procedure that is directly linked to the Hammersmith and Fulham procedure as the commissioning local authority. We were told by the registered manager that all staff has attended training, we looked at staff training records that show that staff have attended safeguarding training. We also spent time talking to staff all of who were knowledgeable about the safeguarding procedure and what action to take if an incident occurred. There has been one protection incident at the home that was dealt with appropriately with records in place to show the action of the organisation. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 19 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well maintained environment provides specialised aids and equipment to meet the needs of the people who live there. EVIDENCE: We spent time with the maintenance team who have a weekly action plan to look at all areas of the home. We were told that any problems are reported directly to the maintenance team and they will action the work straight away. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 20 We had a full tour of the home and 12 resident bedrooms were looked at, the standard of decoration and fixtures and fittings is good. The building is 150 years old and a listed building so there are shared rooms. In discussion with the registered manager and the registered person we were told that a future plan to have all single rooms with en-suite bathrooms is something they are aspiring to have. The residents’ rooms all had personal items including photographs, ornaments and pictures. The residents spoken with were all very happy with their rooms. The expert by experience comments that the home however old was clean, bright and welcoming. Because of the age of the building the windows on the top floor are very high and some residents rooms made it difficult for them to see the view into the garden. There are communal bathrooms on all floors that have specialist equipment in them if required including different types of hoists and baths. All of the residents’ bathrooms have just had a total redecoration completed and all of the bathrooms were looked at and were very tastefully done. There are dinning rooms and kitchens on all floors that residents will have meals. There is a garden that is situated in the middle of Nazareth House that is pleasant for residents to sit or have a walk. There is a room available for the hairdresser to use, and also a room is available for any massages or beauty treatments requested by the residents The home has a security system that has cameras outside the building and a monitor is in the reception area. The home was very clean and tidy on the day of this inspection. We spent time talking to one of the domestic staff who stated that all staff assist in keeping the home clean and tidy and free from any odours. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Management prioritise training and facilitate staff members o undertake external qualifications beyond the basic requirements. The home introduces internal developmental training, to complement formal training as part of an ongoing training plan. EVIDENCE: Comments made by staff, the people who use the service and relatives. ‘I have had so much training the organisation does keep me up to date with any changes in procedures, its like being at school they are always teaching me new things which is good’. I have attended a lot of training and as a nurse I have to attend training to make sure that I am competent in my role. The manager encourages me to attend internal and external training she is very positive about training and development of all staff’. ‘ OI really enjoy training and have recently passed my NVQ level 2 that was very good. I have completed a lot of training we have training coordinators working at the home who are very good’. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 22 ‘ I think all staff are competent in there roles my mother receives excellent care’. ‘Staff are very good at what they do’. We looked at the staffing rota for all floors; the staffing levels are good and are meting the care needs of all residents. We were told by the registered manager if a care package changed and more input was required this would be dealt with immediately. We discussed staffing levels with the nurses in charge on the three floors all stated that they were adequately staffed and if they assessed that more staff were required they would request this from the manager. We looked at four staff files; the recruitment of new staff is co-ordinated by the registered manager and the administration officer. All relevant checks were seen to be in place including CRB’s on all staff, pin numbers were up to date on nurses, all copies of original documentation seen had a date and signature showing that original documents had been seen. A copy of all original qualifications and training is kept on the staff file. Looking at the references in staff files all were checked for validity. We looked at the training and development records of all staff working at Nazareth House. There is an intense induction training covering all mandatory training but also specialised training including Dementia Awareness, Protection of Vulnerable Adults, and a lot more. We were told by staff that they thoroughly enjoyed the training and appreciated the support from the manager in allowing them the time to participate in the training. There are 28 nurses employed including the deputy manager. We were told by nurses that they attended training and are nominated by the registered manager to attend specialist training. All care staff spoken with was very positive about their roles 48 staff has an NVQ or above, there is 11 currently registered to do an NVQ level 2 qualification. The registered manager liaises with the two training coordinators who have set up an annual training programme that staff is nominated to attend as required. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 23 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, 36, 37 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. She works continuously to improve services and provide an increased quality of life for residents with a strong focus on equality and diversity. EVIDENCE: Comments made by the people who use the service, relatives and staff. ‘The manager is very knowledgeable about providing care, she has her finger on the pulse and is very informative about the healthcare of my mother’. ‘The manager is very supportive to me and has an open door policy if I need to discuss any issues’. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 24 ‘The manager is a wonderful person and makes sure that the care given to my aunt is first class’. 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 registered manager attends periodic in-house training sessions. In discussions with the registered manager and staff it was apparent that the she is very knowledgeable about the needs of all residents and also staff development. The expert by experience was very impressed with the registered manager knowing all of the residents and the impressive way that she approached them individually. We were told by the registered manager that all residents are liaised with on a regular basis to make sure they are happy with the care and support provided at the home. There is a quality assurance system in place with residents, relatives and any other stakeholders invited to comment on the service provided. We saw comment forms throughout the home and in the reception area asking for people to make comments. We were told by the registered manager that all information received will be actioned and improvements will be made in any area that is required. We were told by the registered manager that a residents and relatives forum had taken place and they are aiming to have more on a regular basis, as this will be invaluable to get information directly. There have been no complaints or issues at Nazareth House in the last twelve months. In discussion with one of the residents the expert by experience was told that at times the resident may have to wait for staff to respond to her bell but otherwise she was happy. We looked at the finances of ten residents, all records were correct showing what had been purchased with receipts in place. The balance of money kept in the safe for each resident was correct. The residents are encouraged to keep their own money, as there are lockable draws in each bedroom. The registered manager is requested by relatives to keep money for residents if they need to purchase any toiletries or to get their hair done by the hairdresser. We looked at records kept by the home that are either locked away in lockable storage cabinets or are on the computer system where a password is required to gain access. All records looked at were up to date and legible with the relevant information in place. There is an issue that records have to be signed by the member of staff that has completed them. We looked at daily care records in four residents files and some entries could not be read easily, daily records must be legible to show what care has been provided to residents. We looked at all health and safety records including fire safety, water temperatures, safe water checks (legionella), and maintenance records, all records were very well recorded and up to date. We spent time talking to the Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 25 two maintenance officers who told us they do daily and weekly checks in most areas. All staff is fully trained in infection control, and leaflets were seen on notice boards on all floors for staff and residents to follow. All staff has completed moving and handling and is familiar with the equipment in the home. The AQQA had all of the information on health and safety showing that the home is a safe environment for people to live and work. Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 26 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 4 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 3 3 4 Nazareth House DS0000010917.V366990.R01.S.doc Version 5.2 Page 27 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 OP3 OP37 Regulation 17 Requirement The registered manger must make sure that all assessment records are signed by the staff that has completed the record to show that the assessment is up to date and relevant. The registered manger must make sure that all daily records written by staff are legible to show what care has been provided. Timescale for action 12/11/08 2 OP37 17 12/11/08 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.V366990.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V366990.R01.S.doc Version 5.2 Page 29 - 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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