Inspection on 12/06/07 for Nazareth House

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 03/06/09

Nazareth House 16/01/06

Nazareth House 13/09/05

Nazareth House 14/03/05

Nazareth House 27/09/04

Nazareth House 23/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Nazareth House London Road Charlton Kings Cheltenham Glos GL52 6YJ Lead Inspector Mrs Helen James Key Unannounced Inspection 12th June 2007 09:15 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 DS0000016506.V336578.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 DS0000016506.V336578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address London Road Charlton Kings Cheltenham Glos GL52 6YJ 01242 516361 01242 547696 manager.nazhsechelt@bt.com 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) The Congregation of the Sisters of Nazareth Mrs Elaine Lesley Woof Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63) of places Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 16th January 2006 Brief Description of the Service: Nazareth House, a purpose built care home, is situated on the outskirts of Charlton Kings, within walking distance of the local shops and public transport. It is registered to provide accommodation for sixty-three older people who require personal care. The Home is owned and managed by the Sisters of Nazareth, an order of Roman Catholic nuns, but people of any religious faith are welcome at the Home. All the bedrooms offer single accommodation; many have en suite facilities. Further bedrooms are being converted to provide these additional facilities. A shaft lift and stair lift provide assisted access to the upper floors. The communal areas consist of five lounges/quiet areas, three dining rooms plus a large function room and sun lounge. There is also a Chapel attached to the Home where daily services take place. People living at the home have the benefit of a large attractive garden with summerhouse, which is easily accessible and well maintained for use in all weathers. The fees for personal care at Nazareth House range from £350 to £550 dependent on individuals assessed need and the fee is determined by whether the needs for care are high, medium or low and whether the accommodation has en-suite facilities. The fees do not include the cost of items such as newspapers, toiletries, magazines, chiropody and sundry items and there may be charges for some outings/trips. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection took place over eight and a half hours on one day in June 2007 and was completed by two inspectors. Twenty-six Standards for Older People including all twenty-two Key standards were assessed on this occasion. Of these sixteen exceeded the standard and eight met the standard, one almost met the standard and one was not applicable. Time during the inspection was spent speaking with the Registered Manager Mrs Elaine Woof, Sister Teresa Fallon, staff and people living at the home. Ten people living at the home and one visitor were seen during the inspection, all were able to converse with the inspectors fairly well but others who had limited communication were observed. Therefore information was also gained via observing the care being provided to people, observing and listening to interactions with care staff and the manager at the home. The inspectors spent time cross-referencing information about the care and welfare gained from talking to and observing people with individual’s care records. A range of records were examined to include care plans, staff files, training records, quality assurance documentation and health and safety systems. A tour of the environment was also made. The pre-inspection Annual Quality Assurance Assessment (AQAA) record was provided to the Commission prior to the inspection. Comment cards were sent to the service for distribution prior to the inspection and eight relatives/ representatives of people living at the home, the GP, three Health Care Professionals who visit the home returned these, as did fourteen people who live at the home. What the service does well: The Home has the benefit of an experienced Manager who is greatly involved in the home on a day-to-day basis. There is an open, friendly approach to the running of the home, where people’s needs come first and this is reinforced in the training and example given to staff. This results in the home being run safely and efficiently with people’s rights, independence and choice being safeguarded and protected whilst involving them in the running of the home. It was evident through discussion with people living at the home who were able to talk to the inspectors that they felt their views were always taken into account and ‘nothing was too much trouble’. They found the Manager and staff approachable, helpful and friendly. People spoken with all confirmed that they were very happy with the home and they had no concerns. They felt they were kept well informed and felt that there was appropriate stimulation in the home. People felt that they had the Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 6 ability ‘to do what they liked’ and ‘they could go out when they wanted too’. There was confirmation that people were given choice in what they do and that independence was promoted as much as possible. All the comments made by people living at the home, relatives/ representatives in conversation and via questionnaires were very positive about the home, staff, care, activities and the food. There were a few minor grumbles about things but these had no impact on the outcomes for people living at the home. Interactions and communication between staff and people were observed during the inspection and it was noted that tasks were undertaken diligently, respectfully and compassionately. Staff engaged with individuals during all interactions and all interactions were seen to retain people’s dignity, privacy and respect. Whilst staff were busy there was a calm and unhurried atmosphere. Lifestyle and hobbies are well recorded and social activities cater for individual interests. The activities are varied (group as well as individual) and are well attended by people who enjoy the activity and outing programme. Staff were seen fully engaging with people living at the home throughout the day. Really positive interactions were witnessed. They spoke to them respectfully, provided explanations for why they were doing things and supported them throughout activities. Some people still are able to go out alone or with friends or relatives. Management records relating to health and safety issues and regular checks were in place. There was evidence that if any action had been necessary that it had been completed. All incidents and accidents that require reporting under regulation 37 are completed and sent to the Commission. Quality Assurance systems are implemented within the home. What has improved since the last inspection? What they could do better: The Manager has a comprehensive array of documented auditing tools in place to examine quality and effectiveness of systems in the home. To enhance the quality systems in place the auditing tools for care practice need to be developed further. The home also needs to seek and evidence the views of its community stakeholders to give a holistic assessment of the quality of service Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 7 provided to people by the home. An annual Quality Assurance report needs to be produced and supplied to the Commission to evidence the review of the effectiveness of the quality systems in the home and it must include stakeholders’ views and future developments for the home. The issue relating to some night staff being unable to dispense medication needs to be addressed, as this could impact on the quality of night care for people living at the home and also means that staff are not always adhering to safe medication dispensing practice within the home. The Manager needs to ensure that the employment history is scrutinised on each occasion to pick up gaps in employment. 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 DS0000016506.V336578.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 DS0000016506.V336578.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people who use the service are fully assessed prior to admission and on admission, so that all their specific care needs can be met by the Home. The statement of terms and conditions and contract provides people with information about the service they will receive from the home. Intermediate care is not provided. EVIDENCE: All prospective new people are encouraged to visit the home with their relative/social worker/ friends prior to admission, this familiarises them with the home, its facilities and the staff. All people planning to live at the home have their care requirements fully assessed before they are admitted to ensure that the Home is able to meet their needs. Advice is also taken from other people who have been involved in the care at home. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 10 There have several new admissions to the home since the last inspection. People have contracts (a sample were seen) but it tends to be relatives / representative or Social Services who deal with this and not necessarily the person who is to live at the home, due to the fact that many are unable to deal with this themselves or do not want to. The contract contains all the required details and appears compliant with the Office of Fair Trading Standards. The fees for personal care range from £350 to £ 550 dependent on individuals assessed need and the fee is determined by whether the needs for care are high, medium or low and whether the accommodation has en-suite facilities. People spoken with confirmed that they were ‘happy at the home and they liked the carers’. Eight people were spoken with and most confirmed that they or their families had made a positive choice that Nazareth House was where they wished to live. One person said the fact that she can attend Mass in the chapel each day is very important to her and another said after staying for a short period on respite care, she made the decision to move into the home permanently. All were happy with their choice of home. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated with respect and dignity and facilitated and supported by staff to live as fulfilling and independent a life as possible within their own limitations. The care planning system involves the individual and their families and ensures that all members of staff have a clear understanding of the person centred care each person requires. EVIDENCE: Four care files were examined in detail. The home uses the standex system of care planning which appears to be effective. All had a full and informative assessment completed, based on the activities of daily living, which is reviewed regularly. Speaking and observing the people whose files were examined confirmed that the needs identified reflected their current care needs. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 12 All had care planned for the problems identified and this was reviewed on a monthly basis with the person and signed by them where possible. Risk assessments were completed for ‘moving and handling’ and pressure sore risks and these are reviewed monthly. Where someone has been assessed as at risk of pressure sores, health professionals have been contacted and appropriate equipment provided. It was reported that no one has a pressure sore at this moment. One person did have a deep sacral sore but this has healed successfully and the skin is monitored regularly and remains intact. Turning programmes are in place for anyone who is bed bound or at risk of developing pressure sores. Records of doctors and other multi -disciplinary agency visits are kept. These, daily records and conversations with people at the home confirmed visits from other health care professionals such as the chiropodist, optician, dentist etc, are arranged as required. Daily records were also well maintained and recorded any day- to- day incidents that occurred and indicated where these were followed up and appropriate action was taken. Staff spoken with confirmed that they were fully informed about the needs of the people who live here and how to meet those needs. People spoken with confirmed that they were very happy with the care received. Care staff move from one area to another as allocated to ensure that they are familiar with all the people and the care they require. Medication was not examined at this inspection. The blister pack system of administration is used by the home dispensed by a local pharmacy that is very supportive and carries out medication audits regularly. With some prompting, Doctors also review people’s medication when necessary. Medications are listed in the assessment on admission. Some of the staff spoken with confirmed that they had attended both initial medication training from Boots and have more recently undertaken a distance leaning package with a local college. During a conversation with one person it was noted that staff dispense medication into a pot and leave it for this person to take at night if they have pain and no one is available who is able to dispense medication. This is not acceptable practice as the home is responsible for dispensing this person’s medication and it must be dispensed when it is required and the person observed taking it. The medication policy is that the MAR chart is signed when they have seen the person take it. This was discussed with the Manager and she reported that not all staff on night duty are trained to dispense medication, which causes some problems. The inspector felt that this has implications for the quality of care for individuals at night, especially if a person requires medication for any reason during the night. The Manager must address this Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 13 issue to ensure medication practice is fully compliant with the required standards. Staff were observed knocking on doors before entering people’s rooms, addressing people by the names they wish to be addressed and generally respecting people’s privacy and dignity. Nazareth House DS0000016506.V336578.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): 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home participate in age and culturally appropriate activities through engagement in social and recreational activities of their choice. People experience a stimulating and varied life at the home with visitors and community links encouraged. EVIDENCE: The ‘Friends of Nazareth House’ raise funds and plan social events for the home. A full activity programme is planned and is run by staff in the home, volunteers and relatives. A ‘What’s on’ poster is displayed around the home so that people know what’s on and can participate if they wish. Weekly activities include music and movement, quilting, art (pictures displayed in the first floor lounge), shop, bingo, crafts and film shows. Rosary, evening prayers and daily Mass are also held. Within the homes own surveys someone commented that they wished details about outings/social events were advertised early so that they could decide whether to attend and if they were cancelled that they were also notified in good time. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 15 The homes’ summer fete is due to be held on 23rd June 2007 and some of the people spoken with recalled how much they had enjoyed previous fetes. Several also mentioned how they enjoy walking round the grounds and sitting in the beautifully maintained gardens. Trips out are arranged whenever possible using a wheelchair adapted bus loaned from the Star Centre. Unfortunately as the roads have been narrowed next to the local theatre, they are no longer able to park large vehicles outside and for the last theatre trip a small mini-bus was used which limited the number of wheelchair dependent people they could take and this appeared to cause some ill feeling (it is an issue that is to be raised with the local council). A friend of one person who was spoken with related that she often makes arrangements and accompanies her friend to the theatre and they also hire the wheelchair taxi (there are 3 in Cheltenham) to go on a trip to town. Other people spoke of going out regularly with relatives or when they are able on their own, to the library or to town. Residents meetings are held every three to six months regularly. Minutes seen were very thorough in dealing with the issues that arose for people and these are made available to all in the home. The manager chairs this and one person felt that minutes of these meetings did not always give a true reflection of matters discussed. The home use to hold residents meetings run by the residents, but these ended some time ago, some of the residents’ hope to reinstate these. The home operates a policy of open visiting; all visitors’ sign into the home on arrival at reception and there is security on the front door after 6pm. Holy Communion is provided at the chapel at the home or by visiting clergy. The home has information available on advocacy services. From the surveys received eight out of eleven felt there is choice with food, one always liked it, eight usually liked it, one sometimes did and one made no comment. Two felt ‘the rotation of food was monotonous and meat was sometimes tough and could be cut thinner’,’ far too much tinned fruit more fresh seasonal fruit needed’. There is always a fresh bowl of mixed seasonal fruit in each dining area for people to help themselves to each day. Minority and ethnic groups would be catered for and special diets provided but there are no specific needs at the present time. There is an excellent choice of food in the home and hot food at all meals. 75 of staff have had training in food hygiene and there are dedicated catering and dining room staff. Menus were seen displayed outside the dining rooms and meals seen being served appeared to be well presented and appetising. Only two comments Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 16 were received from people spoken with. One stated that she has her meat minced as she is unable to chew meat, and sometimes it is rather dry, only improved when she asked for mint sauce to go on it. Another said she realised the home tries to cook healthily, but she does miss butter on her vegetables, among other things. The Manager is to address this with the Chef and suggest that single portions of butter are put on the tables. Nazareth House DS0000016506.V336578.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to, taken seriously and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The Commission has received no complaints. The home has received one complaint relating to fees and contract that was upheld and they responded and dealt with it appropriately. People spoken to and from surveys say that if they have any concerns they would speak to the manager, Sister Teresa, deputies or staff. Most relatives/advocates said they are aware of the complaints procedure and would speak directly to the manager if they have concerns or worries. There are regular Resident meetings that provide another forum for people to express their concerns. These are well attended and minutes of these meetings were seen and are displayed in the home. The complaints policy and procedure is displayed in the home although this needs to be more prominent as several surveys received said they didn’t know what the procedure was. The Manager has ideas about how to make this more prominent and available. A complaint, concern, compliments record is kept in the home. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 18 All staff spoken with indicated that they are aware of adult protection procedures. There was evidence that staff attend training in Abuse Awareness and that further training will be arranged when the new safeguarding adults policy and procedure are introduced in Gloucestershire. Staff who have completed their NVQ Awards will also have completed a unit on abuse. A copy of the ‘alerter’s guide’ and the Local Adults at Risk information produced by the local adult protection team are kept in the home. The Manager is aware of the implications of the Mental Capacity Act and will attend training herself and then arrange training for all staff in due course. Information about how to access IMCA’S will also be made available to people. Recruitment practices within the home are good and comply with Regulation 19. Nazareth House DS0000016506.V336578.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): 19, 25 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical environment provides for the individual requirements of people living at the home. The home is appropriate for the lifestyle and needs of individuals and is homely, clean, safe and comfortable and complies with infection control standards. EVIDENCE: The standard of the environment in this home is good with people having a pleasant, clean and well-maintained environment to live in. A walk around the environment was conducted and some rooms of people living at the home and some communal areas were viewed during the inspection. The home has a large number of communal areas large lounges as well as smaller quiet seating areas and several dining rooms on each floor. All areas in the home were well used by the people living at the home and their visitors. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 20 Rooms were comfortably furnished, many with personal items of furniture that people had chosen to bring to the home with them. One person spoken with explained that most of the things in her room including her bed and chair were her own, and both she and her visitors said it felt like home because of this. Some rooms offer en suite facilities, others just wash basins, but most have toilets and bathing facilities close by. Assisted bathrooms and toilets are also available throughout the home. All areas seen appeared to be clean and well maintained. All the surveys state the home is always or usually clean and fresh. Only one carpet seen appeared worn/stained and this was on Cheltenham wing, in a room where the person residing in the room was being cared for in bed, so it was possibly difficult to replace this at present. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home. The laundry is clean and well ordered with washable walls and floor surfaces and hand washing facilities. There are dedicated laundry and domestic staff and good practices were observed to be in place. Hazardous products are locked away and data sheets/risk assessments are kept in a file in the home. The home meets infection control standards and staff seen confirmed they had received infection control training and records confirmed this. Nazareth House DS0000016506.V336578.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): 27, 28, 29 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent staff team deliver a person centred approach to people’s care. They have access to training programmes to ensure they have the knowledge and skills necessary to provide care for the diverse needs of people living at the home. People are protected through recruitment practice at the home but the Manager needs to ensure that there are no gaps in the employment history to fully comply with Regulation 19. EVIDENCE: The number of care staff on duty appeared more than adequate to meet the needs of people living in the home at the time of the inspection. Catering, dining and domestic staff supports them at all times. A number of staff were spoken with during the inspection to include care and domestic staff. The deputy managers on both floors were spoken with at length and both had an excellent knowledge of all the people under their care. Senior carers upstairs on the late shift were also spoken with. All had been trained to at least National Vocational Qualification (NVQ) level 2 and confirmed other training that they had undertaken recently such as Fire Safety training, infection control and moving and handling updates. All also confirmed that they enjoyed their work in the home, some having worked at the home for a number of years. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 22 There were no new staff on-duty to speak with during the inspection, so the inspector was unable to explore induction programmes with staff, although induction records were seen. Supervision is given throughout the induction period and then starts routinely to comply with the regulations, evidence seen during the inspection. Several staff have been appointed since the home was last inspected. Recruitment and selection processes are on the whole satisfactory with evidence that at least two or more written references are being obtained as well as proof of identity, an occupational health check and a full employment history in some cases. The inspector examined four new staff files and identified that two had gaps in the employment history and one required a further reference as she had only worked with the referee for two month. Recruitment practice in the main met Regulation 19 but it was noted that two staff started work following a POVA First check; records demonstrated that the full CRB was not received back until after the staff member had started work. The Manager assured the inspector that all new staff work with another carer on induction for 2 to 4 weeks and longer if the CRB is not back at the end of the induction. The Manager must evidence this explicitly on the duty rotas. The Manager is also required to complete a documented risk assessment to describe the processes that are in place when starting staff with only a Povafirst check. The Manager is to implement an interview proforma, which will act as a checklist for the personnel file. Samples of CRB ‘s were seen by the inspector and to comply with data protection these must all now be shredded. Manual handling training records seen confirmed that all staff receive the appropriate mandatory training and that this is ongoing. Training is well supported by regular supervision sessions and yearly appraisals. This is well recorded in the home and demonstrates a proactive approach to staff personal development. The manager is to develop a training matrix to ensure that she has this information at a glance. Nazareth House DS0000016506.V336578.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): 31, 33, 35, 36 & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using the service are safeguarded by good management practice. There is good leadership, guidance and direction to staff from the manager, which ensures that people receive quality care within a safe environment. The home needs to develop its quality assurance system by reviewing its performance and writing a quality assurance report to demonstrate continual improvement and development in the service. EVIDENCE: The staff reported that the Manager is approachable and has an open door policy so is accessible at all times. They feel they have good support from her and have their annual appraisals with her. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 24 The Manager meets domestic staff regularly and they are supervised and appraised by her staff, catering staff are supervised by the Chef. Staff spoken with all said they received supervision and appraisals and the deputy managers now carry out supervision for staff on their floor, and they confirmed this and also enjoy doing this. The Manager does have regular formal staff meetings albeit twice a year, although all the staff are seen on a daily basis at handovers and many staff feel more confident discussing issues on a ‘one to one’ basis, rather than in a large group. The Manager discussed ways of meeting with and supervising the night staff on a regular basis that she will implement, as this is lacking at the present time. Evidence was available to demonstrate that staff receive mandatory training and other training pertinent to their needs. This is implemented through a variety of training organisations and includes fire, health and safety, infection control, moving and handling, food hygiene and first aid training etc, the training records for some staff were seen. Policies and Procedures are reviewed and updated yearly or on an as and when needed basis There are a variety of regular minuted meetings for the home to gain feedback from the people living at the home about the running of the home, food, activities etc and these are very well attended, minutes were seen. There is also a Friends of Nazareth House meeting each month where the voluntary visitors meet with the residents and talk through activities/ events/issues. These volunteers act as a support network for people and visit them as and when or act for them if there is a concern. The Manager has completed the Fire risk assessment for the home. The pre-inspection AQAA confirmed that all equipment is regularly serviced and health and safety checks are in place and they are monitored and reviewed. The environmental checks and the maintenance issues are recorded to evidence the ongoing checks that are in place. The home has quality assurance systems in place. Results of resident and relative surveys for 2006/07 were seen during the inspection. Some of the comments from the relative’s surveys indicated that they felt they did not have enough information about the home, did not know how to complain and did not know about/have access to the inspection reports. But the Manager explained that everyone is given a statement of purpose and information on admission to the home and that the inspection report is openly available by the lift and stairs in the home. But she will look at ways to address these issues one way might be to put the information on the table with the signing in book at the entrance to the home, so that people see it and read it. Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 25 There were a few people who were not always satisfied with the food or the activities provided but on the whole, most of the responses to the questions asked were positive. Staff surveys seen for 2007, comments were very positive about home management they felt there was clear leadership; good support, adequate training, problem and issues were addressed as they were identified and most felt appreciated. One issue raised was the storing of hoists in the locker room and the manager is to look at this issue. A variety of audits are in place and are done throughout the year to examine quality and effectiveness of systems in the home. It was required that these audits be drawn together in a quality report to demonstrate the outcome of the audits and the action implemented for continuous improvement. Some of these audits were seen during the inspection; Auditing tools for care practice need to be formalised and developed further. Whilst the home audits the views of relatives and people living at the home, it is essential that views be sought from GPs, chiropodists, hairdresser, Community Nurses and other community stakeholders to give a holistic assessment of the quality of service provided to people by the home. All of this information should then be drawn together to form an internal quality audit report that is published in the home to demonstrate the strengths and improvement areas for the home to benefit the people living there. This information would then inform the annual development plan for the home and demonstrate the cycle of continuous improvement and quality of service that the home strives for. There is administrative support for fee invoicing, contracts, wages and personnel issues within the home and the Manager is working closely with her to set up some new systems to make the personnel management more streamlined to enable all records relating to staff to be held in one place. All financial dealings are completed through the invoicing system except for personal monies. Some people manage their own personal monies and lockable facilities are available. The Manager also has an accounting system for personal monies managed by the home with written records of transactions that are auditable. Nazareth House DS0000016506.V336578.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. ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 2 3 4 5 6 4 4 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 4 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 4 3 X 3 Nazareth House DS0000016506.V336578.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. 2. Standard OP18 OP29 Regulation 13(6) 19 sched 2(6) Requirement Mental Capacity Act training for all staff The Registered Person must ensure that a ‘Risk assessment’ is documented for staff starting work on a Povafirst check, describing how people are protected from possible harm The Registered Person must address the issue relating to people requiring medication at Night to ensure it is fully compliant with the required standards for medication practice. The Registered person must produce an annual quality assurance report to evidence the review of the quality systems in the home. This must include stakeholders’ views and future developments in the home Timescale for action 30/12/07 30/09/07 3. OP9 13(2) 30/09/07 4. OP33 24(2) 31/01/08 Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 28 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 OP29 Good Practice Recommendations The Manager must evidence on the duty rotas where new staff, with only a Povafirst check, are working with another member of staff. All CRB’s to be shredded to comply with data Protection. Implement audits of the following within the home as part of the Quality Assurance programme: • Care records. • Care practice. A quality assurance policy and procedure should be devised to detail how the systems are used within the home and how this affects the development of the service OP29 OP33 4. OP33 Nazareth House DS0000016506.V336578.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000016506.V336578.R01.S.doc Version 5.2 Page 30 - 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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