Inspection on 12/05/08 for Nazareth House

This inspection was carried out on 12th May 2008.

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 26/03/09

Nazareth House 22/05/07

Nazareth House 04/09/06

Nazareth House 22/02/06

Nazareth House 30/09/05

Nazareth House 16/03/05

Nazareth House 15/12/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Nazareth House Liverpool Road Crosby Liverpool Merseyside L23 0QT Lead Inspector Mrs Trish Thomas Unannounced Inspection 12th May 2008 11:00 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 DS0000005384.V365147.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 DS0000005384.V365147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address Liverpool Road Crosby Liverpool Merseyside L23 0QT 0151 928 3254 0151 9287723 nazarethhouse@crosbyuk.freeserve.co.uk 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) Sisters of Nazareth Sister Johann Rose Ita Doody Care Home 66 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (64) of places Nazareth House DS0000005384.V365147.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 only: Code PC, to people 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 (maximum number of places: 64). Dementia over 65 years of age: Code DE(E) (maximum number of places: 2). The maximum number of people who can be accommodated is: 66. Date of last inspection 22nd May 2007 Brief Description of the Service: Nazareth House is a care home for older people owned by the Sisters of Nazareth. The registered manager is Sister Rose Ita, who has many years experience in health care and service to the community. The ethos of Nazareth House is rooted in Catholicism and there is an integral chapel with daily Mass for those who live there. The religious beliefs of service users of all denominations are respected in this home through arrangements for visiting ministers accordingly. Nazareth House accommodates sixty-six residents and to ensure a homely and personalised service, the accommodation is divided into three self-contained floors or units. Each unit is individually managed by nominated senior staff, under the supervision of Sister Rose Ita, who has ultimate responsibility for the day-to-day management of the home. Nazareth House is situated on the main Liverpool to Southport Road with close links by public transport and nearby shops, a cinema, local churches, and a wealth of local amenities. The fees charged in Nazareth House are £399 - £450 per week, hairdressing is charged for as an extra. Nazareth House DS0000005384.V365147.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 two stars. This means that people who use the service receive good quality outcomes. We (the commission) carried out an un announced visit to Nazareth House. The methods we used to assess the service against National Minimum Standards included discussion with residents, staff and the manager, Sister Rose Ita. To ensure that the home is managed in residents’ best interests, records on health & safety and staffing were read. A sample of six care files was assessed in detail to ensure that staff have the guidance they need to support each person. To assess environmental standards, we made a tour of the premises and grounds, visiting communal areas, bedrooms and utility areas such as the kitchen and laundry. The manager completed the Annual Quality Assurance Assessment (AQAA) and returned it to us. This is a self-assessment document, which gives us information about how the home has improved in the last twelve months, plans for ongoing development of the service and barriers to improvement (if any). Information we have received about Nazareth House in the past twelve months was reviewed as part of this assessment. Questionnaires returned to us by residents and staff of Nazareth House, were read, and the comments received are included in the report. What the service does well: People have had their needs assessed and are given the service user guide and statement of purpose before they move in. This means they have plenty of information about the service before making a decision as to whether Nazareth House will make a suitable home for them. The service user guide informs prospective residents that people who are not of the Catholic faith are welcome and will be supported in following their personal religious beliefs. The care plans, which were looked at in detail, were relevant to each individual’s care needs, giving staff the guidance they need to support each person. Eight residents, who returned questionnaires to us, were satisfied with the care in Nazareth House. A visitor said his mother is well looked after and comfortable in Nazareth House and that the staff are, “Very good”. To ensure that staff have the skills and guidance they need to support people, Nazareth House provides a range of training and written procedures for them. Over fifty percent of staff have NVQ qualifications and ancillary staff also receive training which supports their roles and responsibilities. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 6 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 DS0000005384.V365147.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Prospective residents have had their needs assessed and have the information they need to make a decision as to whether Nazareth House will make a suitable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1, 3. People are given plenty of information about Nazareth House in the service user guide, before they move in. This helps them to make the decision as to whether this will be a suitable home. Eight residents who returned questionnaires told us they were satisfied with the way they were introduced to this home and the support they received when moving in. For one person, the home had been recommended, another person said her family looked at a number of care homes and chose Nazareth House on her behalf. Care files contained pre-admission assessments carried out by social workers and by staff from Nazareth House. By carrying out an assessment for each individual who is referred, staff from the home are able to be sure the service Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 9 can meet each person’s needs before the person moves in. A standard assessment document is followed in Nazareth House, which looks at each individual’s physical and mental health, sensory and mobility needs and personal care needs. The diversity of prospective residents is recognised through recording their social needs and preferences, religious beliefs and family contacts as part of the overall assessment. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. For staff guidance, each person’s health and personal care needs are set out in an individual care plan and their diversity and privacy is promoted by staff in care giving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7, 8, 9, 10. Care plans for six people were looked at in detail. These, in addition to regular reviews and risk assessments, give staff the information they need to support the people who live in Nazareth House. There were care plans in place to meet the assessed needs of each person, including those for pressure care, mobility and emotional support. In eight questionnaires, which had been filled in by residents and returned to us, they told us that they were satisfied with the care they receive in Nazareth House. A visitor said his mother is well cared for and comfortable and there is always plenty of staff around whenever he calls in. A resident said, “The staff are very kind and nothing is too much trouble.” Residents’ diversity is respected through the support they receive for their health needs and frailty. All residents are registered with local doctors and Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 11 receive services from specialist medical and paramedical services. There was evidence of medical interventions clearly set out in people’s care plans, which also record of input from paramedical services, such as chiropodists, and from district nurses for dressings and pressure care support. A range of environmental mobility aids is provided throughout Nazareth House and there are risk assessments and plans in place to support people’s to get around, which promotes their independence. There are policies and procedures for staff to follow in managing residents’ medication and residents may self-medicate, subject to risk assessment. The medication administration records were well maintained and there are designated medication rooms and cupboards/trolleys for secured storage of drugs. There is an audit trail of medication accepted in to Nazareth House and returns to the pharmacy are recorded, to ensure that all drugs are accounted for. Staff who give out medication said they have received relevant training and have clear procedures to follow to avoid the risk of mistakes. Three members of care staff who were spoken with discussed how they show respect for residents’ privacy and dignity. They were aware of the service principles relating to this, saying they have received training and have policy guidance to follow in care giving. Staff were observed addressing residents respectfully and their privacy was being respected in care giving through keeping bedroom and bathroom doors closed. Care records are stored securely in offices on each floor and, for staff guidance there are policies on confidentiality and data protection in Nazareth House. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. The lifestyle in Nazareth House meets most residents’ expectations and the diversity of all is respected, however more attention should be paid towards increasing support and choices at mealtimes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12, 13, 14, 15. There is a wide range of opinion amongst residents of Nazareth House about activities and socializing. Although there are plenty of books, magazines and games in Nazareth House, some people said there is little to do and some days are very quiet. A resident said she gets “comfort” from attending Mass each day. Another said she stays in her room and does not need to be entertained. A resident said, “There could be more to do, the lady who used to arrange things like that has left now.” Another person asked for more classical music, as this was what he has always liked to listen to before moving in. The manager confirmed that a member of staff has left recently and the activities co-ordinator post is currently being recruited. In response to the information received, a recommendation is made that residents are consulted daily about what they would like to do, and arrangements made according to their preferences. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 13 Residents said that their visitors are made welcome and a visitor confirmed this saying he calls in at different times and there is always plenty of staff around. He said he is offered privacy with his relative and staff are approachable and pass on any information he needs regarding his relative’s care or condition. Staff take pride in the standard of meals and the quality of food served in Nazareth House. However, residents and staff on duty during the visit had not been informed of what was on the menu for the day. A member of staff said, “We don’t know what the meal is until the trolley arrives.” A resident on her way into the dining room said, “I don’t know what I am having until I get there.” The cook said that menus are produced and should have been distributed to the three floors where residents are accommodated. A recommendation is given that residents are to be provided with a menu and details of alternatives available, before each meal. In this way their choices and preferences will be catered for. There is a dining room on each floor and each is bright, clean with tables carefully laid, having enough place settings for each person in residence. Meals will also be served to people in their bedrooms if that is what they prefer. There is a small kitchen attached to each dining room, where breakfasts, snacks and drinks are prepared. Hot meals are cooked in the main kitchen and brought to each floor in heated trolleys. Qualified cooks are employed in the main kitchen and there is a team support staff for clearing away and cleaning duties in the kitchen and dining rooms. Food stocks of fresh, frozen, chilled and dry foods were substantial, and were safely stored and labelled. The kitchen is well managed as catering records, which were read, had been well maintained. Staff who were serving the meal, during the visit, were not aware of a resident’s special needs regarding the foods which can be tolerated. This person has difficulty in swallowing, due to a medical condition. A recommendation is given that alternatives are offered to this person, which can be easily ingested, (as discussed with staff during the visit). Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. Residents are protected through training and procedures in Nazareth House and they know their complaints will be listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 and 18. Nazareth House has a complaints procedure, which is given to residents with the service user guide. There is also a copy of the complaints procedure placed in residents’ bedrooms to ensure they have access to it whilst they are living in the home. Seven residents who filled in questionnaires said they knew about the complaints procedure, one person told us she was not sure about it but has never had cause to use it. There has been one complaint about Nazareth House to CSCI since the last visit. This was an alleged breach of confidentiality by a senior member of staff. The findings of a provider investigation were that the complaint was not upheld. The outcomes were sent to us within given timescales and the manager confirmed that the person who made the complaint has also been informed, and has accepted the findings. There has been one safeguarding referral about Nazareth House since the last inspection. A member of staff has been dismissed and referred to the POVA (Protection of Vulnerable Adults) list. The findings of this investigation highlighted an instance where recruitment procedures had not been followed, Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 15 and where (although staff had received training and had guidance to follow), a safeguarding alert had not been passed on to the floor manager or the manager of the home for action. Sister Rose Ita confirmed during the inspection, that three members of staff have received written warnings under the organisation’s disciplinary procedures as a result. Also recruitment procedures have been reviewed and issued to people who are involved in interviewing staff and checking criminal records bureau clearances and references. It is evident that action has been taken to ensure safeguarding procedures will be followed in future in Nazareth House. Sister Rose Ita confirmed that she has been in contact with Sefton Council’s safeguarding co-ordinator and further training in safeguarding has been arranged for all staff to ensure they are aware of the procedures to be followed in alerting suspected abuse. Three staff who were spoken with, said they have received safeguarding training and showed awareness of abuse indicators and the alerting procedures to be followed. It is evident that the manager has taken action without delay to identify shortfalls in adherence to recruitment procedures and has addressed them, to avoid future occurrences of people who are unsuitable being employed in the home. Nazareth House DS0000005384.V365147.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): Quality in this outcome area is good. Nazareth House is clean and well maintained, making a comfortable home for people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19 and 26. A tour of the premises was carried out and discussion took place with residents, the manager, staff and the maintenance person. En-suites with showers have been fitted in rooms, which were previously used as double bedrooms. A resident said, “I am very pleased to have my own bathroom and toilet, it is so much more convenient and private.” The completed work and fittings in the en suites appear to be to a very good standard. The building throughout was clean and odour free. The lounges are decorated and furnished in domestic style and seating for residents is comfortable. The dining rooms are pleasant and bright with serving units attached. The main kitchen and laundry are well equipped, well organised and infection control and COSHH (Control of Substances Hazardous to Health) procedures are in Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 17 practice. The training schedules show that domestic staff are trained to NVQ Level 2 in hospitality. Domestic staff (employed for general duties, kitchen duties and laundry duties) are provided with protective clothing and are on duty every day. Residents’ bedrooms are highly personalised and are individual in aspect and decoration with pleasant views of the grounds. There are assisted baths and toilets on all floors in addition to en-suites. There is a range of moving equipment (hoists) and aids to mobility, grab rails, raised toilet seats, and two passenger lifts. There is a function room on the ground floor where residents from the three floors may meet and socialize. There is also a reception area with close circuit television to the car park for security. There is an integral chapel where Mass is said daily for residents and the religious community. There is ramped access to the front of the building. The service is provided over three floors and all have access to outside space, either garden or raised terraces. The gardens are well maintained with ample parking spaces at the front. A full time maintenance person is employed for the general upkeep of Nazareth House. He confirmed that work has been carried out on the main drain, which runs beneath the ground floor corridor. This has helped to cut out the odours that had been caused through wear on the drain linings. Residents said they were satisfied with their accommodation. A visitor said, “My mother is very comfortable here, she could not ask for more. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. Residents are protected through staff training and recent improvements to recruitment procedures in Nazareth House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. Five members of staff who returned questionnaires told us they have good support from management, one member of staff told us they would like better communication with the manager. All staff said that they receive plenty of training. Three members of care staff who were spoken with during the visit said they have NVQ qualifications and they said they were happy working in Nazareth House and there are regular handovers and staff meetings. During the inspection, residents said they are well supported by staff and this was confirmed in eight questionnaires, which were returned to us by people living in Nazareth House. The staff rosters for each floor gave a true representation of staff who were on duty on each floor, during the visit. A visitor said there is always plenty of staff on duty whenever he visits. There is a training officer and training schedules give evidence of ongoing mandatory training and updates for staff. Over fifty percent of staff have NVQ qualifications and staff said they felt the training on offer is in keeping with their roles and responsibilities. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 19 A sample of three staff files was read and these gave evidence of the recruitment procedure, which is followed in Nazareth House. All files had satisfactory CRB (Criminal Records Bureau) clearances in place, and two references (one from the most recent employer). Each person had filled in an application form before being interviewed, stating their employment dates and qualifications. Each file contained an official document to give proof of the person’s identity. Staff who are employed in Nazareth House are issued with job descriptions and contracts of employment and have access to a grievance procedure. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. Nazareth House is managed in a way, which values residents’ opinions and protects their welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards, 31,33,35,38. Sr. Rose Ita was registered as manager of Nazareth House in 2007 and has a management qualification and many years experience in care. She is currently undertaking a foundation degree course in protecting vulnerable adults. To support the manager, a care co-ordinator has been employed, whose duties include managing the ground floor unit. There is an administration team, which consists of a finance manager a human resource manager and a training manager. There is a care manager on each floor with responsibility for directly supervising care staff and domestic staff. Senior care assistants are appointed on each floor who have supervisory duties and responsibility for managing Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 21 medication. There is a system of key workers to ensure a personalised service and a named contact for residents. People living in Nazareth House confirmed that staff do not take control of their personal finances. There is a system for keeping records of any personal allowances held on behalf of residents and of retaining receipts for any purchases made on behalf of any person. There was evidence that for one resident, her family look after her financial affairs and all residents without personal representation have access to advocacy services if needed. There is a quality assurance system in place. Questionnaires are distributed twice yearly to residents, relatives and staff to obtain their opinion of the service. The outcomes are used to develop the service in accordance with the feelings and opinions of people who use it, their families and the staff. To make sure the building is safe, a series of health & safety checks are carried out by maintenance staff and qualified engineers. Health & safety documentation and safety certificates were in date at the time of the visit. The fire book is well maintained and to ensure residents’ safety in case of fire, the alarm system is checked every week, regular fire drills take place, and fire equipment tests carried out at regular intervals. There is a system in place for recording accidents in Nazareth House and the records had been well maintained at the time of the visit. For residents’ safety, the accident records are routinely monitored and risk assessed. Remedial action is taken to address any identified factors present when accidents occur and/or mobility plans for the individual will be reviewed to ensure they are properly assisted through aids, equipment and staff support. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP15 OP15 Good Practice Recommendations To ensure the social needs of all residents are addressed, there should be daily consultation with them about what they would like to do. Residents should be informed of what is on the menu each day to ensure their right to choice is respected. Staff who serve food should be made aware of the special dietary needs of each individual, to ensure the person receive suitable food, and appropriate support at mealtimes. Nazareth House DS0000005384.V365147.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 DS0000005384.V365147.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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