Inspection on 13/03/06 for Nazareth House

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Nazareth House 12/08/08

Nazareth House 01/10/07

Nazareth House 31/05/06

Nazareth House 13/09/05

Nazareth House 10/03/05

Nazareth House 23/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nazareth House Hammersmith Road London W6 8DB Lead Inspector Jacqueline Derbyshire Unannounced Inspection 13th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 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.V285218.R01.S.doc Version 5.1 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 The Congregation of the Sisters of Nazareth Sister Celine Marie Donnelly Care Home 95 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (65), Terminally ill (5) of places Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 65 beds for elderly medical patients over the age of 60 years of which 5 patients may be received for pallative care for a terminal illness and 25 patients may have a diagnosis of Alzheimer’s Disease. 13th September 2005 Date of last inspection Brief Description of the Service: Nazareth House is registered to care for a total of 94 service users, 73 of which require nursing care and 25 of which have dementia. The home is owned and run by The Sisters of Nazareth. There are currently 87 service users living in the home. Care is provided by a staff team comprising nurses, care assistants, cleaning, catering, administrative and maintenance staff. The home is situated over three floors and accommodation is provided both in single and double rooms. There is lift access to all floors. The home has a very large garden that service users use on a daily basis. Inside the home there is a small library, chapel, hairdressers and a shop. The home owns a specially adapted vehicle for local trips outside of the home. The home is situated in Hammersmith and is close to public transport links and local amenities. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 13th March 2006. Three Inspectors spent a total of 10.30 hours talking with service users, the Deputy Manager, the Administration officer, nursing staff, and care staff, inspecting care and staff records and touring the premises. One of the inspectors spent time looking at medication records. Four of the five requirements set 13/09/05 have been met and two of the three recommendations. The staff were seen on all floors to be interacting with service users, the inspectors were impressed with the number of staff on duty. There is an immediate requirement notice left at Nazareth House regarding numerous medication issues that are noted in this report, the Registered Manager will have to reply to this letter in the form of an action plan to make sure all of the issues are dealt with appropriately. What the service does well: What has improved since the last inspection? All service users have a contract in place that is signed and dated. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 6 Risk assessment records have improved to show how actions have been made to minimise risk areas. All nursing staff ensures that control drug records are completed when arriving at the home. Staff recruitment information files have all relevant information in place for all staff. The staff files are in order for easy access for inspectors to check relevant information. An ongoing requirement for all sluice rooms to be replaced and decorated is taking place as written in the homes action plan. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 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 DS0000010917.V285218.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Contracts are in place for all service users that have been agreed signed and dated. EVIDENCE: The inspectors looked at three service users files and each file had a contract agreement enclosed. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 and 10 Care plans are in place for all service users that show how the home is meeting the service users needs. The medication procedures have to be checked and monitored, as there are numerous issues that have to be dealt with that nursing staff are omitting to do. All service users personal care provision is provided in the privacy of their own room or in one of the designated bathrooms. EVIDENCE: The inspectors looked at three service users care plans and they were found to be up to date and very informative. All areas of health, personal and social care needs are covered. The care plans are reviewed on a monthly basis with records showing when the care has changed for a specific reason. Risk assessments were seen to be in the three files and the assessments corresponded with the care plan that showed risk areas with action plans in place to minimise any risk. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 10 An Inspector spent time checking medication on all floors as requirements had been made in September 2005. The Inspector found a lot of mistakes had taken place such as MAR sheets not being signed when medication had been dispensed, there were two issues that this had been ongoing for three weeks. Fridge temperatures on one floor was set to cold and had been for a while, this was being recorded however certain medication cannot be used if not kept at a certain controlled temperature. Bottles for liquid medication including eye drops had no opening dates on them. Other medication procedure issues were found and Immediate requirements have been set, the Manager will set an immediate action plan in place to ensure the medication procedure is followed by all nursing staff as written in the NMC Code of Practice. The inspectors spent time on each floor and service users were seen to be having personal care assistance in their own rooms or in a designated bathroom. All shared rooms have screens in for privacy. The inspectors spoke with 10 service users who were very positive about the care they are receiving. Staff have induction training that leads onto NVQ level 2 in care this covers all areas of ensuring that service users rights in privacy and dignity are always maintained. There is a Doctors room that service users can see the Doctor in or the Doctor will visit the service user in their own room. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were covered at this inspection as they were looked at in September 2005. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were covered at this inspection as they were looked at in September 2005. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The environment was seen to be clean and tidy in all areas. EVIDENCE: The inspectors spent time on all floors; each floor was seen to be clean and tidy with no unpleasant smells in any area. The home employs a cleaning contractor to complete all cleaning tasks in the home that is monitored by the Management team. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The home has a sufficient amount of staff working in all areas. The homes recruitment policy to show that staff references have to be followed up for validity specifically when not written on professional letter headed paper. EVIDENCE: All of the floors had sufficient staff on to meet the needs of all service users. Service users all stated that they were happy with the staff and that all of their needs were being met. Five staff files were checked for all relevant information including recruitment checks. All five staff files had all relevant documentation in place including up to date CRB records. There is an issue that the two required references have been validated by the Manager or the Administration officer as references were accepted without being written on headed paper and in some instances were returned on the homes letter. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The home has an effective quality assurance monitoring procedure in place. EVIDENCE: The home has regular meetings with service users, relatives and friends to look at any areas of concern they may have regarding the care provision from Nazareth House. Questionnaires are also given to service users to complete and their families, friends, advocates and social services placement officers. Forms were seen in place around the home for anyone visiting to complete. Service users have regular reviews and issues can be taken from them. There are monthly Person in Control visit records were all areas are looked at any actions are recorded and monitored. The Manager, Deputy Manager and administration officer complete audits of specific areas including: service users finances, food provision, medication, staff training, policies and procedures and ensuring records are completed by staff and are up to date. All of the information has been collated and action Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 16 plans have been put in place to meet any recommendations to improve the service provision. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 2 Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 12 Requirement Timescale for action 14/04/06 2 OP9 12 Records to be in place for food and drink intake monitoring as written in care plans and risk assessments. Medication must be given as 13/03/06 prescribed and all medication prescribed must be signed for. Immediate Tip ex or any other correction fluid must not be used on the MAR sheets. Medication risk assessments must be updated and reviewed. The date of opening must be noted on bottles of all liquid medication. Immediate Steps must be taken to ensure that tablets are securely stored and that they are all accounted for. Immediate Medication must only be given to service users whose name appears on the prescription label. Immediate All medication storage rooms and fridges to be monitored daily to ensure medication is kept at a DS0000010917.V285218.R01.S.doc 3 OP9 12 17/03/06 4 5 6 OP9 OP9 OP9 12 12 12 17/03/06 17/03/06 13/03/06 7 OP9 12 13/03/06 8 OP9 13 13/03/06 Nazareth House Version 5.1 Page 19 safe storage temperature. This is a repeat requirement. 9 OP29 19 The Manager to ensure that all recruitment references are checked for validity. 16/04/06 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. Refer to Standard OP38 Good Practice Recommendations Water temperatures to be checked and recorded before service users have a bath, records to be taken in all bathrooms. Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nazareth House DS0000010917.V285218.R01.S.doc Version 5.1 Page 21 - 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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