Inspection on 14/04/08 for Nazareth House

This inspection was carried out on 14th April 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Nazareth House 08/02/10

Nazareth House 30/10/09

Nazareth House 10/09/09

Nazareth House 06/04/09

Nazareth House 25/04/06

Nazareth House 07/02/06

Nazareth House 27/07/05

Nazareth House 08/02/05

Nazareth House 01/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Nazareth House 118 Harlestone Road Northampton Northants NN5 6AD Lead Inspector Linda Clarke Unannounced Inspection 14th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nazareth House DS0000012866.V362271.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 DS0000012866.V362271.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address 118 Harlestone Road Northampton Northants NN5 6AD 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) 01604 751385 01604 580435 sheila@naznptn.plus.com The Congregation of the Sisters of Nazareth Mrs Deborah Elizabeth Miller Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home limits its services to the following service user categories:Care Home personal care only - up to 52 service users within the OP over 65 years category Between the dates of 23.04.05 to 03.05.05 no one falling within the category of OP may be admitted into the home where there are 53 service users who fall within the category of OP already accommodated within the home Between the dates of 23.04.05 to 03.05.05 a named service user can be accommodated in Room 6 of Zone 3 of the home. Between the dates of 23.04.05 to 03.05.05 - 53 service users within the category OP can be accommodated within the home 25th April 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Nazareth House is a care home providing personal care for Older People, it is a large home located on the outskirts of Northampton. The home has been established for many years and is run by The Congregation of the Sisters of Nazareth who also offer a comprehensive range of spiritual support and guidance to meet the individual religious needs and preferences of people living within the Home. Mass and The Rosary are celebrated in the Church, which is attached to the Home on a daily basis. Accommodation is provided over the ground and first floor, with access to the first floor being via a passenger lift, the ground floor provides all the communal amenities, along with bedroom and bathing facilities, whilst the first floor provides additional bathing facilities and bedrooms. Bedrooms in some instances include an en-suite facility. Nazareth House has a large and very well maintained garden, with mature trees, shrubs and plants and benefits from a large water fountain. Information about Nazareth House is provided in the form of a Service Users Guide and a Statement of Purpose. The Manager provided information on the day of the site visit with regards to fees. Fees range from £469.00 to £539.00 per week; the fee charged is dependent upon the specification and amenities of the personal accommodation. Nazareth House DS0000012866.V362271.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 1 star. This means the people who use this service experience adequate quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service and previous Inspection Reports. We (the Commission for Social Care Inspection) sent surveys to sixteen people who use the service of which three were completed and returned, sixteen surveys were sent to families and friends of people using the service, of which four were completed and returned, five staff surveys were sent out of which none were returned, and twelve health and social care professional surveys were sent out of which one was returned. The unannounced site visit commenced on the 14th April 2008, and took place between 09:00 and 16:45 The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff of Nazareth House. Four people accessing services were selected, with a range of individual needs. Discussions were held with seven people living at Nazareth House, one relative and four members of staff and the Manager. What the service does well: As part of the assessment process information about a persons life and work experiences is ascertained, which enables staff to have an understanding of a persons life prior to moving into Nazareth House, and enables staff to provide activities and converse on topics of interest with the individual. Nazareth House through the Church, the Chaplain and the Sisters provide spiritual guidance and support, and provide frequent opportunities for those individuals who are of the Roman Catholic Church to participate in Mass and The Rosary, by holding daily Services. People residing at Nazareth House benefit from a large and very well maintained garden and manicured lawn, which is accessible to all. The garden Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 6 includes a large area of lawn, mature trees, shrubs, plants and flowers and a large water fountain. Surveys, which were returned to us, included additional positive comments, some of which are as detailed. • Genuinely caring, always cheerful and friendly. Good food, comfortable and welcoming. They make sure the health needs are met, and the home is kept clean and tidy. Clean, pleasant environment. Caring staff. A proper, ‘tender loving care’ service. • • What has improved since the last inspection? What they could do better: The management of the Home needs to be pro-active to ensure that agencies responsible for the regulation of the Home are advised as to changes in Management and services provided, and that such changes are reflected in documentation which provides information to those considering moving into the Home. People living at Nazareth House have the potential to receive care, which is more individualised by the introduction of care plans, which are regularly reviewed and include information about their expectations of care, and their views as to how their care should be delivered. Daily records could also be improved to include all aspects of a person’s daily life, including participation in activities and visits to or from relatives and friends. People living at Nazareth House need to have confidence that their welfare is protected, and that they are provided with information, which advises them as to their rights, and how to raise concerns. Individuals living at the home need to be supported by staff who have been recruited as a result of a robust recruitment process, that ensures all pre-employment checks are carried out prior to their commencement of work, and that staff are trained and Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 7 knowledgeable as to their role and responsibility in safeguarding people from abuse. The involvement of people using the service and the gaining of staff views needs to be used with greater effect to improve the service, by ensuring that people using the service are advised as to the outcome of quality assurance processes, and that staff receive regular supervisions to comment on, monitor and improve the care they deliver. Surveys, which were returned to us, included additional comments as to areas of improvement some of which are as detailed. • More trips out could be arranged for those able to go, and more en-suite facilities. 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 DS0000012866.V362271.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 DS0000012866.V362271.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 and 3. Standard 6 is not applicable, as the Home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the Home do not have access to information that is up to date, however they can be confident that there needs will be assessed to ensure that the Home is best suited to them. EVIDENCE: People considering moving into Nazareth House are provided with information in the form of the Statement of Purpose and Service User Guide, which outlines the services provided by the Home, both documents require updating. Documents currently state that the Acting Manager of the home is the Registered Manager, which is inaccurate, as the current Acting Manager has not submitted an application to the Commission for Social Care Inspection, to become Registered. Other inaccuracies include information with regards to the Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 10 environment and the facilities offered, there has been a reduction in the number of places available, and an increase to en-suite facilities. Information with regards to current fees payable also requires updating. The Registration Certificate of the service details the name of the Registered Manager and not the current Acting Manager The format of both documents could be improved to help individuals who are considering accessing the Home to have a clearer vision of the Home by the inclusion of photographs. People accessing the Home have a Contract outlining the terms and conditions of occupancy, contracts are regularly reviewed and a copy is kept within the Acting Managers office. Individuals considering moving into Nazareth House have their needs assessed, to ensure that the Home is appropriate for them. Where individuals care is funded by Social Services an assessment is also undertaken by a representative of Social Services in addition to the Homes assessment. Nazareth House DS0000012866.V362271.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 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People residing at the Home have their health and personal care needs met, however in some instances care plans are not regularly reviewed, which has the potential for some individuals to receive care and support which is not appropriate to their changing needs. EVIDENCE: People living at Nazareth House have a care plan, which details their health and personal care needs. We looked at the care plans of four people living at the Home on the day of the site visit, three of the care plans had been reviewed every month, one care plan had not been reviewed for four months, the Acting Manager did not know why this was the case. Care plans reflect the personal care and support each person requires to maintain a healthy lifestyle, whilst maintaining their independence. Care plans include risk assessments where potential risks to the individual are known, Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 12 such as falls. Staff by reading a care plan have an understanding of the needs of the person and their role as a member of staff in offering support and guidance. Additional information is now included within care plans, which was identified as a shortfall at the last Key Inspection, nutritional assessments and monitoring of peoples weight is now in place. We discussed with the Acting Manager how care plans could be further developed to include the goals and aspirations of people living at the Home, along with information as to there preferred daily routines, this is known as person centred care, and supports an holistic approach to care. Daily records reflect individuals access to health care professionals and their general health, details within daily notes could be extended to include information about how the person spent their day, such as engaging in activities, reading, sitting quietly etc. along with information about their general well-being this would reflect a more holistic approach to care and support person centred care. The medication records of the four peoples whose records were viewed were found to be in good order, we observed the Acting Manager administering medication in the morning and at lunchtime, this was done in a manner to promote the welfare and safety of people living at the Home. Care plans include information for staff about how people using the service should be treated with consideration to their right to privacy and dignity, we observed staff interacting with people living at the Home throughout the day, and noted that staff spoke politely and acted in a manner and with consideration to the persons dignity. We spoke to a number of people living at Nazareth House, and when asked about the care they receive, and the attitude of staff the following comments were made: “The quality of the care is very good, but it’s not as good as it use to be, a lot of the older staff have left, but the staff are very kind and caring.” “Staff are pretty good and have a good attitude.” “The attitude of staff on the whole is very good, they’re very friendly.” “I wouldn’t be anywhere else, the care staff are lovely, and I’m glad and very happy to be here.” Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 13 Information about individuals wishes with regards to ill health, dying and death are included with care plans, a majority of people we spoke with were Roman Catholic, and received great comfort in knowing that the Sisters and the Chaplain would be available, when necessary to provide support and Services required by the Roman Catholic Faith. We spoke with a visiting relative who made the following comment: “The care is very good, my relative has expressed happiness in being here, and they receive the spiritual comfort they need. The attitude of the staff is lovely, particularly the keyworker who keeps me informed about my relative, they are pro-active with regards to the care they provide.” We sent surveys to health and social care professionals, the information we gathered from the surveys is that the health and social needs of people are met by the Home, and that individuals’ privacy and dignity are respected. Staff at the Home seek the advice of professionals, and in the view of the professionals there advice is acted upon. Nazareth House DS0000012866.V362271.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People residing at Nazareth House have their recreational and spiritual needs met. EVIDENCE: Nazareth House provides a range of activities for people who live at the Home to participate in. In the morning we observed the Activities Organiser engaging people in a range of activities, which included darts, picture bingo and skittles. In the afternoon we observed people participating in exercises which involved kicking a ball, enabling people to maintain mobility and ease of movement. In the evening an outside entertainer was to visit the Home to play the piano and encourage people to take part in a sing-a-long. We saw the Sisters supporting people in walking around the garden, everyone we spoke with commented on the gardens, which are accessible to all. Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 15 Information about peoples lives is included as part of their care plan, and includes information on their family, work and social life, hobbies and interests, which enables staff to have a greater understanding of a persons life, and to provide conversation and activities of interest. Visitors are encouraged to visit without restriction, and contact with family and friends is encouraged, people living at the home have access to a pay phone whilst some individuals have a telephone with an independent number and line in their bedroom, which is available at an additional cost. Nazareth House has a Church, which is attached to the Home, and is looked after and cared for by the Chaplain and the Sisters. Mass is celebrated daily with two services being held in the morning, and the Rosary in the evening. Additionally on a monthly basis services are held for those who are not of the Roman Catholic Faith. People we spoke with on the day, who are of the Roman Catholic Faith said that their spiritual needs were of great importance to them and their attendance at Church was a source of comfort. Throughout the day we observed the Sisters walking around the home speaking with everyone including visitors and staff. We spoke with some of the Sisters who spoke of their involvement in the Home, and the support and comfort they along with the Chaplain offer. We sent surveys to people who use the service, the information we gathered from the surveys is that people take part in the activities provided by the Home, and all expressed satisfaction with the meals provided. People we spoke with expressed satisfaction with the meals provided, choices are available and the menu is on display. We spoke with the Chef who said they currently provide the following specialist diets, Vegetarian, Gluten Free and Diabetic. We observed part of the lunchtime meal, which was relaxed and unhurried, tables are set and include an individually named napkin ring. We spoke with a number of people residing at Nazareth House and asked for their comments about activities, religious observance and meals, the following comments were made: “I think the quality of the food has deteriorated.” “The mobile library visits every week, I really enjoying reading.” “The meals suit me, there is always a vegetarian option.” “I choose whether I eat my meals in the dining room or in my own room, I prefer to eat my breakfast and lunch in the dining room, and my tea in my own room, as I like to watch the television.” Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 16 “I join in the activities, and I regularly visit my relatives.” “I attend Mass daily and the Rosary Service.” Nazareth House DS0000012866.V362271.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People residing at Nazareth House do not in all instances know how to raise concerns, and are not supported in all instances by staff who are appropriately knowledgeable and confident in their role in relation to the potential risk of abuse. EVIDENCE: Nazareth House has a complaints procedure, which outlines how to raise concerns with regards to any aspect of the services provided by the Home. The Home has received three complaints in the last 12 months, we looked at the complaints record, and found that the complaints had been appropriately recorded and included an outcome of the investigation and confirmed that the complainant received an outcome following the investigation. We asked people living at the Home, if they knew how to raise concerns, there views were mixed, and we advised the Acting Manager to ensure that all people living at the Home know how to raise a concern or make a complaint, we received the following comments from people living at the Home. “I wouldn’t know who to speak with if I had any concerns.” “I’m happy to raise concerns.” Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 18 “If I was unhappy I would speak to the Manager, and I’m fairly confident that issues would be addressed.” We sent surveys to people who use the service and their relatives, the information we gathered from the surveys is that staff listen and act on what they say, and that a majority of people know how to make a complaint. We asked a number of staff questions to ascertain their understanding of the term ‘safeguarding’, a majority recognised the term was in relation to ensuring vulnerable people are not subjected to abuse. Responses from staff were mixed with regards to their role and responsibility in responding to any suspicions they may have, and in some instances were not aware of all forms of abuse, however all staff said they had attended training. We spoke with the Acting Manager about re-enforcing staffs understanding of abuse, and their role in reporting any concerns they have, through additional staff training and through staff supervision meetings. Nazareth House DS0000012866.V362271.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, 20 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service benefit from an environment that is well maintained and meets individual needs. EVIDENCE: Nazareth House accommodation is set out over the ground and first floor. The ground floor provides four lounges and two dining rooms, each dining area having a kitchenette, from where meals are served. One lounge is used to provide activities for people living in the Home. Bedrooms, bathing facilities and toilets are located on both the ground and first floor with access to the first floor being via a passenger lift or stairwell. Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 20 Improvements to the environment on are ongoing the Acting Manager advised that the Home is reducing the number of bedrooms, and using the rooms to create additional en-suite facilities. The Church has recently re-opened following a complete refurbishment of its interior including the installation of coloured glass windows. Communal and bedrooms, which we looked at, were decorated to a good standard, and bedrooms were personalised by their occupants. All the people we spoke with were happy about the accommodation provided. A number of staff have undergone training in Infection Control, we observed on the day of the site visit that the Home was clean and tidy. We noted that the buzzer requesting assistance by people living at the home, was loud and sounded throughout the Home, this impacts on peoples ability to relax, and take part in daily living activities without interruption. Nazareth House is set back from the road and has a extensive lawn area, to the side and rear of the Home, there is an abundance of mature trees, shrubs and plants, with immaculate lawns, and a central feature of the garden is a large water fountain. We spoke to a number of people residing at Nazareth House, who made comments with regards to the accommodation and garden provided. “I have a lovely view of the fountain from my bedroom.” “Hygiene is very good.” “It’s a nice Home you can just sit and relax, and it’s always tidy and clean.” Nazareth House DS0000012866.V362271.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staff provide care and support to people using the service, and have access to a range of training opportunities, additional training opportunities and the implementation of robust recruitment practices would further promote the safety and welfare of people using the service. EVIDENCE: The Acting Manager said people residing at Nazareth House are supported by nine care staff in the morning and six to seven in the afternoon and evening, in addition to care staff the Acting or Deputy Manager are on duty much of the time. During the night there are two care staff and one senior care staff on duty. Administrative, catering and ancillary staff support care staff. Information supplied by the Acting Manager prior to the site visit states that 57 of staff have attained a National Vocational Qualification (NVQ) in Care with an additional 4 working towards an NVQ. The recruitment records of three members of staff who were relatively new to the staff team were viewed; all had completed an application form, provided documentation to verify their identity, and had been interviewed. In addition all had had a satisfactory Criminal Record Bureau (CRB) disclosure, however Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 22 only one of the three had two written references, two had no written references or evidence that verbal references had been attained. We looked at the records with regards to staff training, and noted that some staff have received training in mandatory topics, which including handling of food, moving and handling of people, first aid and fire awareness, some staff have undertaking training in additional subjects which include dementia care. A plan of training for coming the current twelve months was in place, and topics included the Mental Capacity Act, appraisals, nutrition, wound care, infection control, catheter care, abuse and care of the dying, however it is unclear as to how many staff will be attending the training. We sent surveys to health and social care professionals, the information we gathered from the surveys was that staff have the right skills and experience to support the individuals in their care. We sent surveys to people who use the service, and their relatives; the information we gathered from the surveys is that staff are usually available when they need them. Nazareth House DS0000012866.V362271.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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems within the Home are not effective in all areas, which has the potential to affect the service and safety of individuals living at the Home receive. Individuals living at the Home are encouraged to share their views and influence the service they receive. EVIDENCE: We were not informed by the Responsible Individual who represents the Congregation of the Sisters of Nazareth, as they are required to do, that the Registered Manager of Nazareth House had resigned from their position in September 2006, and therefore their name continues to appear on the Inspection Report as the Registered Manager. Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 24 The current Acting Manager has been in post since September 2006, and information detailed within the Statement of Purpose states that they are a Registered General Nurse, and hold a Diploma in Nursing and a City & Guilds Teacher Certificate. Information supplied by the Acting Manager prior to the site visit states that they are working towards a level 4 National Vocational Qualification. The Acting Manager confirmed their intention to submit an application to the Commission for Social Care Inspection to become the Registered Manager; they took initial steps to commencing this process during the site visit. Staff recruitment practices are not robust, and detailed within the ‘Staffing’ section of the Inspection Report, which has the potential to compromise the safety of welfare of people living at the Home. Surveys to people residing at the Home are distributed on an annual basis, these surveys are used to improve the services offered, completed surveys were viewed, the Acting Manager confirmed that individual issues raised within surveys are addressed with the person themselves, whilst general comments are used to improve the service Nazareth House provides. It was suggested to the Acting Manager that the surveys when analysed lead to the production of a report, which provides statistical and written information as to the views of people using the service, which includes an action plan, which details how Nazareth House intends to improve its service. The report should be made available to all those eligible to take part in the survey, including the people who live at the Home, their relatives and friends. A newsletter is produced by Nazareth House and provides information to people living at the Home about any planned changes. Meetings are held for those living at the Home every four months, and staff meetings take place throughout the year, which enables all to be provided with up to date information, and express their views and make comments. The Acting Manager advised that in a majority of instances people living at the Home or their representative maintain responsibility for the management of their finances, and only in exceptional circumstances is a limited amount of ‘spending money’ kept on the premises which is held and managed by the Sisters for a few named individuals. We spoke to the Acting Manager and a number of staff and the information we received supports that care staff do receive supervision, which is recorded, the supervision is an observation of a task, which they are required to do as part of their role. In addition staff receive an annual appraisal. It was discussed with the Acting Manager that the supervision of staff includes an opportunity for staff to meet with their line Manager on an individual basis Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 25 and discuss aspects of their role and practice, any issues with regards to the care of people living at the Home, and would provide an opportunity to review policies and procedures including those with regards to abuse, and any potential training needs. A written record of supervisions and the issues discussed to be kept. Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1) Requirement Information detailed within the Statement of Purpose and Service User Guide to be reviewed to ensure people using the service have accurate and up to date information about the services and accommodation provided at Nazareth House. Care plans of people accessing a service at Nazareth House should be regularly reviewed and involve the individual or their representative. All staff to receive training about the forms of abuse vulnerable people are potentially at risk of and their role and responsibility in reporting any concerns. The recruitment of all staff to work in the care home undergo all pre-employment checks as detailed within paragraphs 1 to 9 of Schedule 2, which includes two written references. The Responsible Individual to give notice in writing to the Commission of any changes with regards to the management of the home and the range of DS0000012866.V362271.R01.S.doc Timescale for action 14/06/08 2 OP7 15(2) 14/06/08 3 OP16 13(6) 14/07/08 4 OP29 19(1) 14/05/08 5 OP31 39 14/06/08 Nazareth House Version 5.2 Page 28 6 OP31 9 services and accommodation provided, including a revised Statement of Purpose. The Manager to submit an application to the Commission for Social Care Inspection, with regards to becoming the Registered Manager. 14/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations Information with regards to the range of needs that Nazareth House can provide, should be reviewed, to ensure that potential uses of the service know that the service provides care for Older People, and will where possible try to continue providing care and support. People living at Nazareth House would benefit by the introduction of person centred care plans, which would include the views of the individual, including their aspirations and how they wish their care to be delivered and by whom, and to include information about their preferred daily routines. Staff supervisions to be used to re-enforce staffs understanding about abuse, and the policies and procedures which outlines their role and responsibility in reporting any suspicions. People residing at the Home to receive a report, which provides the outcome of their involvement in the quality assurance process, and details the aims of the service to address issues raised and improve the quality of care. Staff to be supported through the introduction of supervisions which provide staff and their line manager with an opportunity to discuss their role, issues affecting people living at the home, training needs and to ensure that they are up to date in all aspects required by them as staff to fulfil their role and responsibilities. And that a record of issues discussed is kept. 2 OP7 3 OP16 4 OP33 5 OP36 Nazareth House DS0000012866.V362271.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000012866.V362271.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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