Inspection on 21/08/07 for Nazareth House

This inspection was carried out on 21st August 2007.

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 10/06/10

Nazareth House 01/02/07

Nazareth House 12/10/05

Nazareth House 05/05/05

Nazareth House 28/02/05

Nazareth House 22/11/04

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 162 East End Road East Finchley London N2 0RU Lead Inspector Tom McKervey Key Unannounced Inspection 10:00 21 August & 3 September 2007 st rd 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 DS0000010519.V342962.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 DS0000010519.V342962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nazareth House Address 162 East End Road East Finchley London N2 0RU 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 8883 1104 020 8444 3691 The Congregation of the Sisters of Nazareth Mrs Anne Fenlon Care Home 89 Category(ies) of Old age, not falling within any other category registration, with number (89) of places Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Fifteen specified service users who have dementia may remain accommodated in the home. The home must advise the regulating authority at such times as any of the specified service users vacate the home. 1st February 2007 Date of last inspection Brief Description of the Service: Nazareth House is a long established residential care home providing a home for eighty-nine people over the age of 65. It is owned and operated by a Roman Catholic order of nuns, The Congregation of the Sisters of Nazareth who are the registered providers. There is a very strong Catholic ethos in the home, including a chapel where Mass is celebrated daily. People from other religious and cultural groups are also accommodated and assisted with religious observance and to maintain contact with their community groups. Nazareth House is a large home split into a number of annexes named after Saints. There are a number of bedrooms with en-suite facilities, but those bedrooms without en-suite facilities have communal facilities close by. The home, with its spacious grounds, offers peace and tranquillity and it is ideally situated close to shops, post office and local transport. The home is light and airy with spacious corridors and has appropriate adaptations and equipment for people with mobility problems. The staff are allocated to work on the same unit so that the residents receive consistent care from the same staff. Each unit has a separate dining area and lounge. The cost of placements is £536 to £589 per week. Additional cost are for hairdressing, chiropody and nail care. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. Following Inspecting for better lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two days in a total period of twelve hours. The manager was on leave when I first visited the home and a senior carer was in charge who offered me every assistance with the inspection. I returned to the home to complete the inspection when the manager was back from leave. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. I visited all areas of the home and spoke to many residents and their relatives who were visiting at the time. I also spoke to the majority of staff and two professional visitors. I had discussions with the manager and the registered responsible person for the home and examined residents’ and staffs’ records and many other documents relating to the management of the home. Valuable information was also taken from the home’s AQAA, (Annual Quality Assurance Audit). What the service does well: Residents live in a home where the standard of accommodation and cleanliness is exceptionally high; where they can enjoy a lifestyle that is stimulating and/or tranquil as they prefer. The home is well managed by a competent and experienced manager who “walks the floor” and meets the residents every day. There were many comments expressing satisfaction from residents and relatives, many of which were written in cards and letters. Staff are well trained and supervised and they have a very positive attitude about their work and interact with residents in a warm and dignified manner. The people who live in the home are well served by the local GP practice and the district nurse who comes to the home for two full days every week. Strong emphasis is placed on assessing peoples’ needs and their likes and dislikes. This takes into account their religious, social and cultural background, and this information is used to tailor their care plan. There is a good range of internal and external activities available, which the residents can choose to join in or not. All the residents spoken to, appreciated the high standard of catering and the range of choice they have about their meals. The residents have been given relevant information about how to complain both internally and externally, and the residents’ welfare is protected through appropriate staff recruitment and training. Quality assurance audits and regular meetings are held to ensure that residents’ views are listened to and acted upon. There are always sufficient numbers of staff on duty to meet the needs of the people who live in the home. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 6 There are good systems in place for accounting for residents’ money and their health, safety and welfare is protected by regular monitoring of the home’s equipment and environment. 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 DS0000010519.V342962.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 DS0000010519.V342962.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): 1, 2, 3, 4 & 5 People who use this service experience good outcomes in this area. This judgement has been made using evidence from records and discussion with residents, including a visit to this service. There is good information about the home for potential users of the service, which is very specific to this resident group. All people who use this service receive a contract of the terms and conditions of their residency, which gives clear information about fees and extra charges. All new residents are fully assessed before admission, which is arranged by staff with skill and sensitivity and people are given the opportunity to spend time in the home before deciding to move in. EVIDENCE: There is an up-to-date “Statement of Purpose”, which provides good information about the service. There is also a “Service User Guide” to the Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 9 home, and the people I spoke to during the inspection, confirmed they had been given these documents at the time of their admission. There were seven vacancies in the home, which the manager hoped to fill by advertising locally. The home has a number of people with dementia. I discussed the home’s registration certificate with the manager and a new certificate will be issued in due course to more clearly identify this client group. By the end of this inspection, I was satisfied that the home was able to meet these persons’ needs. I sampled the case files of six new residents. In the case of one person, who was privately funding their care, they had signed a contract that detailed the terms and conditions and the fees charged. For other residents, there were local authority agreements in place about funding for their placements. In all cases, there were comprehensive needs assessments documented before people were admitted to the home. These were carried out either by local authority care managers, or by the home’s manager in the case of privately funded residents. Local authority care managers also carry out annual reviews of residents’ care. I met a care manager during the inspection and he confirmed that the standard of care in this home was very high. Peoples’ life histories are recorded when they are admitted, which helps when compiling their care plan, and they are allocated a key worker who is responsible for settling them in to their new environment. Nazareth House is a large home split into a number of annexes. There are twenty-seven bedrooms with en-suite facilities. The home has spacious grounds that are fully accessible for wheelchair users and it is situated close to shops, post office and local transport. The standard of accommodation is very high. The home is attractively decorated and there is a relaxed and friendly atmosphere. There was also an obviously warm and caring relationship between the residents and staff which I observed. There are comfortable lounges and areas where residents can receive visitors in private. The corridors are wide and there are appropriate adaptations and equipment for people with mobility problems. The residents and relatives I spoke to during the inspection, were very complimentary about the whole service. Examples of the written comments I saw were; “Just a note to express our family’s appreciation and thanks for all your kindness to X all the years he was with you.” The people I spoke to also confirmed that they had visited the home before deciding to move in and they were able to bring some personal possessions with them for their rooms. Nazareth House DS0000010519.V342962.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made following observation of residents and examination of their records. Resident’s care plans clearly set out their personal, social and healthcare needs and how they will be delivered, and the home arranges for residents to be seen by healthcare professionals when necessary. The home has an efficient medication policy supported by procedures and practice guidance for the protection of the residents. However, in one instance this was not followed. Residents are treated with dignity and respect and their wishes about dying and terminal care are clearly recorded, and respected. EVIDENCE: I examined six care plans at random, particularly those belonging to new residents. The plans were well constructed and gave clear guidance to staff Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 11 about the person’s needs and how to meet them. The care plans are reviewed monthly and any changes necessary are recorded. There were detailed risk assessments about the danger of falls and the risk of pressure ulcers. All residents had nutrition and skin viability assessments and they were weighed monthly. Appropriate pressure relieving equipment was provided in accordance with the care plan. The care plans are reviewed monthly by the key worker and any changes required are documented. The care plans I saw had been signed by the resident or their representative on their behalf. All healthcare appointments are recorded on one sheet in the case files, which makes it easy to monitor. The records showed that all residents were registered with a G.P and had appointments with opticians, chiropodists and dentists. The district nurse to whom I spoke during the inspection, said that the care in the home was of a high quality and staff were diligent about referring residents for treatment when necessary. I observed how staff interacted with the residents. It was evident that the staff were respectful of the privacy and dignity of the residents and knocked before entering their rooms. I noted that the staff explained what they were doing when supporting residents when transferring them from armchairs to wheelchairs for example. This procedure was carried out patiently and safely. At the time of this inspection, three residents were self-medicating. This was recorded in their care plans and had been risk assessed. A lockable facility had been provided for storing their medication in their rooms and regular checks were made to ensure that the process was safe. All records of administration, receipt and returns of medicines were inspected and were accurate. However, I noted that on the ground floor, a resident’s medication had not been signed for by staff for a whole shift and I have made a requirement about this. Storage facilities were good and the temperature-monitoring records showed that medicines were stored at the correct temperatures, including those kept in the fridge. There were separate secure storage facilities on each floor for controlled drugs and the records of administration of these were accurate. The wishes of service users in connection with spiritual rites and functions including funeral arrangements were detailed on service user plans. A number of care plans have a Resuscitation consent form on file, which is either signed by the service user or their next of kin. Nazareth House DS0000010519.V342962.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): All these standards were assessed. People who use this service experience excellent outcomes in this area. This judgement has been made after discussion with residents, observation and looking at records. The people who live in the home enjoy their lifestyle and the range of stimulating activities. Contact with friends and relatives is positively encouraged and the residents are free to choose how to spend their time. The standard of food is high and the residents can enjoy varied and wholesome meals in congenial surroundings. EVIDENCE: I spoke to a large number of the residents during the two days I spent in the home. The comments I received from everyone were very positive, for example; “Everyone here is wonderful. The staff are so helpful and can’t do enough for you”. There is an activities co-ordinator who has a dedicated room for art and crafts sessions. The activities co-ordinator showed me examples of residents’ work and I was particularly impressed with the work done by a resident who has dementia. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 13 There was evidence in the daily reports, that the majority of residents take part in the various activities and also go out in the home’s minibus to places of interest. The planned activities are published in a monthly newsletter, which include regular bingo sessions, video shows and outside entertainers. Residents’ birthdays are also mentioned in the newsletter. Residents told me, “You never get bored; there is always something to do”. There was a record in the visitors’ book of frequent visits by friends and relatives, who can come at any time. Visitors told me that the staff are very welcoming and they are offered cups of tea. Some residents were out with their families during the inspection. It was evident from my discussions with residents that they are not coerced to do anything against their wishes. For example, some residents prefer to “do their own thing”, rather than join in activities. Their likes and dislikes are noted in their records, including preferred time of rising and going to bed. Some people were observed reading newspapers and books. Mass is said every day in the home’s chapel, which many Roman Catholic residents attend. I was informed that religious observance is also arranged for residents of other denominations. Each “annexe” has its own dining room with sufficient chairs and tables to sit everyone. This ensures that dining areas are not overcrowded and meals can be taken in a congenial atmosphere. The menus indicate that the residents have a varied and nutritious diet, with snacks and drinks being available outside of meal times. Special diets, e.g. diabetic and low fat are provided as recorded in the nutritional assessment. At the time of the inspection, there was no culturally specific food on the menu, but relatives brought these in for one or two residents at their request. Meal times were unhurried and I observed that staff generally provided assistance in a sensitive and appropriate manner. However, I noted that in one instance, a staff member stood over a resident while supporting them, rather than sitting beside the person. This is not good practice, which I reported to the person in charge and recommended that she address this with all staff. The residents confirmed that they enjoyed the food and that they could choose alternatives to the planned menu. I visited the kitchen and was satisfied that their was ample stocks of food available and there were records kept to show that the food was stored safely. Nazareth House DS0000010519.V342962.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): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made from discussion with residents, relatives and staff and looking at relevant records. Complaints are taken seriously and addressed promptly. There are good systems in place, including staff training, to protect residents from abuse. EVIDENCE: I examined the complaints log, which showed that no complaints were made in the past year. As stated throughout this report, residents and relatives express a very high level of satisfaction with this service. In discussion with the residents, it was evident that were aware of the procedure and they knew how to make concerns known. They said that the manager always asks if everything is all right and deals with any minor concerns immediately. The home has a copy of the local authority’s adult protection procedure and has guidelines for staff about “whistle blowing”. The staff records show that all support workers had undertaken adult protection training and when I discussed this issue with a group of staff, they were knowledgeable about their responsibilities regarding protection of residents from abuse and exploitation. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 15 Nazareth House DS0000010519.V342962.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): All these standards were assessed. People who use this service experience excellent outcomes in this area. This judgement has been made using a range of evidence including visiting all areas of the home. Residents in this home live in a safe and well-maintained environment. The home is warm, comfortable, clean and hygienic and bedrooms are spacious and personalised to help residents feel more at home. EVIDENCE: Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 17 This is a large property divided into nine areas, which ensures that the home does not appear over-crowded. Each area is named after a Saint. Each area has its own dining room, large and small lounges and quiet places where the residents can sit in private and receive visitors. There is a large entrance where a receptionist receives visitors and ensures that they sign in and out. There is also a spacious hall that is used for large meetings and various entertainments. The home is situated in a residential area in East Finchley, close to a small group of shops and accessible by public transport. All parts of the home are well maintained and are decorated and furnished to a high standard. There are extensive landscaped grounds that are particularly attractive and afford a very tranquil setting for residents to enjoy. A gardener and maintenance person are employed full-time. A number of the bedrooms have en-suite facilities and those that don’t, have shared facilities nearby. All bedrooms are spacious and comfortably furnished. Residents are able to bring their own furniture and other possessions with them, which they said made them feel more at home. There is a call bell in each room, and when I tested this, the staff responded promptly. There are sufficient hoists, assisted baths and grab rails, which are regularly serviced, located in all resident areas. There is a main kitchen and laundry on the ground floor, which cater for the whole of the building. The home is warm and inviting, and the residents I spoke to, expressed their delight at living in this home. There are procedures for infection control including dealing with soiled laundry. At the time of the inspection, the home was very clean, hygienic and smelled fresh throughout. Nazareth House DS0000010519.V342962.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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using evidence from discussion with staff and examining the staff rota and their records. The home is well staffed at all times to ensure that the residents’ needs are met. The residents are supported and protected by care staff who are well trained and competent to support and protect them. EVIDENCE: There is a large staff team consisting of the manager, senior carers, care assistants, receptionists, administrators, cooks, kitchen assistants, dining assistants, domestics, laundry assistants, a gardener and handy person. The rotas showed that there are sufficient numbers of staff on duty at all times. The staff are allocated to work with the same group of residents, which helps to maintain consistency of care. Key-workers are allocated to have special responsibility for individual residents, including reviewing their care plans. At the time of the inspection, thirty-five staff had completed National Vocational Qualifications at level 2 and eight others were currently on the course. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 19 Staff records showed that all new staff undergo a written induction and training in five mandatory subjects relating to health and safety. Other subjects include dementia care, nutrition awareness, mental health and pressure ulcer prevention. The staff told me how much they appreciated the investment in their training, which enhanced their roles as carers. I examined the records of three new staff, which showed that they had completed an application form, attended a formal interview and had been screened by obtaining references and clearances from the Criminal Records Bureau. In my observation and discussions with staff, they appeared to be enthusiastic and committed carers and they were knowledgeable about what constitutes good practice. Nazareth House DS0000010519.V342962.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): 31, 32, 33, 35, 36, 37 & 38 People who use this service experience excellent outcomes in this area. This judgement has been made using a range of evidence including examining records and documents and discussions with the manager, staff and residents. Residents can be confident that the home they live in is well managed by a competent and experienced manager. The residents can also be confident that their financial interests are safeguarded and their health safety and welfare is protected by staff who are appropriately supervised. EVIDENCE: Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 21 The manager has worked at the home in various positions before progressing to the post of manager, some three years ago. The manager has attained National Vocational Qualification level 4 and the Registered Managers Award. She also continues to update her knowledge by attending courses and conferences appropriate to the service. I was impressed throughout the inspection by the relaxed atmosphere in the home, despite everyone being very busy attending to the residents. The relationship between the staff and residents was obviously very warm and friendly. The majority of staff that I met, individually and as a group, spoke highly of the manager and expressed confidence in her ability. They also stated that there was a good steam spirit and that morale was high. However, a small number of staff told me that they felt the manager did not always treat them fairly regarding the duty rota and they felt unable to speak up about issues at staff meetings or in supervision. I discussed these matters with the manager and the responsible person, both of whom strongly refuted them and gave me anecdotes of how individual staff were supported when they had domestic problems. I pointed out that in such a large group of staff, it would not be unusual for some people to be dissatisfied at times. I have recommended that the manager address these issues sensitively through one-to-one supervision sessions and staff meetings. I also recommended that the responsible person makes herself particularly available to staff when she carries out her monthly monitoring visits. The responsible person carries out regular monitoring of peoples’ satisfaction about the service and sends these reports to the Commission. Regular meetings are held with residents and staff to discuss the running of the home and there is a monthly newsletter produced to inform about important events. Shortly after the inspection, the manager sent an Annual Quality Assurance Audit, (AQAA) to the Commission for Social Care Inspection. This document is now required from all care services as evidence of how services assess themselves against the National Minimum Standards. I was able to verify the accuracy of this information by the outcome of this inspection. The home keeps some money for residents for the purchase of personal items and hairdressing etc. I saw receipts for these items and was satisfied that good, accurate accounts were being kept. There were good records of regular one-to-one staff supervision, which with the exception of the people mentioned above, staff said they valued as an opportunity to discuss issues relating to their work as carers. The records and other important documents relating to residents, staff and the general running of the home were all accessible, well structured and easy to read. There were satisfactory records of safety for the gas, emergency lighting, electrical installation and portable electric appliances. Fire alarms were tested weekly and drills were carried out. All hazardous substances were stored securely. Nazareth House DS0000010519.V342962.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 3 3 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 4 3 3 X 3 3 3 3 Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(2) Timescale for action Staff must sign for all medication 30/09/07 that is administered. Requirement 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 OP15 OP32 OP32 Good Practice Recommendations The manager should remind all staff to sit beside residents when assisting them to eat. The manager should meet with staff individually to discuss any concerns they may have about their work. The responsible should ensure that all staff have an opportunity to discuss with her, any grievances they may have. Nazareth House DS0000010519.V342962.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 DS0000010519.V342962.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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