CARE HOMES FOR OLDER PEOPLE
Nazareth House Liverpool Road Crosby Liverpool Merseyside L23 0QT Lead Inspector
Mrs Trish Thomas Key Unannounced Inspection 22nd May 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Nazareth House Address Liverpool Road Crosby Liverpool Merseyside L23 0QT 0151 928 3254 0151 9287723 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sisters of Nazareth Sister Joseph Veronica Crowe Care Home 66 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (64) of places Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 64 OP DE(E) 2 The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 4th September 2006 Date of last inspection Brief Description of the Service: Nazareth House is a care home for older people owned by the Sisters of Nazareth. The ethos of the home is rooted in Catholicism and there is an integral chapel with daily Mass, which residents may choose to attend. The religious beliefs of service users of all denominations are respected and supported in the home. The manager is Sister Rose Ita, who has many years experience in health care and service to the community. Sister Rosa Ita has recently been appointed as manager and has applied for registration with CSCI central registration unit. The home accommodates 66 residents and to ensure a homely and personalised service, the accommodation is divided into three self-contained floors or units. Each unit is individually managed by nominated senior staff, under the supervision of Sister Rose Ita, who has ultimate responsibility for the day-to-day management of the home. Residents are provided with home cooked meals, accommodation and personal care. The service provides residential care and is supported by visiting general practitioners, community nurses and paramedical services. Nazareth House was built at the beginning of the last century and the general style of the interior reflects this period. Nazareth House is furnished in a homely and comfortable way and there was a pleasant and relaxed atmosphere during the visit. Meals are cooked on the premises and served in one of the dining rooms on each unit, or in residents’ bedrooms, if they prefer. Nazareth House also provides a laundry service, carried out on the premises. To accommodate the home’s purpose and function, there are two passenger lifts, a nurse call system throughout, a ramp and individual adaptations in accordance with the needs of people who are in residence. Nazareth House is situated on the main Liverpool to Southport Road with close
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 5 links by public transport and nearby shops, a cinema, local churches, and a wealth of local community amenities. A number of in-house social events take place, and day-to-day activities. Outings are arranged when residents are escorted by staff, or some prefer to go out alone or with family and friends. The home is set in extensive grounds with car park. The gardens are pleasant and well maintained, and views of the garden from the house enhance the general environment and character of the premises. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced visit was carried out over a six-hour period, and the methods used to assess the service were, discussion with residents and staff, reading records compiled in the home relating to care, safety and staffing. A tour of the premises was carried out and reference made to a number of questionnaires, which residents had completed and returned to CSCI. What the service does well:
Nazareth House has a statement of purpose, which gives a description of the service to be provided and information such as, accommodation, number of places and a copy of the complaints procedure. This booklet is placed in residents’ bedrooms for ongoing reference during their stay. Before moving into Nazareth House, for each person, a comprehensive assessment of need is carried out. This is to ensure that the service is able to meet their needs within staff skills and the facilities provided. Care plans follow a standard format and there are records contained, of ongoing reviews and risk assessments. Action plans were in place to cover a range of need for each person, including mobility, continence, personal grooming and nutrition. Residents’ privacy and dignity is respected in the way in which care is provided, which is always in private. Staff were seen speaking respectfully to residents and ensuring their comfort and wellbeing. A resident commented, “I knew that I was coming to live in a community of faith and that was important to me. Everything else stems from this.” Residents’ diversity is respected through recording their needs, beliefs and interests on their care plans and taking action to respect and enable them. Nazareth House has an integral chapel and several residents said they go to church daily by choice. Others were not of the Catholic Faith but said ministers of their own religion are encouraged to visit without prejudice. To ensure that residents’ beliefs and needs are understood and respected, staff have received a wide range of training including a course on equality and diversity. Nazareth House has an activities programme and arranged events are advertised on notice boards on each floor. During the visit, residents were Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 7 taking part in exercises and sing songs. One resident said that she enjoys a quiz, another said, “I go to activities daily and enjoy them.” Nazareth House has a complaints procedure, which is provided to residents when they move in and a copy remains in their bedrooms. Residents who were asked, “Do you know how to make a complaint in Nazareth House?” answered, “Yes.” They said they would feel able to talk to a member of staff if they had a complaint. The complaints procedure provides the complainant with time limits within which their concerns will be addressed. The building is vast and residents’ accommodation is divided into three selfcontained areas on separate floors to provide a more homely environment. When asked about cleanliness of her home a resident said, “My bedroom is cleaned every day.” All parts of the building were clean and odour free at the time of this visit. Nazareth House employs a training officer and at least 80 of staff have NVQ2 and receive ongoing mandatory training. Senior staff have been trained to NVQ4. Staff access diversity and dementia courses and medication training through Sefton social services department training unit. Training is provided in-house on POVA , “whistle-blowing” and moving & handling. Staff receive instruction in complaints handling during their induction training. There was certification of staff training achievements and up to date schedules of planned and completed training. Nazareth House is managed in the best interests of residents and the health, safety and welfare of residents, staff and visitors are promoted and protected. Health & Safety certificates and servicing equipment were up to date and remedial work scheduled to solve a problem with the drainage system. Work has been scheduled to replace the water tanks, in the near future. What has improved since the last inspection?
Care plans and assessments for residents who have been recently admitted to Nazareth House were seen. There was no evidence that residents whose needs are not within the registered category, through mental frailty, have been admitted since the last visit. There are variations to the category in place for two residents due to dementia. Staff rosters were clear and satisfactorily maintained giving the full names of staff and the hours, which they work, also absences and shifts which need to be covered. The staff files were available for inspection and had been satisfactorily maintained. Daily reports were crosschecked with accident records and these had been completed to a satisfactory standard.
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Prospective residents of Nazareth House are provided with the information they need before making the decision to move in and they have their needs assessed to ensure that the service is suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1 and 3. Nazareth House has a statement of purpose, which gives a description of the service to be provided and information such as, accommodation, number of places and a copy of the complaints procedure. This booklet is placed in residents’ bedrooms for ongoing reference during their stay. A resident wrote on a questionnaire regarding information provided prior to admission, “Having lived close by for over fifty years and visited many times, we knew what to
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 11 expect when we needed the help of the nuns and staff here. We are very satisfied.” Before moving into Nazareth House, for each person, a comprehensive assessment of need is carried out. This is to ensure that the service is able to meet their needs within staff skills and the facilities provided. Those people who are referred through social services departments have a social work assessment in addition to an assessment carried out by senior staff from Nazareth House. Staff use a standard assessment form when carrying out pre-admission assessments and areas of need covered include, physical and personal care needs, mobility, continence, sensory needs, mental state and cognition and risk. The outcomes of assessments form the basis of each individual’s care plan. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Care plans address residents’ health and personal care needs, some care records lack detail and there are shortfalls in procedures being followed in managing residents’ medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7, 8, 9, 10. All residents have a care plan and six were tracked by checking assessments, and action plans and by speaking with each resident and the staff who support them. To ensure that each person is respected as an individual, assessments include residents’ personal histories, social interests and beliefs. Care plans follow a standard format and there are records contained, of ongoing reviews and risk assessments. Action plans were in place to cover a range of need for each person, including mobility, continence, personal grooming and nutrition.
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 13 In one care plan, the section on mental health/cognition had been left blank and daily records did not give a clear statement of the person’s behaviour other than to state, “Confused this morning.” To ensure that accurate and ongoing assessments are maintained and associated risks are identified and addressed, a requirement is made that more detail is written regarding mental health and presenting behaviour of residents who have become mentally frail. For a resident who is assessed as at risk of pressure sores, there was no care plan in place to address the risk and record the measures in place prevent pressure sores developing. A requirement is made that a pressure care plan be established and equipment and monitoring systems be arranged. All those who live in Nazareth House are registered with local G.P.s, are supported in attending hospital appointments and have access to paramedical services such as chiropody, dentistry, opticians and audiologists. For one resident, the record of chiropody treatment showed a seven-month gap (between August 06 and March 07). The person in charge of the floor said that this is because the resident, at times, refuses treatment. To ensure that a clear record of access to treatment (such as chiropody) is maintained, and alternatives arranged where risks posed by non-treatment are identified, a recommendation is made that any refusal of treatment be recorded and dated. In a care plan, which was tracked, was evidence of district nurses attending to give treatment to a resident, and of a request to the G.P. for a review of medication. Residents’ prescribed medication is managed independently on each floor and each has a separate storage area. Staff have received training in administering medication and those who discussed medication during the visit were aware of the procedures in place. Risk assessments are carried out and those assessed as fit to do so, self-medicate. For the remainder of residents, staff will manage their medication. Records and storage of medication held for residents were generally satisfactory but some shortfalls were noted as follows. For a drug which is prescribed to be administered once weekly, the records lacked clarity and a small quantity of medication was out of date. There were inconsistencies described by staff, in the signing in of medication across the three floors. Blister packs are delivered every fortnight to cover medication for one month recorded on the MAR sheets. Some staff sign for four weeks medication at the beginning of the month when only two weeks supply have been received, others write out the drugs received when the mid month delivery arrives. To ensure that there is a system in place for the safe recording and management of medication, a requirement is made that the existing system be reviewed with regards to recording and auditing of medication accepted into the home. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 14 Residents’ privacy and dignity is respected in the way in which care is provided, which is always in private. Staff were seen speaking respectfully to residents and ensuring their comfort and wellbeing. A resident commented, “I knew that I was coming to live in a community of faith and that was important to me. Everything else stems from this.” Another comment received was, “They are all very patient when I forget what I am doing, or where I am going. They gently set me on the road again.” Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Residents have a lifestyle, which is to their satisfaction and preference, and they receive a wholesome and balanced diet though the presentation and content of meals was not to everybody’s satisfaction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. Nazareth House has an activities programme and arranged events are advertised on notice boards on each floor. During the visit, residents were taking part in exercises and sing songs. One resident said that she enjoys a quiz, another said, “I go to activities daily and enjoy them.” Another resident said, “These are available to all who wish to take part. I do when possible.” A summer fair had been organised for the following weekend. The grounds are very well maintained and suitable for socializing. The hairdresser was on the premises during this visit and residents were served tea and biscuits when
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 16 having their hair done. Staff said there have been more outings arranged for residents recently including theatre trips, and meals in local restaurants. Nazareth House has an integral chapel and several residents said they go to church daily by choice. Others were not of the Catholic Faith but said ministers of their own religion are encouraged to visit without prejudice. A “service of anointing” was taking place on one floor during the visit. Staff said that such services are carried out regularly for those residents who wish to participate. Residents said that their visitors are made welcome and staff confirmed that residents who have no family have access to advocacy services. Residents said their choices are respected in rising and retiring times and how and where they spend their time. Residents’ opinions written on comment cards about the food served in Nazareth House, were mixed regarding levels of satisfaction. Some residents wrote that they always like the food. One resident wrote, “If I can’t eat something, I get something I can eat. The staff are wonderful about and I am happy understandably.” Another resident asked for more snacks, “It is a long time from 5pm to 8am. A biscuit tin would be of some help.” Another resident wrote, “I would like more variety of food, like sausage, mash and potatoes or toad in the hole.” On the presentation of food, a resident wrote, “Ensure that hot meals hot and not warm, stop serving stale cake for tea.” To ensure that all residents are served meals, which are to their satisfaction, a requirement is made that staff consult with them regularly about their meals. Nazareth House DS0000005384.V337147.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 good. Residents’ complaints are listened to and they are protected by the training and procedures in place in Nazareth House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 and 18. Nazareth House has a complaints procedure, which is provided to residents on when they move in and a copy remains in their bedrooms. Residents who were asked, “Do you know how to make a complaint in Nazareth House?” answered, “Yes.” They said they would feel able to talk to a member of staff if they had a complaint. The complaints procedure provides the complainant with time limits within which their concerns will be addressed. Staff have received training in Protection of Vulnerable Adults and Sefton’s POVA procedure is held on the premises. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Nazareth House is homely, in good order and maintained to good standards of hygiene throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19 and 26. The building is vast and residents’ accommodation is divided into three selfcontained areas on separate floors to provide a more homely environment. There is a central laundry and kitchen and two passenger lifts. There is a large reception room on the ground floor which residents from all floors use for joint activities. There is a dining room with serving area on each floor, and each floor has an office. There is a sunny conservatory at the front of the building
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 19 and an integral chapel where Mass is said daily. Each floor has a lounge and quiet areas for residents’ use and a supply of books, magazines and choices of music and films were in evidence. There is a ramp at the front of the building, well-maintained grounds, including a large car park and a patio area at the back. A series of aids such as, grab rails and assisted bathing facilities and moving aids, are in place to enable residents who have poor mobility. Bedrooms are predominantly for single occupancy but the few rooms, which are shared, have screening in place to ensure privacy. Bedrooms are personalised and comfortable with good views of the garden. There are bathrooms and toilets on all floors and wash hand basins fitted in residents’ bedrooms. A resident who moved in recently said, “My bedroom is very comfortable, I have all I need and staff could not be more kind and thoughtful.” Due to the age of the building, a problem had occurred with the drainage system at the time of visit. This had been reported and remedial work was scheduled. There is an ongoing maintenance programme and a full time maintenance person employed, who has responsibility for health & safety management and repairs. Nazareth House employs domestic staff and has policies in place for the control of infection and control of substances hazardous to health. All cleaning materials are locked away when not in use and domestic staff were wearing protective gloves and overalls. A resident said, “My bedroom is cleaned every day.” All parts of the building were clean and odour free at the time of this visit. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are protected through the recruitment procedure followed in Nazareth House and staff have the training and support needed to carry out their duties. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. There is a senior person in charge of each floor under the supervision of the manager who has overall responsibility for the home. The senior person on the ground floor left recently and the post has been filled, subject to clearances. A member of staff is acting in charge of the ground floor, until the post is filled. According to the rosters, staffing levels were being maintained on all floors with ancillary staff on the premises for cleaning, cooking, administration, reception and maintenance. Nazareth House employs a training officer and 80 of staff have NVQ2 and receive ongoing mandatory training. Senior staff have been trained to NVQ4. Staff access diversity and dementia courses and medication training through Sefton social services department training unit. Training is provided in-house
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 21 on POVA , “whistle-blowing” and moving & handling. Staff receive instruction in complaints handling during their induction training. Certification was seen, of staff training achievements and up to date schedules of planned and completed training. Nazareth House follows a recruitment procedure, which includes advertising posts, interviewing candidates and taking up references and clearances before the candidate commences employment. A sample of staff files was read. These were in good order and there was proof that references have been taken up, CRB and POVA clearances carried out and induction training arranged on taking up the post. Staff, who were spoken with, said they had been issued with job descriptions and contracts of employment. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Nazareth House is managed in the best interests of residents and the health, safety and welfare of residents, staff and visitors are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 31,33,35,38. Sister Rose Ita has recently been appointed as manager having several years experience in care home management and she holds a management qualification. There are clear lines of accountability in Nazareth House and, in
Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 23 conversation, sister displayed knowledge of the needs of residents who were discussed and the daily routines of the home. Nazareth House has a quality assurance system and the outcomes of audits are displayed for the benefit of residents and visitors to the home. The audits include distributing questionnaires to residents and visitors and identified shortfalls in service are addressed. A resident wrote on a CSCI questionnaire, “I have been a resident here for five years and am perfectly satisfied with everything.” Residents said that they or their appointees manage their personal monies and no person from Nazareth House is involved. Charges for services such as hairdressing and chiropody are clearly stated as extras to the fees payable. Staff confirmed that they would retain receipts for any purchases made on a resident’s behalf. Reports of accidents on the care records of two residents were crosschecked with accident reports and these were in order. There are three people employed to carry out maintenance work. Maintenance of the building and equipment was discussed with the maintenance manager, who has good filing systems and was able to access all information requested. Reference was made to the fire book, which was in order, as were safety certificates and equipment servicing records. There is a “no smoking” policy in the building and the fire roll call list is updated according to admissions and discharges. There is a comprehensive building risk assessment and building plan in place. Submersible water temperatures are tested weekly and recorded to ensure temperatures are at a safe level (42 degrees) and showerheads are removed and cleaned every three months. Portable electrical appliance tests were up to date. The passenger lifts and hoists are regularly maintained and tested. The gas certificate is due for renewal on 01/8/07 and the electrical certificate due for renewal on 15/09/07. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement To avoid the risk error, staff to follow the pharmacy instructions when administering prescribed medication and maintain and accurate record of the process. (Outstanding from last inspection, extended time limit given). Timescale for action 26/06/07 2. OP7 15 (1) 3. OP7 14 (2) 4. OP9 13 (2) To ensure that a resident (on 15/06/07 ground floor) who is assessed as at risk receives appropriate support, a care plan for pressure care to be in place. To ensure that accurate and 26/06/07 ongoing assessments are maintained and associated risks are identified and addressed, more detail to be written regarding mental health and behaviour for residents who have become mentally frail. To ensure that there is a system 26/06/07 in place for the safe recording and management of medication, the existing medication system to be reviewed with regards to recording and auditing of medication accepted into
DS0000005384.V337147.R01.S.doc Version 5.2 Page 26 Nazareth House 5. OP15 16 (2)(i) Nazareth House. To ensure that all residents are served meals, which are to their satisfaction, a requirement is made that staff consult with them regularly about their meals. 26/06/07 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 OP8 Good Practice Recommendations To ensure that a clear record of access to treatment (such as chiropody) is maintained, and alternatives arranged where risks posed by non-treatment are identified, a recommendation is made that any refusal of treatment be recorded and dated. Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nazareth House DS0000005384.V337147.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
