Inspection on 24/01/06 for Nazareth House

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Nazareth House 26/04/10

Nazareth House 05/03/09

Nazareth House 25/10/06

Nazareth House 27/07/05

Nazareth House 24/02/05

Nazareth House 21/09/04

Nazareth House 18/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Nazareth House Durnford Street Stonehouse Plymouth Devon PL1 3QR Lead Inspector Fiona Cartlidge Unannounced Inspection 24th January 2006 11:50 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 DS0000003595.V262486.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nazareth House Address Durnford Street Stonehouse Plymouth Devon PL1 3QR 01752 660943 01752 256842 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) The Congregation of the Sisters of Nazareth Sister Anna Maria Doolan Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age of places (43), Terminally ill over 65 years of age (5) Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service Users aged 65 years and over OP Maximum registered 25 service users (both) PD (E) Maximum registered 43 service users (both) TI (E) Maximum registered 5 service users (both) Date of last inspection Brief Description of the Service: Nazareth House is a Care Home run by the Sisters of Nazareth, it is situated in the Stonehouse area of Plymouth Devon. The home is able to accommodate up to 43 Service users of either gender, over the age of 65 years with a maximum of 25 who can receive nursing care. Sister Anna Marie who is a first level nurse with management qualifications heads the staff group. She supports a competent care and domiciliary team within the home. The home is arranged on 2 floors with level access to all parts of the building via a passenger lift. It is currently arranged with nursing beds on the ground floor and residential beds on the first floor. The communal areas are spacious and enjoy good views over Plymouth Sound. The home also has a chapel integral to the building, which can be enjoyed by the Service Users if they wish. The grounds are extensive and well laid out with access to the sea front. The home has its own transport so is also able to offer trips out and into town. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and 50 minutes and was unannounced. A partial tour of the home took place when some bedrooms and the communal bathrooms and living rooms were viewed. Personal records of care of 4 residents were inspected. The inspector spoke with 15 residents, 2 visitors, 2 staff members, the registered manager and her deputy. Written information about the services, facilities and staffing arrangements was received from the registered provider before the inspection. This was the home’s second inspection of the year and readers should consider the contents of the last inspection report and this one to assess how the home has been measured against the National Minimum standards in inspection year April 2005-2006 What the service does well: What has improved since the last inspection? Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 6 The management’s commitment to continually improving the skills of the staff team has continued and a number of staff have received training in care issues associated with meeting the needs of the homes residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 The admission process is safe and ensures staff in the home have the information they need to make a decision about how/if a prospective residents will be met. Information about the home is of good quality and available for all prospective and existing residents. EVIDENCE: The home’s Statement of Purpose was available in the individual accommodation of each resident in addition each resident’s room had a copy of a useful information guide. The information is clear and inclusive. The inspector examined the personal records held within the home on behalf of 4 of the residents (10 ) these contained evidence that information about the individuals’ health, personal and social care had been sought and most perspective residents are visited in their current settings to enable the registered nurses to make a professional judgement about how needs will be met before offering the individual the opportunity of admission. Residents told the inspector that the home had been recommended to them through word of mouth or that their relatives had visited a number of homes and had chosen Nazareth House above the others. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Residents have a clear documented plan of care; there was evidence that residents and or their representatives are involved with planning and reviewing their care. The health care needs of residents are regularly reviewed and action is taken to meet those needs. The home’s medication system is well managed and safe. EVIDENCE: The inspector examined the personal records held on behalf of 4 residents; in all of those seen there were documented assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, nutritional screening and 3 contained information about social needs. The information generates the plans of care, which provide the basis for the care to be delivered. The care plans were clear and easy to understand and had been regularly reviewed with input from the residents and/or their representatives. Records are maintained for all visits to the home by social or health care professionals, all residents are registered with a GP. Records provided evidence that as well as visits from General Practitioners, district and specialist nurses, Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 10 chiropodists, aromotherapist, reflexologists, physiotherapists and dentist’s visit. Records of outpatient appointments show that visits to community and hospital health resources are enabled. The medication system is well managed; the inspector looked at storage and recording – controlled drug stock was checked against records and found to be correct The home uses a monitored dosage system, which is well organised and easily audited and administered from purpose built trolleys directly to the residents on a 1:1 basis. Disposal of unused medication is safe, well recorded and removed by a licensed contractor. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Social activities are organised and meet the needs of the residents. Meals are nutritious and balanced and offer a healthy and varied diet for residents. The arrangements for residents to receive visitors are good. EVIDENCE: Some residents were seen socialising in the lounges others were spending time in their rooms, reading, listening to music, and watching television. One resident was watching the movements of boats and birds on the waterfront through their binoculars. In the afternoon the inspector observed residents at a group craft activity making items for an annual skills exhibition, which the inspector was informed is run by age concern. Residents have won prizes for entries in previous years. Activities are advertised on notice boards and in the homes monthly news letter as well as verbally by the staff on the day the activity is to take place. Residents told the inspector they are able to attend holy mass on a daily basis. The feedback about food was positive all of the residents spoken to said how good it was; on the day of inspection lunch was served, residents were offered Pasty, chips and beans followed by rhubarb crumble and custard; residents Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 12 said they are always offered 2 choices and if neither suit an alternative is found. Most residents ate lunch in the dining rooms; some residents ate their lunch in their own accommodation. Fresh fruit was seen to be available, displayed in bowls on the dinning room tables a list of residents individual choices for supper showed they had choices of soup, cauliflower cheese and cold meat or sandwiches freshly baked cake was served with afternoon tea. Records seen provided evidence that it is usual practise for residents to undergo nutritional screening and have a nutritional care plan, which expects resident’s weights to be regularly monitored. The people living in the home told the inspector they were happy with the visiting arrangements, visitors said they feel welcomed into the home and are able to visit their relative/friend in private or socially. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 The home is simply decorated and furnished and clean, pleasant and hygienic. EVIDENCE: A tour of the home showed that resident’s rooms contain personal items of furniture and ornaments and pictures. All of those spoken to said they liked their rooms, some particularly commented positively about the fact they have there own en suite WC. Rooms are decorated when they become vacant. The home appeared well equipped to meet the needs of those residents identified with moving and handling risks and disabilities that affect their capability to bathe. It was noted that the nurse call system is not accessible to immobile residents in the communal rooms, this risk to safety and possible bar to meeting peoples needs was discussed with the homes deputy manager at the time of the inspection. The gardens are safe and accessible and residents told the inspector how much they enjoyed the homes setting on the water - front. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 15 Specialist mattresses were seen in place for those residents requiring them, as were height adjustable beds. The communal areas of the home were fresh and clean in their appearance; Hand washing facilities are available throughout the home as were protective gloves. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 The deployment and number of staff on duty during the inspection met the needs of the residents. Training needs analysis has been undertaken, training is available and advertised, the staff appear competent. EVIDENCE: The home employs 11 Registered Nurses the trained nurses are assisted by Care Assistants, 18 care staff (56 ) have achieved a National Vocational Qualification In care. The staff records provide evidence that the staff have a wide range of qualifications, skills and experiences. All of the residents spoke of the kindness and helpfulness of the staff, One said they are ‘polite and cheerful’, another ‘they couldn’t do more’. All but 1 resident said they felt there was always enough staff on duty. The inspector found that training sessions available were advertised in the staff offices. Information provided to the commission indicates that the following training has been attended in the last 12 months: fire safety training, first aid, manual handling, health and safety, infection control, palliative care, abuse management, mentors course, anaphylaxis, continence care, basic hygiene, introduction to Huntington’s disease, catheterisation and National Vocational Qualifications. The home supports student nurse placements from Plymouth University the current student had been at Nazareth House for several Months and said it was her first placement she said that the experience had been valuable especially Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 17 with regard to Communication skills, moving and handling techniques, administration of medication and meeting general personal care needs. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,38 The home is being managed properly and there is evidence of clear leadership, guidance and direction to staff. Systems for holding money in the home on behalf of service users are safe. EVIDENCE: The manager of this home is a 1st level registered nurse and holds a number of other post registration qualifications including management and care of the dying and their families. Staff and residents told the inspector that the manager demonstrates clear leadership and communicates well with all she comes into contact with. There are clear lines of accountability within the home. Safety notices were displayed throughout the home including action to be taken in case of fire and Control of Substances hazardous to health. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 19 Written information provided to the inspector by the provider before the inspection indicates that all equipment is regularly maintained and tested. The inspector observed the records and storage of personal money held in the home on behalf of residents. The actual balances of 5 residents were checked against the documentation and found to be correct. Best practise systems are in place for the protection of both residents and staff – 2 signatories are sought for each transaction, all receipts are stored for auditing purposes and the money is securely stored. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 20 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 4 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 2 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X 3 X X 3 Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP20 Good Practice Recommendations An accessible system should be available in communal rooms for immobile residents to be able to summon assistance when staff are not in attendance. Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nazareth House DS0000003595.V262486.R01.S.doc Version 5.1 Page 23 - 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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