Inspection on 27/07/05 for Nazareth House

This inspection was carried out on 27th July 2005.

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 24/01/06

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 PL1 3QR Lead Inspector Fiona Cartlidge Unannounced 27th July 2005 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 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Nazareth House Address Durnford Street, Stonehouse, Plymouth, Devon, PL1 3QR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 660943 01752 256842 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users aged 65 years and over 2. OP Maximum registered 25 service users (both) 3. PD(E) Maximum registered 43 service users (both) 4. TI(E) Maximum registered 5 service users (both) Date of last inspection 24/02/05 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 and a half hours and was unannounced. A full tour of the home took place and personal records of 4 residents and 2 staff were inspected. The inspector spoke to 20 of the residents as well as the deputy Manager. The staff on duty were professional and helpful in their approach to the inspection. What the service does well: What has improved since the last inspection? The management’s commitment to continually improving the skills of the staff team has continued and a number of staff have received training in Palliative care issues and recognising and reporting allegations of or actual abuse. This will safeguard those living and working in the home and ensure the staff have the specialist skills to meet the needs of those who require ‘end of life’ care. The home has also delegated specialist functions to 2 Registered nurses who have had training and act as link nurses for infection control and the osteoporosis falls risk programme. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 6 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,5 People are provided with sufficient information about the services and facilities to make an informed decision about their admission to this home. The admissions procedure enables the staff to make a professional judgement about how the needs of individuals will be met. 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 one resident gave their copy to the inspector stating ‘I’ll just ask for another one’. The inspector examined the personal records held within the home on behalf of 4 of the residents (10 ) these contained copies of contracts and terms of residency. The inspector found 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. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 9 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The health care needs of residents are regularly reviewed and action is taken to meet those needs. Records are maintained to ensure the staff provide a consistent quality approach to care. EVIDENCE: The home provides a comprehensive care planning process for residents based on continual assessment of their needs. Four care plans viewed during the inspection were fully completed and appropriately reviewed. The review processes in the home includes input from the residents and their representatives. Documentation provided evidence that General Practitioners visit residents. Records of multi disciplinary visits also included chiropodist, dentist, reflexologists, aroma therapists, district nurses, phlebotomists and opticians. There were also records providing evidence that residents are referred to specialist community and hospital health specialists when necessary. All residents spoken to told the inspector they were satisfied with the care provided. Registered nurses manage the medication system; the inspector looked at recording systems and found these to be in good order with the exception of a Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 11 reason being specified when at times medication that was prescribed was not administered. The home uses a monitored dosage system, which is well organised and easily audited. A new system is currently being introduced in line with new legislation for the removal/disposal of medication no longer required. Residents told the inspector that the staff treat them with respect and promote privacy particularly when assisting with personal care. Screens were evident in shared accommodation and the inspector witnessed the staff knocking on resident’s doors before entering. The inspector examined the records of a deceased resident, the clients wishes about the end stage of life and following death had been documented and complied with. Family members were supported and able to visit at any time and for any length of time. The records indicated that every effort had been made by the staff employed within the home and the wider community multi disciplinary team to maximise the resident’s comfort. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Social activities are organised and meet the needs of residents. Meals are nutritious and balanced and offer a healthy and varied diet for residents. The visiting arrangements are flexible and meet the needs of residents and visitors alike. Residents are encouraged to make choices about how they live their lives within the community of this home. EVIDENCE: Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 13 Residents confirmed that they are able to receive visitors when they wish. At the time of the inspection people were seen visiting socially in the communal rooms. Arrangements for maintaining contact with relatives, friends and representatives are clearly described in the homes brochure. A tour of the home and discussion with residents confirmed that they are able to bring personal possessions with them into the home limited only by space confines. There is information available to service users their relatives or friends on how to contact external agents (e.g. advocates) who can act in their interests. The home has a policy, which provides service users with access to their personal records in accordance with the data protection act 1998. The feedback about food was positive all of the residents spoken to said how good it was. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 People are safe living in this home and know who to speak to if they are dissatisfied. EVIDENCE: The inspector examined the homes policies and procedures manual and found it contains a complaints procedure, which specifies how complaints may be made and who will deal with them, with an assurance that they will be dealt with in a timely fashion. A record is kept of all complaints made and includes details of investigation and any action taken. The service users guide, brochure and contract contain information about referring a complaint to the Commission for Social Care and Inspection should the complainant wish to do so. The inspector examined the homes adult protection policy/procedure and found it to be robust. A Whistle blowing policy is also available to staff. A record of staff training showed that 20 staff have received training on recognising and reporting allegations of abuse and further training sessions on this subject have been arranged for the rest of the staff team. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,26 The providers maintain an attractively presented environment for residents and staff that is well maintained and safe. EVIDENCE: A tour of the home provided evidence that the providers maintain an attractively presented environment for residents and staff that is well maintained. Resident’s rooms contained personal items of furniture and ornaments and pictures. All of those spoken to said they liked their rooms, some were pleased that their rooms had sea views others were equally satisfied with rooms looking onto the enclosed attractive garden. 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. Specialist mattresses were seen in place for those residents requiring them as were height adjustable beds. The home was fresh and clean in its appearance hand washing facilities are available throughout the home as were protective gloves and aprons and procedures followed by the staff minimise the risk of cross infection. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 16 Safety notices were displayed throughout the home and written information indicates that fire equipment is regularly maintained and tested as are water temperature checks. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The procedures for the recruitment of staff are robust and offer protection to people living in the home. The number and skills of staff available in the home meets the needs of those living in the home. EVIDENCE: The residents told the inspector that there were enough staff on duty, they said they ‘worked hard’ and were ‘very caring’ –‘nothing is too much trouble’. The staff spoken to also advised the inspector that they felt there was sufficient numbers of staff on duty and said they had access to training and development. The home continues to be accredited with Plymouth University and the Nurses & Midwifery Council to facilitate placements for student nurses. The inspector examined the personnel files of 2 recently employed members of staff these provided evidence that the recruitment process is fair, equitable and safe. The inspector examined training records these indicate that most staff receive annual training/updates on fire safety, health and safety at work, food hygiene, manual handling and recognising and reporting abuse. Individual training records show that other training needs have been identified this year and a plan to provide the following training is in place: anaphylaxis, dementia care, ear syringing, the treatment of leg ulcers, mentors award, diabetes catheter care and infection control. Two care staff are undertaking NVQ3 in care, 24 staff have received training in palliative care. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 18 Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,38 The home is being managed properly, there is clear leadership, guidance and direction to staff to ensure residents receive consistent quality care. EVIDENCE: Residents, visitors and staff made positive comments about the management team in the home saying they felt comfortable approaching them with Issues. Communication systems are regular through staff handovers and formal meetings. The provider demonstrated a responsible attitude towards health and safety – notices were displayed throughout the home. Records seen confirmed equipment is regularly maintained and staff are trained on health and safety matters during their induction and updated regularly. All of the records seen during the inspection were clear, well maintained and secure. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 20 Despite the registered manager being on leave the atmosphere in the home was relaxed and organised and the deputy manager was polite and professional in her approach to this inspection. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 4 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 22 n/a 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 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. 2. Refer to Standard 9 26 Good Practice Recommendations When prescribed medication is not administered the reason for not doing so should be clearly stated/recorded. To minimise the risk of cross infection/contamination, soap bars should not be left in communal bathrooms. Nazareth House D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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 D52-D04 S3595 Nazareth House V235155 210705 Stage 4.doc Version 1.40 Page 24 - 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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