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Inspection on 03/06/09 for Nazareth House

Also see our care home review for Nazareth House for more information

This inspection was carried out on 3rd June 2009.

It is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Excellent.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Nazareth House The quality rating for this care home is: The rating was made on: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Ruth Wilcox Date of this annual service review: 0 3 0 6 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: London Road Charlton Kings Cheltenham Gloucestershire GL52 6YJ 01242516361 01242547696 manager.nazhsechelt@btinternet.com Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category The Congregation of the Sisters of Nazareth Number of places (if applicable): Under 65 Over 65 0 63 Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: The previous registered manager retired at the end of March 2009 and a new person has been appointed. Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Nazareth House, a purpose built care home, is situated on the outskirts of Charlton Kings, within walking distance of the local shops and public transport. It is registered to provide accommodation for sixty-three older people who require personal care. The Home is owned and managed by the Sisters of Nazareth, an order of Roman Catholic nuns, but people of any religious faith are welcome at the Home. All the bedrooms offer single accommodation; many have en suite facilities. Further bedrooms are being converted to provide these additional facilities. A shaft lift and stair lift provide assisted access to the upper floors. The communal areas consist of five lounges/quiet areas, three dining rooms plus a large function room and sun lounge. There is also a Chapel attached to the Home where daily services take Annual Service Review Page 2 of 7 place. People living at the home have the benefit of a large attractive garden with summerhouse, which is easily accessible and well maintained for use in all weathers. The fees for personal care at Nazareth House are dependent on individuals assessed needs, and the fee is determined by whether the needs for care are high, medium or low, and whether the accommodation has en-suite facilities. The fees do not include the cost of items such as newspapers, toiletries, magazines, chiropody and sundry items, and there may be charges for some outings and trips. The excellent rating for this service was made on the 12th June 2007. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received or asked for since the last key inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service in a dataset; Information we have about how the service has managed any complaints; What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement; Relevant information from other organisations; What other people have told us about the service. What has this told us about the service? The home sent us their Annual Quality Assurance Assessment (AQAA), which was completed to a good standard giving us all the information we asked for. The AQAA demonstrated that this home continues to be well managed, despite a change in the manager here since the last review, and that a sound understanding of the business exists. Resident occupancy was reported as being low at times, with active marketing of the home successfully taking place. An open style of management was reported and a clear understanding of the homes strengths and areas for improvement was demonstrated. The new appointed manager has not been registered with CQC at the time of this review and an application for this is expected in due course. There are ongoing quality monitoring arrangements in the home, which include seeking the views of the residents and taking action to address them. We were told that residents views were considered through the assessment and care planning stage, as well as at regular meetings and through satisfaction questionnaires. Equality and diversity is addressed also through these means, with staff encouraged to put these issues into practice for people. The AQAA stated that The needs of the residents are central to its runnning, and that all are encouraged to participate in the life of the home. It said that each resident is treated as an individual with dignity and respect. The AQAA told us about the pre-admission process for prospective residents, which included being able to view the home and have access to a good amount of information about it. The process also included an assessment of their needs, which also took account of family and other health and social care professionals involved in the prospective residents case. The assessment and care planning process was identified Annual Service Review Page 4 of 7 as an area for ongoing improvement in the AQAA. A new computerised care planning system has been reported, which staff are receiving training about. The AQQA told us about how the home meets residents needs, including the input and support of all external healthcare services. We were told that residents are supported to manage their own medications if they wished, and that this was done within a risk management framework. Care staff were reported to be responding well towards managing residents more complex needs through supervision and guidance of more senior staff. We were told that the home had implemented more robust nutritional screening and that special dietary needs were being catered for. Visitors are welcomed into the home and social contacts are supported. The role of a new social activities coordinator was currently being developed, and outings and activities were being made available. The home was seeking to increase the opportunities for those residents with sight problems, and was considering ways to address collective and individual needs. Generally good staff retention was reported, particularly amongst senior staff, although a significant turn-over was indicated amongst other staff, with agency staff only used as a last resort. The dataset showed us that there have been thirty-five shifts covered by agency in the previous three months. We were told that more staff had been recruited, with sound recruitment practices reported; supervision arrangements were in place for new staff. Induction training for new staff was being planned in accordance with the Common Induction Standards for Care Workers, and this was in conjunction with an in-house programme as well. There was an ongoing training and development programme for staff, which also included the National Vocational Qualification Award training (NVQ). The AQAA and dataset showed that there was an ongoing maintenance and servicing programme in the home, but also reported that there were some areas currently requiring attention in terms of updating or replacement. Support and guidance had been sourced to improve and develop risk management in the home. An extensive list of policies and procedures was reported, and these were shown to have last been reviewed eighteen months ago. The home has kept us informed of significant incidents and events through the required notification procedure. These have included some accidental falls, a few of which had resulted in serious injury. A concern was raised some months ago regarding aspects of care overnight in the home, and also a complaint was received that raised similar issues. These were addressed at the time and resolved. What are we going to do as a result of this annual service review? Annual Service Review Page 5 of 7 We looked at all the information and our judgement is that the home is still providing a good service and that they know what further improvements they need to make. We are not going to change our inspection plan and will do a key inspection by 12th June 2010. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 7 of 7 - 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!