Inspection on 31/05/06 for Nazareth House

This inspection was carried out on 31st May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Nazareth House 12/08/08

Nazareth House 01/10/07

Nazareth House 13/03/06

Nazareth House 13/09/05

Nazareth House 10/03/05

Nazareth House 23/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nazareth House Hammersmith Road London W6 8DB Lead Inspector Jacqueline Derbyshire Unannounced Inspection 31st May 2006 09:30 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 DS0000010917.V291567.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 DS0000010917.V291567.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nazareth House Address Hammersmith Road London W6 8DB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8748 3549 020 8563 7421 The Congregation of the Sisters of Nazareth Sister Celine Marie Donnelly Care Home 95 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (65), Terminally ill (5) of places Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 65 beds for elderly medical patients over the age of 60 years of which 5 patients may be received for pallative care for a terminal illness and 25 patients may have a diagnosis of Alzheimer’s Disease. 13th March 2006 Date of last inspection Brief Description of the Service: Nazareth House is registered to care for a total of 94 service users, 73 of which require nursing care and 25 of which have dementia. The home is owned and run by The Sisters of Nazareth. There are currently 92 service users living in the home. Care is provided by a staff team comprising nurses, care assistants, cleaning, catering, administrative and maintenance staff. The fees at the home range from £590.00 to £776.24. The home is situated over three floors and accommodation is provided both in single and double rooms. There is lift access to all floors. The home has a very large garden that service users use on a daily basis. Inside the home there is a small library, chapel, hairdressers and a shop. The home owns a specially adapted vehicle for local trips outside of the home. The home is situated in Hammersmith and is close to public transport links and local amenities. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 1st and Thursday 2nd June 2006. Two Inspectors spent a total of 20 hours talking with service users, relatives and other visitors, managers the administration officer, the finance manager and staff, inspecting care records, staff records and touring the premises. One of the inspectors spent time with the maintenance team checking all relevant safe working practices and looking at maintenance records that were seen to be well recorded. The Inspectors found evidence that standards of care in the home are good. There is a shortage of activity staff to provide stimulation and activities suitable to meet service users needs that have dementia. Records of care planning need to be improved and staff must receive training to enable them to record information in conjunction with the care plans. The medication procedure has greatly improved and all of the requirements made for that area have been met. Eight of the nine requirements made at the last inspection have been implemented. There are 9 new requirements from this visit. What the service does well: The homes Statement of purpose and Service user guide are excellent with all of the relevant information and photographs included. All staff were seen to be working extremely hard to provide a high level of care in Nazareth House. Care plans are informative and easy to follow. The home has a GP that visits all service users and is on site 2 days a week. The daily menus are nutritionally balanced and the food provided is good the catering department have good understanding in supplying meals for service users who have specialised dietary needs. All care staff have induction and foundation training with 54 of staff having completed NVQ level 2 or higher. The financial records of the home are very detailed with all relevant information on the budget to show the home is financially viable. The home has an annual quality assurance report that was sent to the CSCI 30th November 2005 that covers 2004-2005. The report contains all relevant quality assurance areas and all of the findings have been collated. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nazareth House DS0000010917.V291567.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 DS0000010917.V291567.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): 1,2,3,4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The agency provides a clear and comprehensive Statement of Purpose and Service user guide. EVIDENCE: The inspector looked at the statement of Purpose and service user guide the documents were excellent with lots of relevant information and photographs included. The inspectors looked at 6 service user files and records of assessments were in each file. The home has a designated registered nurse assessor who is responsible for the pre-admission assessments. These assessments are carried out in the service users usual place or residency that can either be in the service users own home, another care home or hospital. When a service user is referred through care management, a copy of their assessment is received and the home will later undertake their own assessment. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 9 There is an issue for the home to meet the needs of service users that have dementia. The Manager to seek professional advice in dementia care mapping to ensure the home is meeting all service users needs. All six files looked at had a contract in place. The inspectors spoke to service users and relatives/friends all commented that they were happy with the provision of care. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of all service users are met. EVIDENCE: The inspectors checked 6 service user files and in each file was an up to date care plan with all of the service user health and social care needs recorded. The information in each file was informative part of the care plan process is also to assess risk levels for all areas of health and social needs. The care plans need to be more person centred looking at individual’s needs, goals and aspirations. The care plan records are kept in the service users rooms. There is a GP who visits the home every week for 2 days all service users are seen by the GP. The home has access to two physiotherapists, who visit the home three times a week; there is also a treatment room on the ground floor. An optician is available locally or home visits can be arranged, and service users have access to a local dentist as required. Referrals can also be made to speech therapist, dietician, audiologist, community nurses and occupational Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 11 therapist through the GP, records were seen to be in files to show that this does happen on a regular basis. The Manager to refer service users with cognitive impairment to a psychologist when they are showing signs of distress to assist in providing the relevant care. The inspectors checked the medication records for 6 service users. The homes medication recording has improved immensely since the last inspection. The inspector that looked at the medication procedures for safe storage and the temperatures in 1 of the storage rooms was to warm a requirement has been set to ensure that all medication rooms are monitored daily. There is also an issue of miss calculation of Controlled drugs that must be counted and the correct amount recorded that are left. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes activities need to suit all individuals. EVIDENCE: The inspectors checked the files of 6 service users and assessment records and care plans were in place to show how the home would meet their needs. The home holds a number of events including opening evening and lunches for family and friends of service users. The activities co-ordinator facilitates the planning of group activities and one–to–one activities in the home too. These include bingo, singsong, teddy bear tea parties, jigsaws, reminiscent chats, painting and listening to classical music. The inspectors checked the activity plans in the service user files; there is a requirement that activities are provided that are suitable to meet the needs of people with dementia. The home also has a mini bus for service users to go on outings. Family and friends of service users spoken with at the time of the inspection stated that they were always made very welcome by staff when they visited the home. Service users are able to bring personal possessions including furniture into the home with them, rooms observed were personalised. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 13 All service users are assessed for mental capacity and will look after their own finances if able to do so. The inspector checked the finances of 6 service users that were all correctly recorded with expenditure receipts in place. Service users care plans are kept in their rooms and they are encouraged to view them. The menus were seen during the inspection and showed a choice of three dishes at lunch and evening time. The inspectors visited all three floors at lunchtime; the inspectors observed that staff sensitively supported service users who require assistance with feeding. Hot food is served three times a day with snacks in between, service users are prompted to drink regularly and in some instances records were in place to monitor fluid in take. Service users with specialised dietary needs are catered for. Nutrition information was seen in all files and all staff has just completed a nutrition programme. In discussion with the kitchen Manager and staff it was stated that they cater for all service user requirements including cultural and religious diets. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a wellmanaged complaints procedure in place. EVIDENCE: The inspectors checked the 5 complaint records that have been made in the last 12 months. All of the records had the relevant action plans attached to show how the complaint had been investigated and what actions had been taken. The complaint procedure is written in the Statement of Purpose and the Service user guide. Service users, family members and visitors spoken with stated they would speak to a member of staff or to the Manager if they were not happy with something. In discussion with the manager and talking with staff and looking at the homes policy it was apparent that the procedure for the Protection of Adults is in place. The home has had no incidents in the last 12 months. Service users spoken with stated they would speak to the Manager or a member of staff if there were any issues. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 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 the following standard(s): 19,24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is safe and comfortable with adequate decor and furniture in place. EVIDENCE: The inspectors had a full tour of the home and 9 service users bedrooms were seen. The inspectors felt that all of the service users rooms were seen to be individual and comfortable, some of the service users had their own furniture. Communal areas were comfortable with lounge/dinning areas on all floors. The home employs domestic staff to do all the cleaning; all 3 floors were seen to be clean and tidy. Nazareth House DS0000010917.V291567.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): 27,28,29,and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an adequate amount of staff working in all areas. The home has ongoing NVQ training to meet the development needs of all staff. EVIDENCE: The inspectors looked at staff rotas for all 3 floors; all 3 floors had adequate staff on each shift to meet the needs of all service users. Service users, family members and visitors all stated that they were happy with the staff. There is an issue that an adequate amount of skilled staff are in place to meet the needs of service users that have dementia. The homes recruitment procedure needs to be checked to ensure that all checks are completed on all staff prior to employment at the home. All original documents that are copied should have dates and signatures that state original document was seen. All staff employed to have a code of conduct that is in accordance with the (GSCC) General Social Care Council. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 17 In discussion with staff they stated that they are up to date in training the information on training and development was not available as the Manager is at present brining records up to date. All staff to have a training analysis completed. The Manager also commented that one of the Deputy Managers and the Administration officer were doing university level training to ensure they were able to continue providing relevant up to date information to colleagues. 54 of care staff has NVQ’s or equivalent, all nursing staff are up to date on training. A dementia-training course is in place that is provided in house, the inspectors felt that staff should be more skilled in this area and specialists in dementia should be contacted to assist. Nazareth House DS0000010917.V291567.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): 31,33,34,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a very competent Manager who demonstrates good leadership skills to her staff team. The home is financially viable with excellent records in place for all expenditures. EVIDENCE: The Registered Manager has a diploma in management and a BSc (Hons) in Health and social care of older people. The manager has also studied courses in palliative care and dementia care. As well as the above courses, the manager attends periodic in-house training sessions. In discussions with the Manager and staff it was apparent that the manager is very knowledgeable about the needs of all service users and also staff development. There is a very effective quality assurance procedure in place, the home has regular meetings with service users, relatives and friends to look at any areas of concern they may have regarding the care provision from Nazareth House. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 19 Questionnaires are also given to service users to complete and their families, friends, advocates and social services placement officers. Forms were seen in place around the home for anyone visiting to complete. Service users have regular reviews and issues can be taken from them. There are monthly Person in Control visit records were all areas are looked at any actions are recorded and monitored. The Manager, Deputy Manager, administration officer and maintenance team complete audits of specific areas including: service users finances, food provision, medication, staff training, policies and procedures and ensuring records are completed by staff and are up to date. All of the information has been collated and action plans have been put in place to meet any recommendations to improve the service provision. A copy of the annual quality assurance development plan was sent to the CSCI November 2005. One of the inspectors spent time talking to the homes Finance Manager, the inspector was shown very informative records of the budget and financial schedules that show the home is financially viable. The inspectors also spent time talking to staff and all staff stated they were happy with the frequency of their supervision meetings every two months and that any issues raised were always dealt with. All staff has annual appraisals to ensure that training and development including all health and safety training have been completed. As written in this report all-new staff undergoes induction training that covers all mandatory health and safety training The home has a protection procedure in place that was known by all staff when questioned. Service users spoken with stated that if they had a problem they would talk to the Manager or a member of staff. There is an issue with the daily record keeping, all relevant information should be written in conjunction with the service users care plans. One of the inspectors spent time with the Maintenance team checking all relevant health and safety areas; there was excellent records in place that show all checks are completed and issues dealt with speedily. Nazareth House DS0000010917.V291567.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 3 3 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 3 2 3 Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 21 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 OP4 Regulation 12 Requirement The home to meet the needs of service users that have dementia. Sufficient trained staff to be in place to provide stimulation and also provide relevant activities to suit individuals as well as groups. Care plans to be person centred looking at individuals needs, goals and aspirations. All medication storage rooms to be monitored daily to ensure medication is kept at a safe storage temperature. Controlled drugs must be counted and the correct amount recorded that are left. Activities are provided that are suitable to meet the needs of people with dementia. Sufficient qualified staff to meet the needs of service users that have dementia. The Manager to ensure that all recruitment references are checked for validity. This is a repeat requirement. DS0000010917.V291567.R01.S.doc Timescale for action 31/08/06 2 3 OP7 OP9 15 13 31/08/06 05/06/06 .4 OP9 13 05/06/06 5 6 7 OP12 OP27 OP29 12 18 19 31/08/06 31/08/06 30/06/06 Nazareth House Version 5.1 Page 22 8 OP29 19 All staff are employed in accordance with the (GSCC) General Social Care Council. All staff to have a training analysis completed. Service user records to be more informative in conjunction with the care plans, activity participation should also be recorded. 31/08/06 9 10 OP30 OP37 18 17 31/10/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP4 OP8 OP29 Good Practice Recommendations The Manager to seek professional advice in dementia care mapping to ensure the home is meeting all service users needs. The Manager to refer service users to a psychologist when they are showing signs of distress to assist in providing the relevant care. All original recruitment records that copies are taken from to have a signature and date with information stating that the original document was seen. Nazareth House DS0000010917.V291567.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 DS0000010917.V291567.R01.S.doc Version 5.1 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. 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!