CARE HOMES FOR OLDER PEOPLE
Nazareth House Liverpool Road Crosby Liverpool Merseyside L23 0QT Lead Inspector
Mrs Trish Thomas Unannounced Inspection 10:00 4 September 2006
th 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.V295389.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.V295389.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 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.V295389.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 22/02/06 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 Joseph, who has many years experience in health care and service to the community. 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 Joseph, 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 on the two days of the inspection. Meals are cooked on the premises and served in one of the dining rooms on each unit, or in residents’ bedrooms, if they prefer. The home 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 service users. The home is situated on the main Liverpool to Southport Road with close 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 Service Users 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.V295389.R01.S.doc Version 5.2 Page 5 Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over two days (25th August and 4th September 2006), and the methods used were discussion with residents and visitors and interviews with a number of the members staff on duty. Records compiled in the home relating to care practice, health & safety and staffing were read and a tour of the premises was carried out. Reference was made to the preinspection questionnaire, which had been completed by the manager, Sister Joseph, prior to the inspection dates. What the service does well: What has improved since the last inspection?
The majority of requirements from the last inspection regarding care planning, care practice and medication management have been met. Where requirements have not been addressed, this is referred to in the relevant section of this report with extended time limits given. The home has a maintenance programme and improvements to the environment are ongoing. A number of rooms have been decorated, and a new bath, a shower and flooring fitted in various areas of this large building. There is ongoing replacement of furniture and equipment. Residents said they are comfortable and satisfied with their surroundings.
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 7 Fire safety procedures and drills were up to date and fire alarm systems tests were being carried out weekly in the home. The staff training programme is ongoing and they are taking advantage of the training on offer to improve their career prospects and skills. A training development is noted in that training in report writing is now being provided. Records are maintained of medication brought into the home and those not administered. Requirements regarding methods of administration of medication on one floor have been addressed. What they could do better:
To ensure that Nazareth House can meet the needs of all residents and remains within their conditions of registration, the home must not admit residents whose needs are not in accordance with the registered category, (for example, those who have dementia). For residents who have become mentally frail during their residency and require high levels of supervision, applications must be made to the Commission for Social Care Inspection for variations to the registration. To ensure that the home is providing support in accordance with need and making timely medical referrals, records of pressure care, condition, mobility, diet and fluid intake, must be recorded in detail. To ensure that residents are fully involved in the process, care plans and must be reviewed and updated with the resident’s/representative’s written consent obtained (when possible), to any changes. To ensure safe practice in medication management, clear procedures must be available to staff regarding the circumstances in which they will administer PRN medication to any individual. In order that up to date records are maintained of medication administered to residents and to ensure an accurate audit trail is maintained, codes must be inserted in the medication record when the drug has not been administered. To ensure that administration records are accurate, those written by staff (in the absence of a pharmacy printout) should be signed by the writer and checked and signed by a colleague. To ensure that the residents’ right to choice is fully supported, the menu of the day should be distributed to all floors, and made known to staff. For those residents who have poor mobility, staff should be able to let them know what will be served, to ensure there are satisfactory alternatives on offer. To ensure that staff are aware of the procedures to be followed if abuse/neglect of a resident is suspected, it is advised that residents are provided with updates in the Local Authority’s adult protection procedures and the home’s “whistle-blowing” policy.
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 8 To avoid the risk of contamination in the preparation and serving of food, all areas of the kitchen must be maintained to the highest standards of cleanliness, and staff must wash their hands and put on aprons when serving food to residents. To ensure that the home is accountable regarding staff numbers on duty, an accurate staff roster must be maintained of the names of those who have worked each shift. Arrangements must be in place for staff files to be made available to inspectors from the Commission for Social Care Inspection in the manager’s absence. To ensure that environmental and mobility risks may be identified and full details of the circumstances are on record, accidents to residents and staff on the premises must be accurately maintained. To ensure that residents are protected from legionella, a safety certificate must be obtained and a copy provided to the Commission for Social Care Inspection. 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 DS0000005384.V295389.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.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home has systems to obtain an assessment of each prospective resident’s needs prior to admission. Services and facilities in the home were in accordance with the home’s registration and aimed at meeting residents’ presenting needs within that category. Variations have been granted in some instances and the current situation regarding category and admission of residents must now be reviewed in accordance with the home’s registration. EVIDENCE: Records for recently admitted residents contained a copy of an application for residence and a detailed assessment, completed before moving into the home by a senior member of staff. Social work assessments are obtained for residents who are placed by the Local Authority. In order to ensure that prospective residents’ needs may be met within the services and facilities available in the home, support needs, beliefs and preferences are stated.
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 11 The home is registered to provide care for older people, not falling within any other category of care needs and is not registered to admit residents who have dementia. One recently admitted resident has a diagnosis of vascular dementia. There are two variations to registration for long-term residents whose mental health had deteriorated over time, and staff have attended courses in dementia care. The manager, Sister Joseph, must arrange reviews of residents’ needs (as appropriate) and arrange for variations accordingly, with the Commission for Social Care Inspection, regarding dementia. Training schedules were reviewed and there is a good level of training available to staff, appropriate to the care and support of residents whose needs are within the registered category. The ethos in the home is predominantly of Roman Catholicism and this is clear in the home’s brochure. Residents of other faiths confirmed that they are supported in following their religion and their ministers visit the home. Residents who are Catholic, may attend Mass daily in the chapel, some are assisted in wheelchairs, and communion is brought to the units for those who are frail and are unable to attend. Nazareth House DS0000005384.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. All residents have a care file and further work will be necessary to upgrade the content and updating of care plans and medication records. The home has measures in place to provide residents with access to health services. EVIDENCE: Seven care plans were tracked for residents on each of the three floors. There is a standard format in use which incorporates assessment, action planning and review systems. Care plans cover a wide range of need and promote residents’ independence in supporting their health, personal care and social preferences. It is advised that for residents who are frail and receiving high levels of personal care and support, their weight, diet and fluid intake is recorded. If residents refuse to be weighed or are unable to use the scales, this should be referred to in the resident’s weight record (one resident had last been weighed in March 06). Requirements are made with regards to updating pressure care assessments (on one care plan this had last been reviewed on 21/3/06). It is required that records are maintained of the condition of
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 13 pressure areas as they are observed (these were absent in the relevant care plans which were read). It is required that moving and handling risk assessments are updated, (one had last been reviewed in April 05). It is also required that bedrail checks are updated (one had been last checked in December 05). A care plan contained the signature of a resident’s representative regarding the fitting of bedrails. In another instance staff confirmed that verbal permission for this had been obtained from the resident’s family. Generally, changes to care plans had not been signed and a requirement from the last inspection is repeated. For a resident who has some specific support needs for mobility, it is advised that a referral is made to the occupational therapy service and the moving and handling assessment reviewed. A member of staff said she does not consider the bath hoist to be fully meeting the resident’s needs, as it is not individually moulded. Residents’ health care needs are referred to on their care plans and there was evidence of referrals to G.P.s, district nurses and paramedical services referred to in residents’ individual medical records, which are compiled in the home. Requirements have been referred to previously regarding ongoing and frequent updates to pressure care support needs, to ensure that those residents, who are at risk, receive medical treatment and equipment, without delay. The home has a medication administration procedure and prescribed medication is secured on each floor. Staff on duty said they had received some training in medication administration, which they found to be useful and further training is arranged. A requirement is made regarding providing a care plan for residents in relation to PRN medication. There was no such plan for a resident who is prescribed two named pain-killing drugs as required. A requirement is made regarding maintenance of accurate medication administration records. On reading the records, gaps (with no codes inserted) for some doses were observed and instances of self-medication had not been made clear. A recommendation is made regarding instances where a pharmacy printout of prescribed medication has not been provided and these have been hand written by staff. These records should be signed by the writer and checked against the drug containers and signed by a colleague. Regarding one record, which was read, a requirement is made regarding following pharmacy instructions and maintaining accurate records of administered medication. As the manager, Sister Joseph, was not on duty during visits to the home, requirements regarding care planning and medication were discussed with senior staff on each floor. Residents who commented said that the staff are friendly and helpful and attend to requests for assistance. There is a call system throughout the home to enable residents to summon assistance. A visiting relative said she had no concerns regarding her mother’s care and treatment. This visitor said that arrangements are made for ministers of denominations other than Catholicism to attend the home, in accordance with individual beliefs and preferences. Residents’ personal preferences are ascertained and recorded on their care plans at the time of admission. No resident expressed any concerns regarding respect for their privacy and dignity. Obvious attention had been paid to the
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 14 clothing and personal grooming, care and comfort of residents requiring higher levels of support. Screening was observed in shared rooms and bathroom, toilet and bedroom doors were kept closed during the visit. Staff were observed treating residents respectfully in tone and terms of address, and the senior staff on duty demonstrated knowledge of residents’ preferences and support needs. Nazareth House DS0000005384.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality of this outcome was good. The judgement has been made using available evidence, including a visit to the service. Nazareth House has a religious based culture, which is clearly stated to residents, prior to admission, in the home’s brochure. A number of home-based activities are arranged for participation by choice and residents’ opinions and wishes are supported through procedure, training and practice. EVIDENCE: It was observed that number of residents attended Mass in the chapel and a resident who is frail, received communion in the main lounge. Bingo had been arranged on the ground floor and residents from upper floors had been invited, two being assisted in wheelchairs. One lady said, “I have to live somewhere and I’m glad it is here. The place is marvellous.” Her companion said, “I agree.” These remarks were typical of verbal feedback obtained from residents. A number of were not able, or chose not to comment, and they looked comfortable and well care for. Staff were in attendance in the lounges during the inspection and residents appeared at ease with them. A variety of reading materials and quiet areas are available to residents and some were observed making use of these facilities. Reference was made to the preinspection questionnaire where a summary of leisure activities is stated
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 16 including provision of computers, videos and books, outings and shopping trips. Residents’ care plans contained brief social histories and details of next of kin. Residents who commented said their family and friends visit, and staff do not interrupt when they are entertaining visitors. A resident who was feeling unwell was in her bedroom, her visitor was with her, and they were left undisturbed. One visitor said, “The staff are very helpful and it is the same whenever I come here.” There are residents’ notice boards on the corridors where information is made available to them, such as Residents’ Rights, Fire Procedure, mobile-shop day. Residents were spending time in their bedrooms, the lounges and quiet areas. They have freedom of movement in communal areas and meals are served in their bedrooms by choice. A resident said, “I like being sociable, but if I want some peace, no one forces me to play bingo or take part in the quiz.” The home has a main kitchen and each unit has a serving area, stocked with drinks and snacks. Menus of the day are distributed to each floor, though on one floor the menu was not in evidence and residents and a member of staff who were asked, did not know what was to be served for dinner. In general, comments on food were favourable. Residents said the food was to their liking with alternatives offered. The main kitchen and food storage areas were visited and there were good stocks of food in the stores and in the fridges and freezers. There are regular deliveries of fresh fish, meat, fruit and vegetables. There is a dining room on each floor and all were well presented with space and seating for those in residence. Residents requiring assistance to the dining room and during meals were assisted discreetly. They said they are regularly served drinks throughout the day and at night if requested. Nazareth House DS0000005384.V295389.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home has policies in place to protect resident’ rights. Provider investigations via the Commission for Social Care Inspection are completed within given timescales. EVIDENCE: Since the last inspection, one complaint has been referred to the provider for investigation, the outcome being, not upheld. The manager states in the preinspection questionnaire that no adult protection investigations have taken place since the last inspection. A member of staff said that she has not received the relevant training recently, and it is recommended that staff receive updates in Local Authority adult protection procedures and the home’s “whistle-blowing” policy. There are some outstanding concerns, which were received at the Commission by telephone. As the registered manager was not present, these could not be fully looked into, although some relevant information has been obtained during the inspection process. Nazareth House DS0000005384.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The quality of this outcome was adequate. This judgement had been made using available evidence, including a visit to the service. There are systems in place to ensure that the home is safe, clean and well maintained. Further attention to infection control in the serving and preparation of food is necessary. EVIDENCE: As observed during a tour of the premises and as stated in the pre-inspection questionnaire, a number of areas have been recently decorated with new flooring, furniture and equipment provided throughout the home. Due to the age of the building, repairs to the roof have been necessary, now completed. Division of the service into three floors/units gives a more homely and personalized service to residents. The grounds are very well maintained with well-maintained lawns, shrubs and flowers. Domestic staff are employed and training courses in infection control are arranged regularly. In the main, the building was clean and hygienic but two areas for improvement were observed. Care staff were seen on one floor
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 19 serving meals without protective clothing. There must be a clear procedure to be followed by staff, of hand washing and putting on aprons before they serve/handle food. Although, in general, food preparation areas were clean, the fans at eye level over the cooking area in the main kitchen were coated in dust and grease. A requirement is made that these areas be maintained to the highest standards of hygiene. Nazareth House DS0000005384.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. Staff numbers and skills were meeting residents’ care and support needs. The home has systems for the recruitment and vetting of staff, aimed at the protection of residents. EVIDENCE: Care staff numbers were being maintained but on one floor, inaccuracies were observed in the staff roster. The names of staff who cover for colleagues on holiday are written in a book and not inserted on the roster. A requirement is made that the roster includes the names of staff who work on each shift as set out in schedule 4 (7). There is a good level of ancillary support including an administrator, training co-ordinator, handy person/gardeners, laundry assistants, housekeepers and chefs. Over 50 of care staff employed in the home hold NVQ qualifications and there is a programme of mandatory training, which is reviewed through staff appraisals and ongoing performance monitoring. Staff said they receive encouragement and support in accessing training from their floor managers. They said that members of the management team are approachable and they stated no concerns regarding the general running of the home. Staff who were spoken with said that they have police clearance, contracts of employment and were interviewed prior taking up employment and have provided references. There was no further evidence available as staff files
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 21 were not accessible due to the manager not being on the premises. A requirement is made that arrangements are made for staff to files available to inspectors of the Commission for Social Care Inspection, as set out in Schedule 2. Nazareth House DS0000005384.V295389.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The registered manager, Sister Joseph, is qualified, competent and experienced to manage the home in a manner, which promotes residents’ best interests and the home’s purpose and aims. EVIDENCE: The manager, Sister Joseph, has many years experience in care and nursing and holds a management qualification. Sister Joseph is supported in her role by three floor managers. Members of staff said that Sister Joseph is very supportive towards staff and is well respected. The home has a quality assurance system and based on seeking the views of residents and which is aimed at meeting the objectives of the home. The process is facilitated by an external consultancy.
Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 23 Reference was made to the pre-inspection questionnaire where it is stated that all residents receive their full personal allowance to dispose of as they wish. Some of the residents’ personal representatives have Power of Attorney and those with no families have access to advocates. It is stated in the questionnaire that the home does not invest saving for residents and the majority handle their own finances, the home being appointee for a minority. Additional charges are stated for hairdressing and chiropody. Health & Safety Certificates and the fire book were up to date. The home did not have a legionella certificate due to work on replacing some water tanks not having been completed. The home maintains a record of accidents to residents and staff. One such report lacked detail, not providing a full account of events and outcomes (as set out in Schedule 3). Nazareth House DS0000005384.V295389.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 X X 2 3 X N/A 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 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Nazareth House DS0000005384.V295389.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 OP3 Regulation 14 Requirement The registered person must not admit residents whose needs are not within the registered category of the home. The registered person must make arrangements (as appropriate), for residents’ mental health needs to be reviewed to ensure that their needs are within the registered category of the home. The registered person must ensure that for residents at risk of pressure sores, the condition of their pressure areas is recorded as observed and their diet and fluid intake is accurately recorded and medical referrals made accordingly. The registered person must arrange for residents or their representatives to have the opportunity to read, agree and sign their care plan. (This is outstanding from the last inspection, extended time limits are given). The registered person must
DS0000005384.V295389.R01.S.doc Timescale for action 11/10/06 2. OP3 14 11/10/06 3. OP7 15 11/10/06 4. OP7 15 11/10/06 5. OP7 13 11/10/06
Version 5.2 Page 26 Nazareth House 6. OP9 13 7. OP9 13 arrange for residents’ moving and handling assessments to be updated and regularly reviewed. The registered person must arrange for action plans to be established for PRN medication, detailing for staff the circumstances in which it will be administered. The registered person must instruct staff that they are not to leave gaps in medication administration records. Codes must be inserted as needed (Outstanding from the last inspection, extended time limits given). The registered person must ensure that staff follow the pharmacy instructions when administering prescribed medication and maintain and accurate record of the process. The registered person must arrange for staff to wash their hands and wear protective clothing before serving food. The registered person must arrange for the fans in the main kitchen to be maintained to the highest standards of hygiene. The registered person must ensure that staff rosters include the full names of staff who have worked on each shift. The registered person must arrange for staff files to be made available to CSCI inspectors in her absence. The registered person must provide CSCI with a copy of the home’s legionella certificate. The registered person must ensure that accident records are accurately maintained. 11/10/06 11/10/06 8. OP9 13 11/10/06 9. OP26 13 11/10/06 10. OP26 13 11/10/06 11. OP27 17 11/10/06 12. OP29 19 11/10/06 13. 14. OP38 OP38 23 17 11/01/07 11/10/06 Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 27 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. 4. Refer to Standard OP7 OP7 OP14 OP18 Good Practice Recommendations The registered person should ensure that residents weight is monitored monthly and if this is not possible, this should be recorded and the reason stated. The registered person should arrange an occupational therapy referral for one resident with regards to the resident’s handling needs when bathing. The registered person should arrange for the menu of the day to be made available to residents on all floors. The registered person should arrange for staff to receive updates in Sefton’s adult protection procedures and the home’s “whistle-blowing” policy. Nazareth House DS0000005384.V295389.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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