Inspection on 05/05/05 for Nazareth House

This inspection was carried out on 5th May 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 10/06/10

Nazareth House 21/08/07

Nazareth House 01/02/07

Nazareth House 12/10/05

Nazareth House 28/02/05

Nazareth House 22/11/04

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 162 East End Road East Finchley London N2 0RU Lead Inspector Rebecca Bauers & Tola Akinde-Hummel Announced 5th May 2005 @ 10.00am 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Nazareth House Address 162 East End Road, East Finchley, London N2 0RU 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) 020 8883 1104 020 8444 3691 Sister Hilary Marrinan for the Congregation of the Sisters of Nazareth Anne Fenlon PC Care Home only 89 Category(ies) of OP Old Age registration, with number of places NAZARETH HOUSE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Fifteen specified service users who have dementia may remain accommodated in the home. 2 The home must advise the regulating authority at such time as any of the specified service users vacate the home. Date of last inspection 28 February 2005 Brief Description of the Service: Nazareth House is a long established residential care home providing a home for eighty-nine people over the age of 65. It is owned and operated by a Roman Catholic order of nuns the Sisters of Nazareth who are the registered providers. There is a very strong Catholic ethos in the home, including a chapel where Mass is celebrated daily. Service users from other religious and cultural groups are admitted and assisted to maintain contact with their religious and/ or community groups. Nazareth House is a large home split into a number of annexes named after Saints. There are a number of bedroom with en-suite facilities and those bedrooms without en-suite facilities have bathrooms facilities close by. Nazareth House with its spacious grounds offers peace and tranquillity and it is practically situated with ready access to shops, post office and local transport. Ample space is available in the grounds for a leisurely stroll along specially made pavements around the garden, providing an atmosphere where independence is encouraged. The home is light and bright with appropriate adaptations and equipment. The home is divided into a number of separate units. Staff generally work on the same unit so service users receive care from the same staff. Each unit has a separate dining area and lounge.· NAZARETH HOUSE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 5th of May 2005 as part of the annual inspection programme to identify progress with previous requirements and to check standards of care against the core standards. The inspection took two inspectors seven hours to complete. A full tour of the home took place, fourteen service users were spoken to in small groups and on and individual basis. One relative spoke to the inspector on the day another spoke to the inspector on the telephone. Care records, staff records, quality assurance audits and health and safety records were examined. Twenty- five staff were spoken to and the inspectors were able to have discussions with the registered manager and the registered person during the feedback session. Further information was obtained from the pre-inspection questionnaire and comment cards. Twenty-four comment cards were received from service users; five from health care professionals including GPs and twenty-two from relatives. Positive comments were given with regard to the care received and the caring attitude of the staff team. There were mixed feelings expressed with regard to the access to activities with staff support. What the service does well: The home has a comprehensive pictorial statement of purpose and service guide to enable prospective service users to make decisions about the home. The service users benefit from having detailed assessments of need in place, individual plans are comprehensive providing a holistic view of the individual that staff are able to follow and provide continuity in care. This is supported by service users who said ‘the staff are very kind, caring and know what I like’. Risk management strategies are detailed ensuring the safety of service users. Social and personal health care needs are met by a variety of health care professionals. The food provided in the home is fresh, hot and well balanced to meet the needs and preferences of service users. NAZARETH HOUSE Version 1.10 Page 6 Medication policies and procedures are followed by staff to safe guard service users. Service users know how to complain and have been given the relevant contact information to enable them to complain both internally and externally. Quality assurance audits ensure service users views are listened to and acted upon. Staff morale is good which promotes good positive team working. The environmental conditions are calm and serene. The health, welfare and safety of service users are protected through regular health and safety checks. What has improved since the last inspection? The two requirements made at the last inspection had been met. The service users ‘interests’ had been recorded in their individual plans. These activities mainly related to daytime activities. Progress still needs to be made with evening activities to stimulate service users. All fire doors are able to effectively close and are not wedged open. They have been fitted with fire door guards so that in the event of a fire and the alarm being raised they will self close to safe guard service users. These are being checked weekly. NAZARETH HOUSE Version 1.10 Page 7 What they could do better: Nine requirements and three recommendations were made during this inspection. Service users must receive annual dental checkups, particularly those with dentures that do not fit correctly. This will aide eating, drinking, talking and general positive self-esteem for service users. Service users wishes in the event of their death must be recorded in their individual plans of care to ensure that their wishes are respected. Staff must ensure that in the event of a service user becoming unwell or displaying symptoms not peculiar to their specific condition they must call for medical assistance from a GP or Ambulance. This is essential to safe guard service users health and welfare. The lack of activities in the home during the evening and especially during the summer evenings must be reviewed to ensure that service users are stimulated to meet their own recreational needs. Befrienders or volunteers could benefit service users who do not have regular visitors and who can sometimes become lonely. Recommendations have been made for the ‘home delivery library service’ to be promoted to ensure that all service users are aware that it exists. Some service users stated ‘ I didn’t know that this service existed’. The quality assurance audit must be developed to include the views of external stakeholders such as health professionals and care managers. The results from the audit carried out in March 2005 must be summarised and made available to interested parties. New CRB checks must be applied for so that the staff files for three new staff are complete with up-to-date information to safeguard service users. These staff must not work alone until clearance has been obtained. Evidence must be sent to the Commission. Staff must be trained in mental health issues such as depression in order to meet the needs of some of the service users living in the home. A recommendation has been made for staff supervision records to be more detailed and reflect actual discussion with regard to work practice. The complaints book must contain a clear outcomes section and the fire check pro-forma should be filled in correctly to reflect if a fault is found with the fire equipment. Documented evidence must state that the batteries in the newly fitted door guards are checked and in good working order. The fire risk assessment should be reviewed annually to ensure the safety of service users, relatives and staff. NAZARETH HOUSE Version 1.10 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. NAZARETH HOUSE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection NAZARETH HOUSE Version 1.10 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 standard(s) 1,2,3,6 Service users are given detailed information they need to make an informed choice about the home. Each service user is assessed prior to admission and express confidently that their needs are met. Each service user is provided with a contract eight weeks after admission. Intermediate care is not provided in the home. EVIDENCE: Service users records demonstrated that service users had visited the home prior to admission and are provided with a detailed, pictorial statement of purpose and service user guide, these were seen in each service users bedroom. Six service users have moved into the home in the last six months. One service user who had moved into the home four weeks ago confirmed the receipt of the service user guide and statement of purpose stating that they ‘gave a clear indication of what is provided in the home, what the rooms look like, where they can eat, activities provided and the staff provided. Another service user was visiting the home for the second time but with her family on the day of the inspection to decide if she wanted to move in. NAZARETH HOUSE Version 1.10 Page 11 The service user spoken to expressed her delight with regard to the staff understanding her needs following an initial assessment and through further conversations with them. The seven files examined all contained detailed assessments of need. Each service users has a contract with a statement of terms and conditions. New admissions do not receive a contract until eight weeks after admission following a follow up review to ensure the home is still able to meet their individual needs. The home does not provide short-term intensive rehabilitation. NAZARETH HOUSE Version 1.10 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 standard(s) 7,8,9,10,11 Service users health, personal care and social care needs are set out in the individual plans, although dental treatment is lacking. The home had been overly cautious in two known cases and had not called for medical assistance (GP/Ambulance) when it was needed to safe guard service users. Service users are supported to self medicate and staff are appropriately trained to ensure the safe administration of medication. Service users feel that they are treated with dignity and respect. Service users wishes in the event of their death are not in place consistently. EVIDENCE: The seven service users files examined demonstrated that service users benefit from the home having a clear, consistent understanding of their health, personal and social care needs. Individual plans were detailed, reviewed monthly and intervention had been sought from multidisciplinary teams. Appropriate risk assessments were in place to safe guard service users, this included infection control and in the event of MRSA. A district nurse spoken to was very positive with regard to the care provided and the staffs understanding of the service users care needs, this included key workers NAZARETH HOUSE Version 1.10 Page 13 ability to update individual plans to reflect changes in care. Daily notes were very detailed providing a holistic understanding of the service users. Some fourteen service users were spoken to and said that they are reassured that their personal and health care needs are met by the staff team in a consistent manner. Some of the comments made were as follows ‘staff are very thoughtful’, ‘I couldn’t be more content here’ and ‘its splendid living here’. One service users said ‘why are you asking me if my needs are met? If they weren’t I wouldn’t live here.’ The inspector received no negative comments with regard to the care provided by the home from service users or relatives. Relatives were very positive in their praise for the home. It is evident from the signed and dated records that individual plans are developed with service users, family, friends and other professionals. This is an example of good practice. Staff were seen talking to service users in a respectful and kind manner. Service users said that their privacy and dignity is always maintained whilst personal care is given. It was evident in the health care records that dental treatment for some service users was lacking particularly for those with dentures, this must be rectified and a referral must be made to ensure that all service users receive annual dental treatment. Medication policies and procedures are followed by trained staff to ensure service users are protected. Service users who self-medicate are supported through risk assessments and the management of these. Service users spoken to who self-medicate were knowledgeable about their own medication and the importance of safe storage (in lockable cabinets) of their medication in their bedrooms. The service users wishes in the event of death had been recorded sporadically, only two of the seven files examined contained information with regard to this. This information must be recorded for all service users to ensure that their wishes are respected. It was noted in recent team meeting minutes dated 18/11/04 that a member of staff had not called for a GP during her shift when a service user had been unwell during the day, but appeared to be restful and sleeping at the end of the day. The GP was contacted at 9pm instead by another member of staff. This delay in calling for medical assistance could prove to be detrimental to a service user, staff must always call for assistance when a service users health deteriorates or if they experience new symptoms not recognised as part of their medical history. This type of error had also been made in the case of one service user who had a seizure, his medical notes did not reflect this as a known condition and so an ambulance should have been called. This hesitancy must not be part of the homes practice and must be addressed immediately. NAZARETH HOUSE Version 1.10 Page 14 All accidents and incidents had been recorded appropriately with risk assessments being reviewed accordingly to safe guard service users. All reportable incidences under regulation 37 had been submitted to the CSCI. NAZARETH HOUSE Version 1.10 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 standard(s) 12,13,14,15 Service users are generally satisfied with their lifestyles in the home and feel that most of their social and all of their cultural needs and interests are being met. Service users maintain good contact with family and friends who are welcomed by the home. Service users exercise choice and control over their lives on a daily basis and more formally through three monthly meetings. Service users are provided with good home cooked food in pleasant surroundings with flexibility. EVIDENCE: Most service users expressed that the home met their expectations and preferences to satisfy their cultural, religious and recreational interests. A group of service users were spoken to and observed during activities being carried out with the part- time occupational therapist, comments were very positive with regard to the benefits of this input. Service users seemed happy and interacted well with each other during this session. A requirement made at the last inspection for service users interests and preferred activities to be documented in their individual files had been met in some detail. Information also included likes and dislikes with regard to food, sensory needs, activities and how staff need to approach and encourage service users to participate. NAZARETH HOUSE Version 1.10 Page 16 Through discussion the inspector found that service users were not always aware of certain recreational activities on offer, for example the home delivery library service, it is recommended that the home promotes and supports service users to access this. Additional activities had been promoted using a poster. Another service user stated that there are not always enough evening activities particularly during the summer months. This must be addressed to enable service users to walk in the grounds with support from staff, volunteer or befriender if required. Volunteers and/or befrienders may be useful support for service users who do not always have friends or relatives visiting them and who can sometimes become lonely. Service users are supported to practice their religious beliefs through attendance at the on-site chapel or if preferred in their own rooms. Service users have three monthly meetings and attendance is good. Service users are able to exercise choice and express views about the home and future development during these meetings. Family and friends were complimentary with regard to the care provided in the home and the flexibility to visit. Service users confirmed that their visitors are welcomed by the home and often offered tea and home made cake, or visitor’s sometimes access the local community with their relative or friend. The service users benefit from an experienced cook and kitchen assistants who always use fresh meat and vegetable to prepare wholesome meals to meet the service users preferences and dietary requirements. Again service users comments included ‘the food here is very good,’ ‘we have good choices’ and ‘the food is always hot.’ ‘ I sometimes eat in the dining room or in my own room depending on how I feel.’ The kitchen is maintained to a good standard and all necessary safe guards are in place with regard to the storage, preparation and serving of food to protect service users. NAZARETH HOUSE Version 1.10 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 standard(s) 16,18 Service users and relatives are confident that their complaints are listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Two complaints had been made since the last inspection; both had been documented and resolved. Both complaints had been made by service users and had been dealt with satisfactorily. The complaints book did not contain a clear ‘outcome section’ to indicate the result of the actions taken by the home, this must be added to the existing complaints record. Service users were very open with regard to complaining, ‘I always speak my mind, otherwise no-one knows what is troubling me.’ Other views expressed were similar. An openness and calmness was evident in the home where service users are able to express themselves freely. Relatives spoken to expressed a willingness by the home to ‘please’ and to create a calm, open atmosphere. There have been no adult protection issues in the home. The last adult protection issue following a complaint made by a service user and mentioned at the previous inspection had been dealt with appropriately following a strategy meeting held on the 7/1/05. Correct adult protection procedures had been followed the home had kept the CSCI fully informed and concluded in March 2005. NAZARETH HOUSE Version 1.10 Page 18 Staff are trained in the adult protection procedures and fully aware of the boroughs adult protection procedures to safe guard service users. NAZARETH HOUSE Version 1.10 Page 19 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) 19,23,24,25,26 Service users live in a safe well-maintained environment; bedrooms are spacious and personalised to meet individual needs. The home is warm, clean, pleasant and hygienic. EVIDENCE: Service users benefit from a safe, serene well maintained environment. Service users were seen walking around the home freely or being supported by staff. Some service users were in their own bedrooms; others were in the communal lounges or dining rooms. Ten of the bedrooms seen were nicely decorated and had been personalised by the service users themselves who explained that they had been able to bring some of their own furniture into the home. There was evidence that bedrooms are redecorated each time a new service user moves into the home. Bedrooms were generally very spacious. The home was warm, clean, fresh, light and airy. NAZARETH HOUSE Version 1.10 Page 20 The home is commended on the high environmental standards maintained in the home. NAZARETH HOUSE Version 1.10 Page 21 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 Service users needs are met by the numbers of staff on duty. Service users feel safe and are protected by the homes recruitment policy and practices in all cases except for three new staff who have transported their CRB checks. Staff have been trained to meet the needs of most of the service users except those with depression. EVIDENCE: The staffing rotas showed the number and designated role of staff on each floor in the home across a 24-hour period. The rota appeared to indicate that the staff numbers meet the needs of the service users. Staff were seen supporting service users throughout the inspection. Six staff files were examined for new staff employed to work in the home in the last six months. These records confirmed that staff have been trained to do their jobs. All six files contained evidence of completed induction and mandatory training to protect service users. All had received practical first aid and manual handling and lifting. The twenty-five staff spoken to said that they had all received a thorough induction and regularly attend refresher courses. Staff files indicated that service users are protected by the homes recruitment policy and practices. All six staff files contained CRB checks however three of the new staff member’s checks had been transported from their previous place of employment. These must be re-applied for and until that time the care staff NAZARETH HOUSE Version 1.10 Page 22 must not work alone. All other records were in place including the two references. Staff awareness of dementia, nutrition and weight management, medication, infection control and manual handling and lifting for example was good. However staff have not received training with regard to the wide and varied nature of depression. Some of the service users suffer with depression and so in order to meet their needs training must be provided. Service users have a good rapport with staff whom they can trust and feel safe with. Staff morale is very high and good team working is evident. NAZARETH HOUSE Version 1.10 Page 23 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) 32,33,36,38 Service users benefit from living in a home which is run in an organised and open manner. Service users are consulted regularly to ensure that the home is run in their best interests. Some additional feedback for external stakeholders and a summary of the audits would benefit service development. Staff are appropriately supervised. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The twenty-five staff spoken to expressed that the registered manager and their direct line managers were open, approachable and welcomed discussion about the service provision. Staff confirmed that they receive supervision every two months, supervision records indicated this. However, the notes made during supervision were not detailed enough and so did not necessarily reflect the actual discussion nor did they reflect the homes statement of what should be covered during a NAZARETH HOUSE Version 1.10 Page 24 supervision. It is recommended that this be addressed to ensure more accurate and work practice based notes are in place and useful. The registered manager is competent and experienced and has created a very well run and organised home. The best interests of the service users are promoted by the home. They undertake three monthly service user meetings and annual audits (March 2005), which ask, service users what theirs and relative’s views are about the home. The results have not been summarised as yet, nor does the audit include the views of other health professionals and care managers. These issues must be addressed to ensure that a summary of results is available to those interested; to enable service development and to achieve a wider perspective of the service provided. All relevant health and safety checks had been carried out to protect the welfare of service users. A requirement made at the last inspection for all fire doors to be able to effectively self-close at all times and not be wedged open had been fully addressed. Fire door guards had been fitted to all service users bedroom doors. These devices are checked during weekly fire point checks to ensure that they close; however there was no clear record indicating these specific checks occurred. This must be rectified to ensure that the batteries in the fire door guards are fully operational. In addition the fire maintenance check form had not always been filled in clearly, it should indicate correctly if a fault is found or not. The homes fire risk assessment was last reviewed in February 2004 it is recommended that this is reviewed again soon to ensure this is an annual an occurrence and to safeguard service users, visitors and staff. NAZARETH HOUSE Version 1.10 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 4 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 4 x x x 3 4 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 3 2 x x 3 x 2 NAZARETH HOUSE Version 1.10 Page 26 no 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 8 Regulation 13(1)(b) Requirement The registered person must ensure that all service users receive annual dental treatment, more specifically those with dentures. The registered person must ensure that medical assistance (Ambulance, GP) is accessed when a service users health / medical needs change. More specifically if a service user expriences symptoms of illness that are in additon to their known medical history. The registered person must ensure that the the wishes of service users in the event of death is recorded in their individual plan. The registered person must review the activities provided in the home, especially during the summer months and specifically in relation to one service user who has requested evening walks in grounds with staff, volunteer and/or befriender support. This service user may also benefit from input from a CPN to ensure multi-agency working. Version 1.10 Timescale for action 1/8/05 2. 8 13(1)(b) 6/5/05 and from then on. 3. 11 12(3) 1/9/05 4. 12 16(2)(n) 1/8/05 NAZARETH HOUSE Page 27 5. 16 22, 17(2) Schedule 4 (11) 19 (1) Schedule 2 (7) 6. 29 7. 30 18(1) (c ) (i) 8. 33 24 (2)(3) 9. 38 23(4) (c )(v) The registered person must ensure that the complaints book includes a clearly defined outcome of the investigation into the complaint section. The registered person must ensure that the three new staff members who have transported their CRBs from their previous employer, reapply for a CRB. In the meantime they must not work alone. A copy of the new CRB check must be sent to the CSCI. The registered person must ensure that all staff receive mental health training specifically related to the mental health needs of the sevice users, for example depression The registered person must ensure that a summary of results from the recent quality assurance audit is compiled and made available to service users. The quality assurance audit must also include the view of other stakeholders such as health professionals and care managers for example. The registered person must ensure that the newly fitted door guards are checked weekly with the fire call point checks. A record must be kept demonstrating that the batteries in the door guards are in working order. The current fire record forms must clearly identify if faults are found or if the fire system is working correctly. 1/6/05 1/6/05 1/8/05 1/10/05 1/6/05 NAZARETH HOUSE Version 1.10 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 12 Good Practice Recommendations The registered person should aim to promote that the home has access to a home delivery library service to ensure that all service users are aware of the service and utilise it. The registered person should consider recording more detailed notes to reflect work practice issues discussed during supervision. The statement at the front of each supervision file which states what will be covered during supervision is not currently being followed. The registered person should make arrangements to review the fire risk assessment annually. The last review occurred on the 5/2/04. 2. 36 3. 38 NAZARETH HOUSE Version 1.10 Page 29 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 Version 1.10 Page 30 - 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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