Inspection on 20/12/05 for Nazareth House Nursing Home

This inspection was carried out on 20th December 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 Nursing Home 21/11/06

Nazareth House Nursing Home 08/03/06

Nazareth House Nursing Home 14/07/04

Nazareth House Nursing Home 22/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Nazareth House Nursing Home Manor Hill Claughton Birkenhead Wirral CH43 1UG Lead Inspector Lynn Sharples Unannounced Inspection 20th December 2005 01:00 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 Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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 Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nazareth House Nursing Home Address Manor Hill Claughton Birkenhead Wirral CH43 1UG 0151 652 7811 0151 653 0816 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) The Congregation of the Sisters of Nazareth Sister Ellen Curran Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 24 beds nursing care / 23 beds personal care in an overall total of 47 Date of last inspection 14th July 2004 Brief Description of the Service: The care home is situated in Claughton a quiet suburb of Birkenhead. The home is set in it own grounds, with ample car parking to the front of the house, and well cared for and tended gardens to the side and rear of the home. The home offers both nursing and personal care for elderly adults. The majority of the bedrooms in the home are single occupancy, many of the service users have personalised their rooms with their own possessions. The home is well maintained, decorated and furnished throughout to a high standard Service users if they so choose can attend daily mass in the homes chapel All service users are encouraged to maintain their links with family and the local community. Therapeutic diets can be catered for, if service users have a medical condition. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know about the visit, which took four hours. The inspector spent time with service users, the registered manager, two members of staff. The inspector also spoke with a GP and some guests who were visiting on the day. What the service does well: What has improved since the last inspection? What they could do better: The home’s Statement of Purpose should be revised and the monthly visits by the responsible person should be recorded and forwarded to CSCI office. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 6 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 Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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 Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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): 1,2,3,5. The homes Statement of Purpose is good and the Service User Guide is excellent providing service users and prospective service users with details of the services and home provides enabling an informed decision about admission to the home. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 9 EVIDENCE: The care home has a comprehensive Statement of Purpose outlining the aims, and objectives, philosophy of the home. The registered manager should ensure that all the items in Schedule 1 of the Care homes regulations 2001 are included in the Statement of Purpose. The service users guide has just been updated and is provided to all prospective service users, and those service users who reside in the home. The care home has a very comprehensive and detailed pre admission assessment document. Registered nurses assess all service users before they move into the home. Where possible family and other health care professionals contribute to the assessment to ensure that service users needs are identified. The registered person encourages prospective service users and their family to visit the home, or have a trial period of stay before they move into the home on permanent basis. The home is not registered for intermediate care category of service users. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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): 7,8,9,10,11 There is very clear, consistent care planning system in place to provide staff with the information they need to meet service users needs. The health needs of service users are very well met with evidence of very good multidisciplinary working taking place on a regular basis. The medication at this home is very well managed promoting good health. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 11 EVIDENCE: All service users in the home have individual care plans and risk assessments, which are constructed by registered nurses and input from the service user. The home is currently using computerised documents both for care plans and daily recordings of service users progress. The senior nurse and carers in the home review care plans on a monthly basis. Members of the care staff have an individual secret password to the computer (electronic signature) so they can input events and daily records of the service users. The computer programme does not allow retrospective entries of data on service users files. Hard copy and discs are maintained as records. The care home ensure that photographic evidence, skin mapping is recorded in the files of service users with pressure sore. The records for the receipt, recording, storage handling administration and disposal of medicines in the home is in accordance with the regulations of the NMC. The care home does have a policy regarding the privacy and dignity of service users and it is communicated to all new employees on their induction course. By direct and indirect unobtrusive observations of staff on the day of the inspection, service users were observed to be treated with respect and courtesy at all times. The inspector spent time talking with service users who felt well respected. Policy and procedures for handling dying and death are in place and observed by staff. The registered manager encourages family and friends to be involved in the care of service users who are terminally ill or dying. The service users wishes concerning terminal care and arrangements after death are discussed and carried out. Many of the service users who die in the home, have their funeral service in the homes chapel. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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): 12,13,14,15 Links with the community are good and support service user’ social opportunities. The systems of service user consultation are good with evidence that service user views are sought and acted upon. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 13 EVIDENCE: Service users in the home have the opportunity to exercise their choice in relation to food, meals and mealtimes. Leisure and social activities in the home reflect the choices and preferences of the service users. Service users are able to express their views on the running of the home in the service user/ relative, staff meetings. The home has a minibus, outing for service users are arranged on Tuesdays and Thursday’s of each week. Documentation regarding service users participation in arranged activities is documented in each service users personal file and activities they do not enjoy is included in this. Service users in the home may entertain their visitors in the communal lounges or in their private bedrooms. The registered manager encourages visiting at any reasonable time of day. On the day of the inspection the inspector observed the lunch time meal being served to service users. This was the homes Christmas meal with family members, priests eating with the service users. The meals appeared to be wholesome and nutritious. Care staff served meals in a calm unhurried manner. The dining rooms are pleasant, all tables were laid with a table cloth and serviettes. Service users may take their meals in the dining room, or in their own bedrooms Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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): 16,17 Staff are provided with excellent information regarding Adult Protection issues which protects service users from abuse. EVIDENCE: There is a robust complaints procedure in the home, which is contained in the statement of purpose, and in the service guide. Complaints are logged and action taken by the homes management is recorded, as evidenced on the day of the inspection. The Whistle blowing policy is in place in the home, this information is communicated to all newly appointed employees in the home on their induction course. The home has a copy of the Wirral’s Adult Protection Policy manual, which is incorporated into the homes policy and procedures. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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): 19,20,23,26. The overall quality of the furnishings and fittings is very good. The home is comfortable and creates a very pleasing and pleasant environment for the service users to live in. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 16 EVIDENCE: The location and layout of the home is suitable for its stated purpose. The fabric and furnishings of the home are of a high standard. The homes well cared for and tended gardens, have had a “make over” with extra planting of shrubs and flowers. A programme of routine maintenance and renewal of fabric and decoration of the premises is produced and implemented with records kept. The home has three communal lounges, conservatory, and small sitting areas for service users and family. All the communal spaces are decorated and furnished to a high standard, and are suitable for the range of interests and activities preferred by service users. The lounges have television, radio and wide selection of reading materials. The decor of the lounges gives the impression of being homely. In some lounges the furniture and décor are representative of a typical domestic family lounge. Service users spoken to on the day of inspection stated they enjoy the tranquillity and the ambience of the lounges. The small sitting areas mainly consist of two comfortable armchairs, standard lamp and electric fire, with rugs to compliment the fabric of the armchairs. The heating and lighting in the home is domestic in character. The private accommodation for service users is furnished and decorated to a high standard. The registered manager encourages service users to bring in their own possessions and personalise their own rooms. On the day of the inspection the home was clean and tidy. The home has an infection control policy in place, which is communicated to all newly appointed employees on their induction course. Foul laundry is sluiced before being washed; washing machines in the home have the specified programming ability to meet disinfection standards. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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. Staff morale appears high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 18 EVIDENCE: The staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed needs of the service users. Registered nurses are on duty at all times in the home. Domestic and catering staff is on duty seven days a week. At present, nine care staff in the home are undertaking NVQ Level 2 courses. The recruitment procedures in the home are in accordance with the NMS regulations. Staff files evidenced on the day of the inspection included, two references contract and terms and conditions of employment. The majority of the staff in the home is in receipt of their CRB clearance certificates. All members of staff receive induction training to National Training Organisation (NTO) specification within six weeks of appointment to their posts, including training on the principles of care, safe working practices in the home. Records, certification of training is maintained, as evidenced on the day of the inspection. Specialist training, i.e. Stroke, Parkinson’s Disease, Confusional states, Dementia, etc are also being facilitated via the training coordinator. The deputy manager, and the training coordinator, have both successfully completed an NVQ Level 4 programme. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,33,37,38 The manager has a clear plan and vision for the home, which she has effectively communicated to the service users, staff and relatives. EVIDENCE: The registered manager is a first level nurse, with many years experience of care home management, and is competent to run the home and meets its stated purpose, aims and objectives. The manager has completed a level a NVQ Level 4 programme. Staff and service user meetings are held on a regular basis in the home. Minutes of meetings are recorded and actions taken when appropriate, as evidenced on the day of the inspection The registered provider produces a monthly report on the conduct of the home; the registered provider must ensure that these reports are forwarded to the CSCI office monthly. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 20 Where possible service users control their own money. Records and receipts are kept of possessions handed over for keep safekeeping are maintained in the home. Individual service user care plans; risk assessments personal record files are maintained in good order by the homes management team. A doctor who was visiting on the day of the inspection commented on the excellent care his patients receive at the home. Individual service users records are secure up to date and are maintained and secure as in accordance with the Data Protection Act 1998.Certificates of maintenance and worthiness for machinery, hoists, gas and electrical installations, fire equipment, lift were evidenced on the day of the inspection. All certificates were in date and valid. Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 3 X X 3 X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 3 3 Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 Requirement The registered person must ensure that all the details contained in Schedule 1 are included in the Statement of Purpose. The registered person must ensure that monthly visits are recorded and sent to the CSCI office. Timescale for action 24/01/06 2 OP33 26 24/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Nazareth House Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Nursing Home DS0000020918.V273169.R01.S.doc Version 5.0 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. 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