Inspection on 04/12/06 for St Joseph`s Nazareth House

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

St Joseph`s Nazareth House 07/03/06

St Joseph`s Nazareth House 21/03/05

St Joseph`s Nazareth House 25/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s (Nazareth House) 111 London Road Southend On Sea Essex SS1 1PP Lead Inspector Mr Trevor Davey Unannounced Inspection 4th December 2006 10:15 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 St Joseph`s (Nazareth House) DS0000015549.V323176.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. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Joseph`s (Nazareth House) Address 111 London Road Southend On Sea Essex SS1 1PP 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) 01702 345627 01702 430352 The Congregation of the Sisters of Nazareth Sister Mary Merriman Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nursing and personal care to be provided to service users who are aged over 65 years. Total number of service users not to exceed 34. To provide care for a service user under the age of 65 whose name is known to the Commission 7th March 2006 Date of last inspection Brief Description of the Service: St Josephs is registered to provide personal and nursing care with accommodation for 34 older people over 65 years of age. It is one of two separately registered care facilities sited at Nazareth House, which also has its own chapel, kitchens and laundry. The home is near to the town centre at Southend, railway station, the theatre and all local amenities. The grounds include well maintained gardens and ample car parking facilities. The premises are older in style and retain many of the characteristics including a large main hall, which is used for activities and entertainment. The home also has its own beach hut at Shoeburyness that residents can use. Facilities are sited on three floors and shaft lifts are available. Accommodation includes lounge and dining facilities as well as single and double rooms, some with ensuite facilities. A few of the residents have their own living accommodation. The current rate of fees as shown in the Pre-inspection questionnaire, range from £408.80 to £512.50 per week. Additional charges are made for hairdressing, chiropody, toiletries, newspapers as well as personal telephone calls. Plans are in progress to develop the Nazareth House complex into a care village and these may be viewed in the home’s reception area. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit went into two days and covered a period of 12.75 hours. The visit mainly focused on the progress the home had made since the last inspection and covered all key standards. In addition, as part of this unannounced inspection, the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helps them to make choices. The information included the service users guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that the Commission for Social Care Inspection are carrying out about the information that people receive about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.CSCI.org.uk The Registered Manager, the Responsible Individual for the home, the Facilitation and Care Co-ordination manager together with other staff, residents and relatives were spoken with during this site visit. Their comments and contributions received were helpful in assisting the Inspector to compile this report. In addition, case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters had also been sent out to health care professionals requesting feedback of the service provided by the home. The management of the home had also conducted their own survey with residents and visitors and these responses were made available to the Inspector. Overall, feedback, which had been given to the Inspector, was complimentary and positive regarding the standard of care provided. The inspection also took into account previous information submitted by the Registered Manager including the completed pre-inspection questionnaire. What the service does well: From conversations with residents, relatives and staff as well as feedback from the survey conducted by the management of the home, residents felt safe, well cared for and appreciated the service provided. Examples of comments received included Thank you for the kindness shown, More than happy with the care given, It is as near as home-from-home as one could get. The home is good at monitoring its own service as well as taking into account feedback received and using this information to form a development plan to improve the quality of life of residents and enhance the effectiveness of staff. The home has been able to demonstrate its effectiveness in taking appropriate action when issues of concern arise. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 6 Overall, personal care records were comprehensively documented and reviewed on a regular basis. Some of the residents spoken to were able to recall being involved together with their families, with pre-admission procedures, as well as having been given a service user guide. In some cases they were able to confirm that the contract/terms and conditions information had also been included. The home has recognised that because of various sensory impairments among residents, it has been necessary to issue an audio addition of the service user guide, which has been available since the beginning of this year. Positive comments were received from residents confirming that staff were approachable and any concerns, which had been raised, had been dealt with effectively. A detailed recording system covering recruitment procedures was in place as well as documentation of induction and training courses attended by the staff team. Regular maintenance of services and equipment take place, which was documented. Following the introduction of new fire safety regulation reforms in 2005, the home has been pro-active by supporting the gardener/handyman to attend and successfully complete a managers course on fire safety. Various social activities and outings are arranged and the management are wanting to introduce life story books when the new activities organiser commences their duties in January 2007. The spiritual needs and aspirations of residents are well provided for in the home and arrangements are made for clergy of other denominations to make visits as required. What has improved since the last inspection? Since the last inspection, requirements recommendations have been met or are in the process of being implemented. This includes more detailed information in care plans and provision of videos to reflect individuals interest and hobbies. In October 2006, the home issued survey questionnaires to residents and their relatives to obtain feedback relating to the quality of care, friendliness of staff and other issues regarding the service provided. Approximately 87 of the questionnaires were completed and returned with 96 indicating that the quality of care in the home came within the excellent/good category. Details of the home’s annual development plan were made available which included monthly summaries from March till November 2006. This identified improvements targeted and whether these had been achieved together with other comments. Areas of improvement, which had been achieved, included refurbishing and replacements, specific training e.g. dementia, nutritional audits, communication books and setting up a relative’s forum in planning the various transitional stages for the development of the new residential accommodation. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 8 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 St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. Information regarding the home and services provided had been made available to residents and/or relatives. Pre-admission assessment details for care/health needs had been completed to give staff suitable information to determine whether the needs of potential residents could be met by the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A sample check was made regarding the pre-admission assessment details together with information relating to contracts/terms and conditions for three residents. Two of these residents had been admitted in 2006 and another in 2003. In one case, pre- assessment information had been sent by the funding authority and other information was faxed direct to the home from the St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 10 hospital. The Registered Manager had also carried out her own assessment, which included a diagnosis together with nursing requirements and activity for daily living. Other information recorded related to personal care, communication, eating and drinking. An application for admission had also been completed and copies of the terms and conditions were also on file. In some cases the next of kin acts as the representative on behalf of the resident. The contract had been issued by the funding authority direct to the family and other supporting evidence was on file. Correspondence relating to fees payable and funding arrangements were also on the file. The home’s service user guide is given direct to the resident or relative responsible which includes attached information relating to terms and conditions plus details of extra charges involved for which the resident is responsible. Copies of service user guides, terms and conditions and letters relating to fee increases and the date from when these applied, were also available on files where appropriate. Contracts/terms and conditions had been dated and signed by the resident concerned and the Person in Charge of the home. In cases where there are visionary impairments, service user audio/guide books are offered to residents. One of the residents advised the Inspector that he himself had visited the home prior to admission and information about the home had been made available to him. As well as medical history and behavioural information, details of social history had also been included as part of the pre-admission assessment. Some of the residents spoken to confirmed that members of their family had responsibility for their financial arrangements. Another resident told the Inspector that their service user guide did include the contract arrangements and that they had received letters regarding fee increases. Wherever possible, the manager visits prospective residents as part of the pre-admission procedure and residents also have the opportunity of visiting the home. The home does not provide intermediate care. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. The care and health needs of residents were being met appropriately. Care records were generally well documented but some information had not been included to confirm care needs had been met or reviews had taken place. Medication administrative procedures were not always being followed strictly in accordance with guidance provided by the Royal Pharmaceutical Society. Residents are treated with respect and individual privacy is upheld. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Case tracking took place in respect of three residents and other personal care records were also looked at, including recent admissions. Residents spoken to were positive and complimentary regarding the assistant staff offered with personal care whilst at the same time, allowing them independence to provide St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 12 self-help wherever possible. The home was able to demonstrate its ability to be sensitive in meeting the emotional needs of residents. Residents spoken to were happy with the way they had been welcomed into the home and that staff were ready to listen and were very caring. Residents confirmed that health appointments were made for them, including arrangements for the provision of new hearing aids, chiropody and dental treatment. Records were available showing treatment and dates where doctors and other health care professionals had been involved. Responses from the homes survey questionnaire expressed appreciation for the kindness shown and the loving care given. New equipment had been installed to monitor the response time by staff when residents call bells are activated. Some of the residents spoken to confirmed that their care needs were discussed with them and that staff respected their privacy and dignity. Staff were said to be very good at involving residents in discussion relating to care/support needs. Other residents told the Inspector that they had settled well into the home and that their personal wishes regarding ongoing health care were respected by the staff and discussed with relatives as appropriate. Residents were found to be comfortable, well dressed and overall, had a good rapport with their key workers. The format of care plans was well laid out, clear and comprehensive and included photographs of residents to clarify identity. Wherever possible, residents had been involved in discussing care needs, and records had been signed and dated by staff members and the residents involved. Details relating to the identified need/problem, goal/aim and care plan action required were recorded. The next review date had also been recorded which had generally been carried out. Where necessary, specialist advice had been provided by the stoma nurse and the tissues /viability specialist. Some of the risk assessments, which had been introduced, covered poor condition of skin due to the stoma, risk of falls and the safe use of bed rails. There were good examples of where risk assessments had been introduced and included as part of the care plan and which had been regularly reviewed. Dependency rating scales had also been included. In other cases risk assessments for prevention of falls had been completed but these had not been dated or signed by the staff concerned. Day and night log reports had been regularly completed but although residents had been checked at night, there was no indication as to the times these checks had been carried out. A sample check was made of the medication administrative records as well as observing the system when drugs were given to residents. It was noted that some details of medication had been transcribed on to the M.A.R. sheets but these had not been countersigned by two staff signatures. One resident was being administered gaviscon advance liquid three times per day but the prescribing instructions on the bottle was for one to two 5ml spoonfuls to be St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 13 taken after food at bedtime. Another resident was being given calogen strawberry three times per day but the medication instructions on the bottle were not specific and were shown as to be taken as directed. Other medication was given e.g. two paracetamol because of pain but this was not signed for at the time and there was no record made as to the reason the resident was given these tablets. It was noted that the reverse side of the M.A.R. sheets were blank and there were no columns to enable staff to record details of P.R.N. (to be taken as required) medication. Although residents were observed being given medication, the M.A.R. sheets were not being initialled for individual residents at the time medication was administered. This could pose a risk to residents if staff are distracted and entries on the medication records have not been completed to clearly indicate that prescribed medication has been taken by the residents concerned. Risk assessments for self-medication were in place, which had been dated and signed by the resident concerned, and member of staff. Staff spoken to, confirmed that they had attended training on medication procedures and practice. Appropriate arrangements were in place for the disposal of discontinued drugs, which had been properly recorded. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. The home provides an activities/recreational programme to meet residents preferences, social, cultural and religious needs. Meals are provided which take into consideration residents choice. Relatives and friends are encouraged to have regular contact with the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the last inspection, the home has taken steps to improve the variety of recreational/social activities available in accordance with residents preferences and interests. The annual development plan, which has been reviewed monthly, has included this area for improvement and has identified named staff to be responsible. Although at the time of the inspection, there was no activities organiser in post, this vacancy has been filled and the new person St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 15 will commence in January 2007. Sports videos have been purchased to meet the interests of some of the male residents and other activities have included music and movement, shopping outings, and shoe sales. The Inspector was advised that it is intended to begin life story books as a means of stimulating the interests and past memories of residents. Other activities include Christmas parties, visits to the local pantomime and carol services. Personal care records inspected included background information and social histories of residents. Some of the residents spoken to talked about careers they had followed which included entertainment, singing as well as photographs of special occasions. Some of the residents experience visionary and hearing impairments and the home have attempted to address these needs by providing suitable formats e.g. audio version of the service user guide. Not all residents spoken to appeared to be aware that alternative formats relating to information about the home can be made available. The home should look at alternative ways in which communication can be improved by using these and other methods, e.g. picture symbols to enhance the quality of life and interaction with residents. Where possible, residents are able to exercise their independence and enjoy the use of their own personal transport e.g. electric wheelchair for visiting the local shops as well as attending other appointments. The spiritual needs of residents are well provided for on an individual basis and regular services take place in the chapel. Clergy from different denominations visit residents as required. Some of the residents spoken to confirmed that they had regular contact and visits from families. Relatives visiting at the time of the inspection, confirmed that they were pleased with the standard of care and the trouble staff go to in meeting needs of residents. This had been a source of relief for the relatives concerned. Menus were available to show that a variety of food was made available and every attempt is made by the home to meet individual preferences regarding the selection of meals. Some of the residents said that they had difficulty with chewing and found some of the meals difficult to digest but did not like to ask for alternatives. The staff are aware of these issues and are taking steps to remedy problems and to ensure that residents have food, which they enjoy and which is nutritious. A record of meals provided to individual residents was being maintained which included details of allergies, likes and dislikes but it was noted that for three days during the last weekend of November, the dinners which had been provided, had not been recorded. An audit and quality report had been prepared by the home relating to the standard of meals and this identified ways of presentation and other ways in which improvements need to be made. This demonstrated that the management of the home were St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 16 regularly monitoring the standard of food and how improvements could be introduced. St Joseph`s (Nazareth House) DS0000015549.V323176.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. There is an established complaints procedure in place. The home has appropriate reporting procedures for the prevention of harm to vulnerable adults. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure is referred to in the Statement of Purpose and set out in the Service Users Guide a copy of which, is given to all residents or their representative. Residents spoken to were aware of the complaints procedure although in some cases, all documentation and information regarding the home, was handled by relatives. Residents also gave examples of where they had raised concerns with the management and that these had been attended to promptly. Staff were said to be approachable and did their best to help when issues of concern were discussed. The management has demonstrated that where complaints have been received, these have been properly investigated in accordance with the homes complaints procedure and within the twenty- eight-day timescale. Appropriate action has also been taken by the management following the outcomes of investigations and procedures updated as required. In the survey questionnaires that were completed by residents, twenty-two responses were received (representing 81 of questionnaires completed), confirming that the response by the home St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 18 to complaints was either good or excellent. Other respondents to the survey said that they did not give a rating for this question, as they had never raised any complaints. A number of positive comments had also been made regarding the care and support provided by the staff team and the service provided. Up to date policies relating to the prevention of harm to vulnerable adults and reporting procedures were in place. Records were also available of when P.O.V.A. training had been attended by staff. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home was clean and hygienic. Ongoing maintenance and servicing of equipment takes place to ensure residents can continue to live in a safe and well maintained environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean and hygienic and residents spoken to, confirmed that their rooms were kept tidy and clean by domestic staff. Rooms had been personalised to accommodate individual possessions and items of interest belonging to residents. Appropriate furniture, floor coverings, hoisting and lifting equipment was available as required. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 20 Records were being maintained showing dates of servicing/maintenance to equipment and services to the home and this was also detailed on the Preinspection questionnaire previously submitted to the C.S.C.I. Maintenance certificates were available although the latest gas safety certificate was awaited for a check, which had been carried out in the home on 2nd of October 2006. This document is being chased up by the home. Records were also available of regular hot water temperature checks, which had been carried out to ensure the safety of residents, including the flushing out of unused shower facilities. A recent check had been carried out for legionella and a report is awaited. A water tank inspection/sterilisation certificate was available dated 30th September 2006. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. The number of staff on duty together with supervision provided, was sufficient to meet the needs of residents. Recruitment practices are robust and staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were available and the normal provision of staff allows for the manager, lead nurse and six care assistants to be available for the early shift and a similar arrangement applies for the afternoon shift except there are five care assistants on duty. Night cover is provided by one nurse plus two care assistants who are on awake duty. The staffing establishment also allows for domestic and laundry assistants and the main kitchen for Nazareth House has its own chef and staff who provide meals for St Josephs and Maristella. A new part-time social activities organiser is being recruited with effect from January 2007, which will form an important role in meeting individual and group social activities. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 22 Recruitment records were comprehensively detailed and maintained which included application forms, proof of identification, references as well as P.O.V.A. First/ Criminal Records Bureau disclosures. Where there are gaps in this information being provided, procedures are systematically carried out and followed through to conclusion to ensure residents are supported and protected at all times. Contracts/terms and conditions had been issued to staff together with job descriptions. Detailed records were also available of staff induction and ongoing training, which had been completed. As well as course details, certificates were available for inspection. Training covered, included moving/handling, pressure area care, dementia, diabetes, colostomy and palliative care. Courses completed by staff are underpinned by the criteria set out by Skills for Care and documentation includes specific areas to be covered as well as outcomes and guidance for staff who have responsibility for supervision. Staff spoken to, confirmed that ongoing training takes place and they are well supported by management. According to the pre-inspection questionnaire, 46 of care staff have achieved N.V.Q. level 2 or above and two staff are to commence N.V.Q level 3. Other staff are to commence N.V.Q. level two as more places become available. Positive comments had been included in the survey questionnaire regarding staff which referred to their friendliness, kindness and the excellent loving care shown. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. The Responsible Individual, Registered Manager and team, operate the home in the best interests of residents. Staff are properly supervised and measures are in place to ensure the health, safety and welfare of residents at all times. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Commission for Social Care Inspection has been notified that a new Responsible Individual has recently been appointed to Nazareth House and Sister Mary Airey was available during the inspection. The Registered Manager has continued to develop the service to ensure this is run in the best interests of residents. This has involved meetings as well as consulting with residents St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 24 and their families. An important part of this exercise has included obtaining peoples’ views by the completion of questionnaires/surveys and creating an Annual Development Plan for the home. This has been broken down into monthly summaries, which give specific targets for improving the service and whether these were achieved. This included addressing requirements and recommendations outlined in the previous inspection report. Copies of these surveys and the overall summary, was made available to the Inspector. It is suggested that additional questions could be included to obtain feedback regarding individual/group, social and recreational activity. Discussions have also taken place with residents, relatives and other interested parties relating to the new proposed development of the Care Village, which will include new residential nursing/care facilities as a replacement for the existing care home buildings. The staff team includes the Facilitation and Care Co-ordination Manager who oversees recruitment, training, health and safety as well as maintenance and upkeep of the building. In addition, an administrative member of staff is responsible for residents contracts of care and liaising with funding authorities. A sample check was made of residents personal allowances and financial transactions, which had been properly documented and accounted for with receipts as, required. It is recommended that for good practice, procedures be introduced for managers/senior staff to provide signatures /receipts when they have received money on behalf of individual residents from relatives or other parties. The Responsible Individual has submitted regulation 26 reports to the C.S.C.I. regarding the regular monitoring of the home but the last monthly report received was June 2006. As already referred to in this report, records and certificates were available regarding maintenance and servicing agreements in relation to the health and safety of the premises. Fire procedures, checks and preventative measures were in place and staff have fire awareness training. During the inspection, the fire alarm was activated and as already mentioned in this report, the staff responded promptly and appropriately but the Fire Brigade were not called which could have put residents at risk. It is recommended that the Fire Officer be consulted to clarify the procedure and any other action, which should be taken by staff in these circumstances. Work place risk assessments had been completed for a safe working environment. St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement The Registered Person shall ensure that all care plans and risk assessments are reviewed, updated and properly documented to include staff signatures and dates as required. The Registered Person shall ensure that personal care records include the care/support provided to residents. This refers to night log reports indicating time of checks and assistance provided. (See sch 3). The Registered Person shall make arrangements for the correct recording, handling, safe keeping and safe administration of medicines received into the care home, as referred to guidance provided by the Royal Pharmaceutical Society. Timescale for action 31/01/07 2. OP7 17 31/01/07 3. OP9 13(2) 31/01/07 St Joseph`s (Nazareth House) DS0000015549.V323176.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. Refer to Standard OP12 Good Practice Recommendations Alternative formats using symbols and other methods of communication, should be considered for assisting residents with dementia and others who may have sensory impairments. Survey forms should include a question allowing residents/relatives to give feedback on the individual/group social activity provided in the home. Staff signatures/receipts should be provided for any money received from relatives or other parties in respect of individual residents. The Fire Officer should be consulted regarding any update in procedures, which may be necessary following activation of the fire alarm. 2. 3. 4. OP33 OP35 OP38 St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Joseph`s (Nazareth House) DS0000015549.V323176.R01.S.doc Version 5.2 Page 29 - 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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