Nazareth House - Crosby

We found the following examples of good practice.

Social distancing was promoted by the placement of coffee tables between chairs in lounges.

Additional ventilation was provided by the opening of windows throughout the building.

Window visits were made more secure and accessible through the use of an intercom system.

Further information is in the detailed findings below.

People’s experience of using this service: We found there could be some improvements to the décor in some parts of the home, to support people living with dementia. On the ground floor, doors and walls were the same colour, potentially making it difficult for people to differentiate between the two. Other floors were more suited to those living with dementia. Staff told us there were people living with dementia on all three floors of the home. However, overall the home looked nice and décor was clean and fresh.

People told us they felt safe living in the home due to the support they received from staff. Staff understood the risks to people and the measures were in place to keep them safe. Safeguarding procedures were followed and incidents were raised with the appropriate professionals.

Staff were supported in their role and had access to relevant training to help ensure they had the necessary skills to meet people's needs.

People’s medicines were managed safely.

Measures were in place to reduce the risks associated with the spread of infection. We found the home to be clean and well maintained. Environmental risks were assessed and well managed to prevent any harm to people.

Sufficient numbers of staff were employed to meet people’s needs. Staff were caring and always promoted people’s dignity and independence.

A system was in place to monitor applications and authorisations to deprive people of their liberty and any conditions attached to them. Consent to care and treatment was sought and recorded in line with the principles of the Mental Capacity Act. Staff supported people in the least restrictive way possible.

Care plans were detailed and contained information regarding people’s preferences, likes, dislikes and routines. This helped staff support people in line with their preferences.

People received the support they needed to eat and drink and maintain a healthy and balanced diet. Staff knew people's dietary needs and people told us they enjoyed the food available to them. People could enjoy snacks throughout the day, and were able to choose alternative meals if they did not like what was on the menu.

People were given the opportunity to take part in a variety of activities. People told us activities had improved recently.

People were supported to enjoy the best health outcomes possible, and staff were supported to do this by the systems the registered manager had put in place to promote good working with other health and social care professionals.

The registered manager notified CQC about important events which happened at the home, so they could be sure they were consistently meeting their legal obligations.

Staff understood their role and had confidence in the manager. Staff told us they worked well together as a team, and there was good morale amongst them. People, staff and relatives were highly complimentary about the managers. We were told the management team were approachable and responsive to any issues. Systems were in place to gather feedback from people.

Since the last inspection, the home had improved the systems in place to monitor the quality and safety of the service. At this inspection we found there was good oversight from the provider, and the registered manager was well supported.

People told us they would recommend the home to others.

Rating at last inspection: Requires improvement (Report published 12th May 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Nazareth House is a large ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide accommodation with personal care for up to 66 older people. At the time of the inspection there were 39 people living in the home. Accommodation is located over three floors and facilities include four lounges, three dining rooms, 64 single bedrooms, 24 bedrooms with en-suite facilities, one large function room and a large garden area. A car park is available to the front of the building.

At the time of the inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. During the inspection we found the registered manager to be open and transparent and receptive to the feedback provided.

At the last inspection which took place in August, 2017 we identified breaches of Regulations 9, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection we issued a warning notice regarding Regulation 12 and 17 and asked the registered provider to complete an action plan to tell us what changes they would make and by when. During this inspection, we looked to see if the registered provider had made the necessary improvements.

At the last inspection we found that the registered provider was in breach of regulations in relation to safe care and treatment people were receiving. We found that medicine processes and systems were unsafe and information regarding people’s medication support needs was inconsistent and conflicting. We also identified that people’s health and well-being was not safely being supported and areas of risk were not being safely managed. During this inspection we found that the registered provider was no longer in breach of regulation in relation to ‘safe care and treatment’.

We have made a recommendation that the registered provider consults best practice in relation to improved medicine management systems.

At the last inspection we found that systems to monitor and assess the quality, standard and safety of the service were not effective. During this inspection we looked at the audits completed and found that improvements had been made. Audits were routinely completed, the quality and standard of the care being provided was being assessed and improvement action plans were in place. The registered provider was no longer in breach of regulation in relation to ‘good governance’ although further improvements are required.

At the last inspection, we found that care plans were not person centred and did not always provide sufficient information to ensure staff could meet people’s needs. During this inspection we found that care plans were detailed, reflected people’s individual needs and preferences and were reviewed regularly. We found that improvements had been made and the registered provider was no longer in breach of this regulation regarding ‘person centred care’.

At the last inspection, we found that staff were not receiving adequate supervision or being supported with training which would enhance their skills and knowledge. During this inspection we found staff received regular supervisions and annual appraisals. The registered provider was no longer in breach of this regulation regarding ‘staffing’.

At the last inspection, we found that the registered provider did not have effective systems in place to ensure ‘fit and proper persons’ were employed to support people who were living at the home. During this inspection we identified that safe recruitment practices were in place, prospective employees had undergone the necessary Disclosure Barring System checks (DBS) and appropriate references were being sought. The registered provider was no longer in breach of this regulation.

Records showed that applications to deprive people of their liberty had appropriately been made. Consent to care and treatment was reviewed to ensure the registered provider was complying with the principles of the Mental Capacity Act 2005, (MCA) including best interest decision making when people lacked the capacity to provide consent. We identified one example where the information around this was unclear.

People told us they felt safe living in Nazareth House. Staff were knowledgeable about safeguarding and whistleblowing procedures and knew how to report any concerns.

We found that there was sufficient numbers of staff on duty to meet the needs of people in a timely way. We received positive feedback from people, relatives and staff about the staffing levels at the home.

We reviewed health and safety audit tools which were in place to monitor and assess the quality and standards of the home. There was a variety of different audits/checks being conducted which meant that people were living in a safe, clean, well maintained and hygienic environment.

Accidents and incidents were routinely recorded and analysed although it was not always clear how trends were being managed. The registered manager also ensured that any significant events were also discussed as part of the daily handover.

The home appeared to be clean, well maintained and odour free. Infection prevention control (IPC) measures were in place and staff understood the importance of complying with IPC policies and procedures.

People’s nutrition and hydration support needs were regularly assessed and measures were in place to monitor and mitigate risk. We found that appropriate referrals were being made to external healthcare professionals when risk was identified.

People’s health and well-being was routinely supported. Care files showed that advice was sought from professionals and their advice was followed and incorporated within care plans.

Adaptations had been made to the environment to support people living with dementia. The environment had been adapted and reasonably adjusted to support people’s needs, promote independence and minimise risk.

People living in Nazareth House and relatives we spoke with told us that staff were kind, caring and friendly. Interactions we observed between staff and people living in the home were warm, sincere and familiar and it was clear that staff knew the people they were caring for well.

A complaints procedure was in place that provided clear information on how to raise concerns and included contact details for the local authority and the ombudsman. People told us they knew how to raise any concerns they had and felt that they would be listened to

There was a range of different activities taking place at the home. People told us they enjoyed the activities available and were able to choose whether or not they wanted to join in. There was a schedule of different activities advertised around the home.

Systems were in place to gather feedback regarding the provision of care. The registered manager ensured they had oversight of the quality and standard of care being provided. These included staff and ‘resident and relative’ meetings.

Following the last inspection the registered provider created an action plan to address the areas of concern we raised. The registered provider submitted a number of different action plans to evidence how they were progressing with their improvement. During the inspection we identified that actions were being completed and the quality and standard of care being provided had improved

The registered manager had notified the Care Quality Commission (CQC) of all events and incidents that occurred in the home in accordance with our statutory requirements.

Ratings from the last inspection were displayed within the home and on the registered provider’s website as required.

Nazareth House is a large care home, registered to provide personal care for older people. The care home can accommodate up to 66 people, at the time of the inspection there were 51 people living at the home. The care home has accommodation over three floors and is situated in extensive grounds. Facilities include four lounges, three dining rooms, 64 single bedrooms, 24 bedrooms with en-suite facilities, one large function room and a large garden area. A car park is available to the front of the building.

At the time of the inspection there was a registered manager in post. A manager was in post and they had applied to the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the previous comprehensive inspection which took place in July 2016 the home was rated ‘Requires Improvement’. We found the registered provider was not meeting legal requirements in relation to person centred care, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and staffing. Following the inspection the registered provider submitted an action plan which outlined how they were improving the standards of care and quality of service.

During this inspection we found a number of improvements had been made however the registered provider was found to still be in breach of safe care and treatment, person centred care, good governance, staffing and fit and proper persons employed. We are taking a number of appropriate actions to protect the people who are living in the home.

During this inspection we found that the systems and processes which were in place to maintain the quality and the standard of care were not effectively being used. Care records were not being maintained, risks were not appropriately being assessed, audits were not being used effectively, and action plans were not being completed. This meant that the delivery of the care being provided was not effectively being monitored or reviewed meaning that people were exposed to unnecessary risk.

Recruitment was not safely and effectively managed within the home. Staff personnel files which were reviewed during the inspection demonstrated unsafe recruitment practices. This meant that some staff who were working at the home had unsuitable and insufficient references and had not had the appropriate criminal record checks.

During the inspection we found that the area of ‘staffing’ had not improved. Routine supervisions and appraisals had not been taking place, the completion of training had not improved and staff were not being provided with specialist training such as dementia awareness training.

Accidents and incidents were being recorded on an internal database system however there was little evidence to suggest they were being analysed or if lessons were being learnt.

Medication processes and systems were not effectively managed. During the inspection we found that routine medications audits were not being conducted, medication administration records were not being appropriately completed, people living in the home were not receiving the appropriate medication as prescribed by the GP and medication was not safely stored away.

Person centred care was not always being provided. People’s care records were found to be very basic, contained minimal information and didn’t offer staff important or significant detail about the people they were caring for.

There was evidence to suggest the home was operating in line with the principles of the Mental Capacity Act, 2005 (MCA) When able, people must be involved with the decisions which are taken in relation to the care and treatment which is provided, records we reviewed suggested that the principles of the MCA were being routinely followed. The registered provider was no longer in breach of the regulation in relation to the ‘need for consent’

The MCA requires that as far as possible people make their own decisions and are helped to do so when needed. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. We found that the registered provider was suitably submitting the necessary DoLS application forms and conducting the necessary best interest meetings in accordance with the principles of the MCA. The registered provider was no longer in breach of the regulation in relation to ‘Safeguarding service users from abuse and improper treatment’.

There was evidence during this inspection that improvements had been made and the environment. The environment had been adapted to support people who were living with dementia.

The day to day support needs of people living in the home was being met. External healthcare professionals we spoke with on the second of the inspection were positive about the level of care and support which was being provided. The appropriate referrals were taking place when needed and the relevant guidance and advice which was provided by professionals was being followed accordingly.

People told us that their privacy and dignity was respected. Staff were able to provide examples of how they ensured privacy and dignity was maintained and relatives felt that the care being provided was done so with the utmost respect and dignity.

On the second day of the inspection a Short Observational Framework for Inspection tool (SOFI) was used during the lunch time period. SOFI tool provides a framework to enhance observations; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at the home who could not express their experiences for themselves. Staff provided support to people with care, compassion and kindness, staff spoke in a friendly, sincere and warm manner when they were engaging with people and people appeared to be happy and content.

There was a part time activities co-ordinator in post who was responsible for organising a range of different activities. The feedback about the activities was mixed. People we spoke with said that the range of different activities had improved however other people we spoke with, staff and visitors explained that the range of different activities needed to be improved.

There was a formal complaints policy in place and people knew how to make a complaint. There was evidence of how complaints were being responded to which were in accordance to the organisational procedures. At the time of the inspection there were no formal complaints being investigated.

Staff morale appeared to be positive. Staff did express that due to the recent changes which had taken place in relation to the management the morale had been affected however, staff also expressed that the morale of the home was improving and staff felt supported by the new registered manager.

The registered manager was aware of their responsibilities and had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with the CQC’s statutory notifications procedures. The registered provider ensured that the ratings from the previous inspection were on display within the home, these were also available for the public to review on the provider website, as required.

Specific policies and procedures were available such as whistle blowing, safeguarding and equality and diversity and staff were able to discuss them with us.

We are taking a number of appropriate actions to protect the people who are living in the home. The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in ‘special measures’ must be inspected again within six months. If insufficient improvements have been made we will take the necessary actions in line with our enforcement procedures which is to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Situated close to shops, local facilities and public transport links, Nazareth House is a residential care home that can support up to 66 people who require accommodation and personal care. Located in spacious grounds, the accommodation is arranged over three floors. During the inspection, there were 61 people living in the home.

A manager was in post and they had applied to the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

A safe environment was not always maintained. We observed chemicals around the home that were not stored securely. There were windows that were observed to have broken or no window restrictors on them in order to maintain people’s safety. Vulnerable people had access to boiling water putting them at risk of potential injury.

We looked at people’s care files and found that not all identified health needs were assessed and reflected in their care plans. This meant that staff may not have access to sufficient information to support people safely.

The care files we looked at showed staff had completed some risk assessments to assess and monitor people’s health and safety. However not all risk assessments provided sufficient detail, such as some personal emergency evacuation plans.

We looked at the systems in place for managing medicines in the home. A medicine policy was available for staff and staff had completed training in relation to safe medicine administration. Medicines were stored safely and records showed they were administered as prescribed. We found that people’s allergies were not always clearly recorded.

People we spoke with told us they felt safe living in Nazareth House and staff and visitors to the home agreed that care was provided to help keep people safe. We found that there were adequate numbers of staff on duty to meet people’s needs.

Staff had a good understanding about adult safeguarding. We found that appropriate safeguarding referrals had been made and a system was in place to monitor the outcomes of referrals.

We looked at accident and incident reporting within the home and found that this was reported and recorded appropriately. There was a system in place to report any maintenance work required and this was signed off when completed to ensure the home was kept in a good state of repair.

One person had an authorised Deprivation of Liberty Safeguards (DoLS) in place, however records showed and the manager confirmed, that there were other people who required a DoLS application but these had not been submitted at the time of the inspection.

We observed staff gaining people’s consent during the inspection. We found that when people were unable to provide consent, the principles of the Mental Capacity Act 2005 were not always followed.

Staff completed an induction when then commenced in post. The manager told us that approximately 50% of staff required refresher training in what they considered to be mandatory training. Not all staff we spoke with had received regular supervisions to help support them in their role. No staff had received an annual appraisal, though staff we spoke with felt supported in their role.

People told us they received enough to eat and drink but we received mixed feedback regarding the choice and quality of the food.

No changes had been made to the environment to support people living with dementia since we made a recommendation regarding this during the last inspection. The environment had not been adapted to meet people’s individual needs. There was no secure area for people to sit outside and the communal areas of all three floors of the home were similarly decorated.

People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing.

People told us staff were kind and caring and treated them with respect. We observed people’s dignity and privacy being respected by staff, such as staff knocking on people’s door before entering their rooms. Interactions between staff and people living in the home were warm and genuine.

Most care plans we viewed showed that people and their families had been involved in the creation of the care plans. Plans were written in in such a way as to promote people’s independence.

People we spoke with told us that there religious needs were met. Nazareth House has a chapel within it and mass is held there daily for people who wished to attend.

We observed relatives visiting throughout both days of the inspection. The manager told us there were no restrictions in visiting, encouraging relationships to be maintained. For people who had no family or friends to represent them, contact details for a local advocacy service were available within the home for people to access.

Although the care plans we viewed were reviewed regularly, they did not always contain consistent information throughout the care file regarding people’s needs.

Staff we spoke with demonstrated a good knowledge of people’s individual care, their needs, choices and preferences and these were reflected within care files. Care files contained a pre admission assessment; this ensured the service was aware of people’s needs and that they could be met effectively from admission.

People told us there were activities available for them to participate in should they choose to.

Processes were in place to gather feedback from people and listen to their views. A complaints procedure was available within the home; however this was not on display for people to access. People we spoke with told us they knew how to raise any concerns they may have and felt able to do so.

Not all actions and recommendations had been acted upon since the last inspection.

The provider employed an internal quality team who visited to assess the service and provided reports of their findings. The clinical director also visited the home regularly and completed checks as well as providing support and training to staff when required.

We viewed completed audits which included areas such as uniforms, care plans and medicines; however they did not identify all of the issues we highlighted during the inspection.

Feedback regarding the management was positive from people living in the home. People told us they knew who they manager was and that she was approachable.

Staff were aware of the home’s whistle blowing policy and told us they would not hesitate to raise any issue they had.

Care files were not always stored securely in order to maintain people’s confidentiality.

The manager had notified CQC of events and incidents that occurred in the home in accordance with our statutory notifications.

The manager told us they had plans to further improve the service.

The people we spoke with were positive about the care and support they received. One person said, 'The staff are nice and friendly. They will do anything for you.' Another person told us, 'I like it here and am well looked after.'

People told us they could make choices about how they spent their day. They said they could get up in the morning and go to bed at times that suited them.

We heard from people that there was enough staff available to support them at all times. They said they did not have to wait long if they needed help as staff came along promptly when they called for assistance. One person said, 'It is alright here. There are plenty of staff to help you.'

Assessments and care plans were in place for each person and they were reviewed each month with the person and/or their representative to take account of the person's changing needs.

A complaints procedure was established and this was made available to people and their relatives/representatives in the 'Service user guide' which was located in each person's bedroom.

An effective process was established for the recruitment of new staff.

We also spent time with relatives who were visiting the home at the time of our inspection. They told us they were happy with the care provided. We heard the communication from staff was good and they were contacted by staff if there were any changes to their dependent relative's care needs.

Throughout the inspection we observed people were relaxed and were engaging in conversation with each other, and with staff. We noted staff supported people with their personal care needs in a discrete and dignified way.

Effective arrangements were in place for monitoring the quality and safety of the service provided.