Nazareth House - Birkenhead

Nazareth House – Birkenhead provides accommodation for up to 57 people who need help with nursing or personal care. At the time of the inspection 44 people lived in the home. Some of the people living in the home, lived with dementia.

People's experience of using this service

We commenced an inspection at the home on the 16 June to initially just to look at infection control standards. During this inspection, however we identified wider concerns pertaining to the environment that lead to the inspection being widened to a focused inspection. This meant we looked at all aspects of the domains of safe and well-led. We subsequently identified concerns with the management of risk, the delivery of care, premise safety, medication management, leadership and governance.

Information relating to people’s medical needs and risks was insufficient Staff lacked information on what these conditions were, the signs and symptoms to spot in the event of ill health and the action to take. Records relating to the care people received were not properly maintained. The records we looked at did not demonstrate that people received the support they needed to mitigate risks and keep them safe and well.

Medication management was unsafe, did not adhere to best practice guidelines and placed people at risk of significant harm. Some medicines could not be accounted for, which meant some people had not received their medicines as prescribed. There was a lack of overall guidance on the administration of ‘as and when’ required medicines and medicines that needed to be taken at specific times. High risk medicines had not been risk assessed and information pertaining to medicines was not always clear and sufficient.

The systems in place to monitor quality and safety were ineffective. This is the sixth time the service has been given an overall rating of requires improvement since 2015. At each inspection, the well-led domain has been rated as requires improvement. The repetitive nature of this rating indicates that the provider does not have clear oversight of the service or a proactive and positive approach to continuous improvement in the home.

Staff recruitment and staffing levels were safe.

Infection control standards were generally satisfactory but record keeping in relation to cleaning, lateral flow testing and temperature checking for COVID-19 required improvement. On the day of the inspection, the environment was clean and pleasant for people to live in.

Accident and incidents and safeguarding events were recorded, investigated and reported appropriately.

Staff were observed to be kind, caring and respectful. People told us they felt safe and well looked after. People and relatives were positive about the service and had no complaints.

Staff we spoke with liked working in the home, felt the manager was supportive and had improved the service since they had come into post 12 months prior. People told us staff and the manager were approachable and that they were always made to feel welcome.

Rating at last inspection

The last rating for this service was requires improvement (published 13 March 2021).

Why we inspected

The home experienced a COVID-19 outbreak during February 2022, as a result an inspection to examine the standards of infection control commenced on the 16 June 2022. During this inspection, concerns relating to environmental safety were identified and the inspection was widened to a focused inspection of the domains of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we found breaches of regulations 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to the failure to ensure people received safe care and treatment and a failure to ensure the service was governed and managed adequately.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

Nazareth House Birkenhead is a nursing home providing personal and nursing care to 51 people. At the time of the inspection, there were 46 people receiving support, some of whom were living with dementia.

People’s experience of using this service and what we found

At the last inspection we identified a breach in regulation regarding the governance of the service. At this inspection we found that although improvements had been made and the provider was no longer in breach of regulation, further improvements were still required.

Systems were in place to help reduce the spread of COVID-19, however, staff testing procedures were not completed as frequently as government guidance recommended. Following the inspection, the registered manager told us they now visited the home daily to help ensure tests were completed and provided an updated matrix to evidence clearer oversight of staff testing.

Most people’s care files included assessments of risks and detailed care plans to guide staff how best to support them. However, records in place for people receiving end of life care did not always provide clear information regarding people’s current needs, risks or preferences.

Substantial refurbishment of the home was underway. Risks regarding this had been assessed to reduce impact on people and people told us Nazareth House was a safe place to live. Sufficient numbers of safely recruited staff were available to meet people’s needs, although feedback regarding staffing levels was mixed. Systems were in place to help ensure medicines were stored and administered safely. Staff had received training in the management of medicines and had their competency assessed. Staff were aware of safeguarding procedures and how to raise any concerns. Records showed that referrals had been made appropriately to the local authority when required.

A range of audits were in place to monitor the quality and safety of the service and any identified actions were monitored through the service improvement plan until they were fully addressed.

Feedback regarding the quality of service people received was positive and relatives told us they were kept updated regarding any changes within the home, or with their family members health and wellbeing.

The registered manager was aware of their role and responsibilities and was responsive to the issues raised during the inspection. They worked closely with other health and social care professionals to help ensure people's needs were met.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 11 December 2019). At the last inspection a breach was identified in relation to the governance of the service. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of Regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was planned based on the previous rating and in line with our systems response to the pandemic. The inspection was also prompted in part due to concerns received regarding the impact of ongoing building works, use of personal protective equipment and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe section of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nazareth House Birkenhead on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Nazareth House Birkenhead is registered to provide nursing or personal care for up to 51 people. The service is divided into two separate units; the ground floor unit providing nursing care and the first floor unit providing personal care. At the time of the inspection there were 37 people living in the home.

People’s experience of using this service and what we found

Regular checks were undertaken to monitor the quality and safety of the service, however they were not always effective in identifying areas that may require improvement. Feedback regarding the management of the service was positive

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People told us staff asked for their consent before providing support. Records showed systems were in place to seek and record consent, but we found that they were not always completed comprehensively. We made a recommendation regarding this in the main body of the report. Staff received regular training and support to help them meet people’s needs effectively. People’s nutritional needs had been assessed and specialist diets and preferences were catered for.

Care plans had not all been updated to reflect people’s current needs, but we found that staff knew people well, including their needs and preferences. There was a range of activities available, both in the home and in the community and people told us they enjoyed these. Staff were trained to support people at the end of their lives.

Risks to people and the environment had been assessed and staff were aware of the measures in place to reduce identified risks. Regular checks were made on the building, utilities and equipment to ensure it remained safe. Staff were recruited safely and we observed people received care in a timely way. People and their relatives told us Nazareth House was a safe place to live. Staff were aware of safeguarding procedures and how to raise any concerns they had.

People told us they were well cared for by staff that treated them with compassion and respect. One person told us, “They are kind carers and they do everything they can for us.” Staff supported people to maintain their independence and dignity.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 May 2019). We identified breaches of Regulations 12 (Safe care and treatment), 17 (Good governance) and 18 (Staffing) at the last inspection. The provider completed an action plan to show what they would do and by when to improve. At this inspection, we found that enough improvement had not been sustained and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in regulation regarding the governance of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: At the last inspection in February 2018 we found that the registered provider was in breach of Regulation 12 regarding risk management. During this inspection, we found similar concerns. The building, equipment and utilities were checked regularly, however not all identified risks had been addressed.

Systems in place to assess and monitor the quality and safety of the service were not always effective as they did not check all areas of the service and actions were not always taken to address concerns identified.

Although there were usually sufficient numbers of staff on duty, the high use of agency staff impacted on the consistency and quality of the care people received. Staff recruitment was underway, which the registered manager hoped would reduce the use of agency staff.

Recruitment checks were completed; however dates of the initial checks were not always clearly recorded to evidence checks had been made prior to employment. We made a recommendation regarding this in the main body of the report.

Records regarding the management of medicines were not always adequately maintained. We made a recommendation regarding this in the main body of the report.

At the last inspection we found the registered provider to be in breach of Regulation 17 as care plans did not reflect people’s needs accurately and planned care was not always evidenced as provided. Since then, care plans had been reviewed and rewritten and were detailed and person centred, providing information regarding people’s needs and preferences.

People and their relatives felt they were safe in the home. Individual risks to people had been assessed and measures were in place to mitigate those risks. Staff were knowledgeable about safeguarding and how to raise any concerns they had.

Consent was sought and recorded appropriately for some people, but this was not always consistently recorded. People told us staff asked for their consent and when people had their liberty restricted lawfully, any conditions attached were met.

Staff told us they were well supported, they received regular training and supervisions and were able to raise any concerns with the registered manager.

People told us they were treated with kindness and compassion by staff and their family members agreed. We observed familiar, warm interactions between staff and people living in the home.

People told us their dignity and privacy was always respected by staff, that they were able to make choices regarding their care and they were encouraged to be as independent as they could be.

Systems were in place to manage complaints and we saw that they were investigated and responded to appropriately.

Feedback regarding the management of the home was positive. Staff told us they had seen improvements since the registered manager had been in post. The registered manager worked with other agencies to help provide joined up care.

Rating at last inspection: Requires improvement (Report published March 2018). This is the third consecutive time the service has been rated as requires improvement.

Why we inspected: This was a planned comprehensive inspection based on the previous rating.

Enforcement: Please see the ‘action we have told the provider to take’ section towards the end of the report.

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.

We will also meet with the provider and registered manager to discuss the required improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Nazareth House- Birkenhead is a ‘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. Nazareth House is registered to provide accommodation, nursing and personal care for up to 51 people. At the time of the inspection there were 39 people living in the home.

At the last inspection in December 2016, we found that the provider was in breach of regulations and the service was rated as requires improvement. The breaches were in relation to the safety of equipment and care planning. Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the service and ensure regulations were met. The provider told us that all improvements would be completed by the end of March 2017. During this inspection, we looked to see whether the provider had followed their plan and necessary improvements had been made.

We found that concerns identified at the last inspection had been addressed. For example, windows had appropriate window restrictors fitted to prevent accidental falls from height, fire doors were not wedged open, appropriate bed rails were in use and systems were in place to ensure air mattresses were set at the correct settings. However, we found that other areas required improvement.

At the last inspection we identified concerns as care plans did not always reflect peoples’ current needs. During this inspection we found that although many care plans were detailed and person centred, not all had been updated when peoples’ needs had changed. We also found that planned care was not always evidenced as provided. The provider was in breach of regulations regarding this.

Checks to monitor the quality and safety of the service were regularly completed, but were not always effective in identifying areas that required improvement. Not all risks previously identified had been addressed by the provider. The provider was in breach of regulations regarding this.

Not all risk assessments accurately reflected the risk people faced, however we found that appropriate action had been taken to address risks. Personal emergency evacuation plans did not provide sufficient information to ensure people could be safely evacuated in the event of an emergency and not all identified risks had been addressed. The provider was in breach of regulations regarding this.

We found that medicines were not always managed safely and we made a recommendation regarding this.

A registered manager was 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. Feedback regarding the management of the service was positive.

Systems were in place to ensure safe staff recruited procedures were followed. We received mixed feedback regarding staffing levels, but found that there was sufficient staff on duty to meet peoples’ needs at the time of the inspection.

All people we spoke with told us they felt safe living in Nazareth House. People told us, “I have nothing to be afraid of” and “Staff are around so I never have any worries.” There were systems in place to help ensure that lessons could be learnt from incidents and accidents were recorded and reported appropriately. Internal and external checks were completed to help maintain the safety of the environment.

Applications to deprive people of their liberty lawfully had been made appropriately to ensure people received care with least restrictions. Consent to care was gained in line with the principles of the Mental Capacity Act 2005, including best interest decision making when people were unable to provide their consent.

People living in Nazareth House were supported by staff and other healthcare professionals in order to maintain their health and wellbeing.

Peoples’ nutritional needs were met by the service. The chef told us that they provided meals based on people’s dietary needs and we saw that they had detailed information regarding the nutritional needs for people with varying religious, medical or cultural requirements.

A range of policies and procedures were available to help guide staff in their role and they received regular training and supervisions and completed an induction when they started in post. .

People told us that staff were kind and caring and that they were treated with respect. We observed interactions that were friendly, familiar and respectful and peoples’ dignity and privacy was maintained.

People told us and records reflected, that staff encouraged people to be independent as possible and relatives agreed. People were given information and explanations regarding the service to enable them to make choices and decisions about their care.

Peoples’ friends and family were able to visit the home at any time and relatives told us they were always made welcome. For people that did not have any family or friends to support them, details of advocacy services were available within the home.

Care files contained advice and information regarding people’s medical conditions. They also contained information regarding peoples’ preferences in relation to their care. This helped staff get to know people as individuals and provide support based on their needs and preferences.

Staff had completed training to enable them to provide effective end of life care to people. Care files showed that this had been discussed with people and their preferences had been recorded within their plans.

Peoples’ religious needs were met by the service. There is a chapel on site which is used by people living in the home and the local community. The chapel can be used by clergy from various religions.

A system was in place to ensure people knew how to complain if they needed to and we found that complaints had been dealt with appropriately.

A schedule of activities was available to people, both within the home and in the local community. People told us they enjoyed the activities available.

Systems were in place to gather feedback from people regarding the service and actions had been taken to address any issues raised through these processes.

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

During this visit we found that improvements had been made in all of these areas, however further improvement was needed in order for the service to be fully compliant with the Mental Capacity Act. We found breaches of Regulation 12 of the Health and Social Care Act because people did not always have in place equipment that was safe and suitable for their needs and care plans did not always contain up to date, relevant information which placed people’s health at risk.

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Nazareth House Birkenhead is a care home registered to accommodate up to 51 people who require nursing or personal care. It is situated in a residential area of Birkenhead. There were 43 people living at the home when we visited.

The service had a 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.

People who lived at the home told us they felt safe. Policies and procedures were available for safeguarding vulnerable adults and for whistle-blowing, and nearly all of the staff had received recent training about safeguarding. Information about who to contact to report safeguarding concerns was displayed in the entrance area.

Maintenance contracts were in place for equipment and services. The premises were clean and tidy with no unpleasant smells and a programme of refurbishment was underway. We saw unsafe bedrails in place on some people’s beds. Pressure mattresses were not all on the correct weight setting to protect people from pressure damage. Window opening restrictors had been over-ridden in two bedrooms. We saw no systems in place to check any of these.

Applications for a Deprivation of Liberty Safeguard had been made on behalf of some people living at Nazareth House, however this was inconsistent and further work was needed to ensure full compliance with the Mental Capacity Act.

People’s medicines were managed safely and people told us they had their medicines at the right time.

On the day we visited there were enough staff to meet people’s needs and staff rotas showed that these numbers were maintained. However, members of staff thought there should be one more care assistant on duty because the people living at the home had a high level of dependency. Safe recruitment processes had been followed before new staff were employed.

Training records showed that there was an annual programme of training and most staff were reasonably up to date with all of this training. A new system of on-line training was being introduced. In the absence of a manager during 2015/16, staff supervision and appraisal had lapsed, however we saw evidence that this had now recommenced.

We observed that people were provided with a variety of nutritious meals and had the support they needed to eat their meals.

People we spoke with said the staff were kind and caring. People received the support they needed to maintain a good standard of personal care. People were able to receive pastoral support from the nuns who lived in a separate part of Nazareth House.

Records in people's care files showed us that people received support to access a range of health professionals. This included podiatrists, dentists, GP, district nurses and attendance at medical appointments.

Care plans were written using an electronic system and it was not always easy to find up to date information about people’s care and treatment. Care plans contained some information about the choices people could make in their everyday lives but were not always accurate and up to date.

Complaints were logged and records showed that they had been addressed.

Some monitoring and auditing systems were in use, however these had not identified shortfalls that we found during the inspection. People were given opportunities to express their views.

Is the service safe?

Medicines were stored, administered, and recorded safely and consistently by qualified staff. Records showed that staff received regular training, supervision and appraisal. No Deprivation of Liberty Safeguards were currently in place but the service had appropriate policies and procedures.

Is the service effective?

People told us that they were happy with the care and their needs were met. Staff had a good understanding of people's care and support needs. One person told us 'I love it here, I couldn't be in a better place.'

Is the service caring?

Staff were kind and patient to the people who lived at the home. One person told us 'The girls are brilliant to me, I couldn't have nicer carers.' The Sister Superior based at the service carried out a monthly 'core values' audit.

Is the service responsive?

People's needs were assessed before they moved into the home. Care plans recorded people's personal preferences and interests, and care was provided in accordance with people's wishes. People had access to activities and to pastoral support.

Is the service well led?

The manager was a registered nurse and had been in post for five years. He was supported by a deputy manager and a unit manager. The home was part of the Nazareth Care Charitable Trust and senior management provided support in all areas of the service.

Everyone who lived at the home was weighed monthly and a nutrition risk assessment was recorded for everyone and reviewed monthly. People we spoke with told us 'It's very good food', 'I always have plenty to eat' and 'They are very good cooks'.

The home employed a full-time maintenance person who carried out regular health and safety checks including a weekly fire alarm test, checks of equipment safety including bedrails and wheelchairs, and a checklist for the minibus.

Many staff had worked at the home for twenty years or more and all except one of the care staff had a national vocational qualification in care at level 2 and more than half at level 3.