Nazareth House - Cheltenham

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation safe care and treatment and good governance at the service.
 

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not always a clear record to demonstrate the provider had a proactive and positive culture of safety, or that lessons had been consistently learnt to continually identify and embed good practice.

Whilst incidents and accidents had been recorded, and concerns and complaints had been responded to, there was not always a clear record to demonstrate analysis, reflective review, or consideration of underlying causes or emerging themes. There was no evidence that information about incidents was being used consistently to identify learning, implement improvements, or prevent reoccurrence. This limited the provider’s ability to recognise patterns of risk and to embed safer practice. For example, there was no clear record to show that incidents where a person had become distressed had been analysed to understand underlying trends and themes. Similarly, there was no clear record to show how complaints and concerns had been considered before arriving at a judgment. This absence of a clear record meant that we were not always assured lessons had been learnt to drive continuous improvement.

Staff told us they understood their responsibility to raise concerns and report incidents and accidents. One staff member said, “I am happy to raise any concerns to management, and escalate if I am not happy with the outcome.” People told us they were supported by staff who knew them well and relatives told us they felt confident to raise concerns.

The provider was responsive to feedback and was making improvements to the record keeping following incidents, accident records, concerns and complaints to demonstrate lessons had been learnt.

Whilst feedback from professionals working directly with the service was positive, there was not always a clear record to demonstrate how the provider had consistently managed or monitored people’s safety.

Systems to support safe care were not consistently reliable, with gaps in records, monitoring, and follow-through creating risks to continuity of care. We found incomplete checks, and unclear accountability, meaning it was not always evident who had completed tasks or whether actions had been taken. The service used a ‘post-fall 72 hour monitoring report’ to track people’s health and ensure any deterioration was promptly escalated, however, these were not always fully completed. For example, 1 person’s post-fall record was not completed with either the required observations or a rationale for not completing them. This meant managers could not be assured effective monitoring had been completed.

During our assessment, we saw 1 person who had been identified by staff as being unwell in the morning. Staff did not escalate the concern to a healthcare professional until the afternoon. Whilst we saw no impact to the person, we were not assured staff had responded to the person’s change in health presentation in a timely manner.

Whilst the registered manager responded promptly to the concerns we raised, the provider had not, through their own systems, identified the shortfalls we found at assessment. Systems to review and update care plans in response to changing needs were not always fully effective. For example, we saw that some people’s care plans contained contradictory information relating to their healthcare diagnosis between the summary of care and main care plan. As a result, staff were not consistently provided with the accurate and up-to-date information required to deliver safe and effective care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Whilst safeguarding policies and procedures were in place, there was not always a clear record to show these had been consistently followed in practice. Staff documented concerns and the management team assured us staff followed the relevant local authority decision making tool. However, the absence of a clear record meant we were not always assured these had been consistently recognised or escalated appropriately.

We saw incidents where people were entering other people’s bedrooms without consent, and another example where 1 person was noted to have bruising on more than 1 occasion. There was no clear record to show comprehensive investigations had been undertaken. This meant we were not assured that all reasonable measures had been taken to identify potential risks, understand how they occurred, or reduce the likelihood of similar incidents happening again.

Some people living at the service had been deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). This meant the decision for where people lived and some restrictions on their daily lives had been approved by authorities, because the person was unable to make these decisions themselves. Some of the authorisations had conditions attached which the provider had to meet. We reviewed records in relation to this, and found the provider was mostly meeting the conditions which had been set. However, we raised one concern with the registered manager where we couldn’t see a clear record that conditions were being met. The registered manager gave us verbal assurances and told us they would strengthen their systems to ensure they maintained a clear record of the process moving forward.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some care plans lacked key information regarding the management of risk. Whilst people's risks had been identified and recorded, staff did not have enough information on monitoring and management, or the strategies they needed to effectively manage the risk. For example, 1 person required weekly weights and the care record stated they were under the guidance of a dietician. Weights had been recorded inconsistently and there was no record of ongoing dietician involvement. Weight loss had not been raised with health professionals in a timely manner.

Records in relation to people's care were not always well maintained. For example, staff had not reliably recorded fluid intake for a person who was unable to drink independently and without full staff assistance.

One person raised concerns about the management of risk. They told us they had raised concerns about another person entering their room and taking their items. Whilst a risk assessment was in place, it lacked sufficient detail to guide staff on how to reduce the likelihood of further incidents or consistently manage the identified risk.

Other risks were well managed, for example, each person had a personalised evacuation plan with clear guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. This information was easily accessible.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were cared for in a safe environment that was designed and adapted to meet their needs. The provider carried out various checks on the physical environment to help ensure it was safe. These included tests by qualified contractors relating to fire, gas, electricals and water safety. The provider also carried out health and safety assessments to ensure the home remained safe for people. The service had its own maintenance person so all jobs could be prioritised and appropriately addressed.

Staff understood their responsibilities and followed clear procedures to manage environmental risks. Most people said they felt safe in the environment and confident staff maintained it well. Relatives spoke positively about the environment and one relative told us, “The Home is clean and well maintained - five star.”

We received mixed feedback about whether the provider always made sure there were enough staff.

We reviewed dependency tools which routinely calculated the needs of each person and the overall number of staff needed in the home at any one time. Although staffing levels aligned with the provider’s dependency tool, feedback from people, relatives and our observations indicated that staffing was not always sufficient to meet people’s needs in communal areas, or to dedicate time to meaningful interactions. One person said, “The lack of engagement of [staff] with [people] is an issue that needs addressing. Of course, staff are friendly and kind, but those little, casual conversations with people mean everything” Other people and relatives told us that they felt there were enough staff available, or staff would attend if they were called.

The service used an electronic call bell system to ensure that people were able to call for assistance when needed. Whilst the service completed an audit of call bell waiting times by completing ad hoc checks and taking action when the call bell had been activated for a prolonged period, they did not complete a formal audit of the call bell data. This meant that opportunities to identify trends or delays in responding to people could have been missed. There had been some occasions where records showed people had been waiting for prolonged periods. The registered manager told us this was an issue with the record as the call bell had not reset been appropriately after someone had been attended to. The registered manager was responsive to our feedback and told us they would review their system so they could demonstrate people were consistently receiving timely support from staff in response to their needs.

Staff told us they received effective training to deliver care safely and competently, and we saw that there was a training matrix in place to monitor the training which staff received.

Staff were recruited safely. All required checks were made before new staff began working at the home.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff followed infection prevention procedures in line with national guidance. We observed the service was clean and well maintained, with good hygiene standards throughout. Staff used Personal Protective Equipment (PPE) correctly and understood when it was required. They prepared and handled food safely and followed good hygiene practices.

Managers ensured staff received training and completed audits to maintain standards. Staff told us they recognised signs of infection and reported concerns promptly. One staff member said, “I wear PPE when delivering personal care or [managing] outbreaks of infection.”

Whilst the provider made sure that medicines and treatments were safe, there was not always a clear record to show how they met people’s needs, capacities and preferences.

Medicines were administered as prescribed and were available. PRN (when required) medicines had protocols in place to support medicines administration. However, two protocols were missing. This meant there was no clear record to ensure that staff administered PRN medicines consistently and in line with people’s needs. We shared the feedback with the provider who assured us they would complete them.

Allergy statuses were consistently completed. Medication support plans were completed for most records, these were personalised and people’s preferences were considered. However, for 1 person, there was a lack of consistent physical monitoring as specified in the medicines support plan. For another person, who was prescribed time sensitive medication, the stated times in the eMAR were different from the medication support plan. This created a risk of inconsistent administration of time-critical medicines.

One person who could not verbally express pain was prescribed ‘as required’ pain relief. However, their medication and care plans gave conflicting guidance on when staff should administer it. During the assessment, we observed behaviours identified in the care plan as signs of pain, yet no medication was given. The registered manager stated the record was incorrect and the person was not in pain. This lack of clear, consistent recording placed the person at risk of unmet needs and inconsistent care.

Medicines were stored securely in designated rooms and fridges with restrictions on access. Room and fridge temperatures were monitored regularly and risk assessments to address medicines related risks identified were completed. There was evidence of the necessary documentation for a person receiving covert medication. The provider had a clear policy for managing medicines safety and effectively and staff involved in administering medicines had training and competencies in place.