Nazareth House - East Finchley

Nazareth House is a residential care home providing accommodation and personal care to people aged 65 and over, some of whom were living with dementia. The service is registered to support up to 84 people. At the time of the inspection there were 59 people living at the home.

The home is a large adapted residential house which has living space and bedrooms over two floors.

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

The management and the staff team had made significant improvements overall in the management of the home and the quality of care people received since the last inspection. This was reflected in the feedback we received from relatives, staff and health care professionals.

We observed people to be safe and were supported by care staff who knew them well and responded to their needs accordingly. Staff understood safeguarding and how to keep people safe from abuse.

Care plans were person centred and were reflective of people’s current care needs. Individualised risk associated with people’s health and care needs had been assessed and documented with clear guidance for staff on how to minimise the identified risk and keep people safe.

People received their medicines safely and as prescribed. We did identify some issues around assessing risks associated with people who had been prescribed high risk medicines and evidencing multi-disciplinary discussions and decision on the administration of covert medicines.

Processes in place supported the recruitment of staff who had been assessed as safe to work with vulnerable adults. There were enough staff available to ensure the safety of people. Staff received the required training and support and applied learning effectively in line with best practice.

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 were seen to eat and drink well and were supported to maintain a healthy and balanced diet. People were supported to maintain healthy lives and had access to health and social care professionals where required.

Staff were caring and kind and relatives confirmed this. We observed staff responding to people's needs with dignity and respect. However, we did receive some feedback from people and relatives that certain staff did not always respect people’s privacy and dignity.

People overall received care and support that was person centred and responsive to their needs and requirements. Relatives had been involved in the care planning process. However, people did not always have access to appropriate activities which would provide interaction and stimulation and support their mental well-being. Not all staff took a responsibility to ensure there was varied programme activities planned and delivered in the absence of the activities coordinator.

People and relatives knew who to speak with if they had any concerns or complaints to raise.

The management team had reviewed and implemented several audits and checks to monitor the overall quality of care people received. Issues identified were clearly linked into an evolving action plan which was reviewed and updated regularly. The provider was working closely with the local authority to implement and sustain improvements.

We have made 3 recommendations to the provider and the management team about sustaining the improvements and embedding all learning and developments going forward and ensuring people's privacy and dignity is respected at all times.

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

Rating at last inspection and updates

The last rating for this service was inadequate (published 17 June 2022) and there were multiple breaches of regulation. We took enforcement action due to the significant concerns found. A Warning Notice for the breach of regulation 12 and 17 was issued to the provider following the inspection. 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 those regulations and had met the requirements of the Warning Notice. However, we did identify a new breach of regulation 9, person centred care.

You can see what action we have asked the provider to take at the end of this full report.

This service has been in Special Measures since 17 June 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 7 and 8 December 2022 to check that the provider had followed their action plan, to confirm they now met legal requirements and to check if the provider had met the requirements of the warning notice we previously served. Whilst improvements have been noted under each of the key questions looked at, the overall rating for the service has remained as requires improvement.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will work towards ensuring they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

Nazareth House is a residential care home providing accommodation and personal care to people aged 65 and over, some of whom were living with dementia. The service is registered to support up to 84 people. At the time of the inspection there were 77 people living at the home.

The home is a large adapted residential house which has living space and bedrooms over two floors.

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

During this inspection we found significant concerns around the overall management oversight of the home, documentation relating to care, medicines management which placed people at the possible risk of harm.

There was a high number of unwitnessed accidents and incidents occurring within the home resulting in people sustaining injuries. There was no management oversight of these, which meant that people were being placed at risk of avoidable harm.

Risk to people were not always identified or assessed. Where risks were assessed, risk assessment documents were not always comprehensive and were generic. Guidance and direction to staff on how to minimise risk was not clear and detailed, placing people at risk of harm.

People were not always receiving their medicines safely and as prescribed. Systems and processes in place to manage medicines safely were ineffective and placed people at risk of harm.

The provider was not implementing current government guidance on the prevention and control of infection especially related to COVID- 19. We have made a recommendation for the provider to implement current government guidance on infection, prevention and control.

Daily monitoring and recording of people’s health and care needs was inconsistent which meant that people may not have been receiving the required intervention in response to their needs.

There was a lack of managerial oversight of the home. There were no documented audits or checks of any aspect of care delivery. Whilst senior managers were aware of some of the issues identified during this inspection, ineffective service improvement plans meant issues were not being addressed as priority and within specific timeframes depending on the seriousness of the issue.

Staff understood safeguarding and how to keep people safe from abuse. Staff told us that they received training on safeguarding to support them in their role.

People and relatives told us in general they were happy with the care and support delivered at Nazareth House. Care staff were seen to be kind, caring and approachable.

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.

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 22 September 2021) and there were breaches of regulations 12 and 17.

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 the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about medicines management and administration and the high level of notifications received about unwitnessed accidents and incidents resulting in injury. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well-led only.

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.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

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

Enforcement and Recommendations

We have identified repeated breaches in relation to regulation 12; safe care and treatment and regulation 17; good governance at this inspection.

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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Nazareth House is a residential care home providing accommodation and personal care to people aged 65 and over, some of whom were living with dementia. The service is registered to support up to 84 people. At the time of the inspection there were 78 people living at the home.

The home is a large adapted residential house which has living space and bedrooms over two floors.

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

Throughout the inspection we observed people to receive appropriate care and support at Nazareth House. Relatives were happy with the care their family member received. However, we found significant concerns around medicines management and administration, risk management, accident and incident management and documentation relating to care, health and safety which could place people at the risk of harm.

People did not receive their medicines safely and as prescribed. Systems and processes in place did not support medicines management and administration.

Risk assessments identifying people’s risks were not always comprehensive, consistent and person centred. Guidance and direction to staff on how to minimise risk was not always clear and detailed, placing people at risk of harm. Accidents and incidents were not always recorded and acted upon to ensure further re-occurrence could be prevented and to promote further learning and development

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Deprivation of Liberty Safeguards (DoLS) had not been reviewed and applied for in a timely manner and where required, best interest decisions had not been considered and documented.

We have made a recommendation about the implementation of the Mental Capacity Act 2005.

Audits of care delivery were ineffective and did not identify the issues we found as part of this inspection. Where historic issues like those found during this inspection had been identified, the required improvements and learning had not been implemented and sustained.

The registered manager and senior management team immediately responded to the concerns that had been found and put in place an urgent action plan to ensure people received safe and effective care going forward.

Staff recruitment checks were complete and provided assurance that staff employed had been appropriately assessed as safe to work with vulnerable adults. However, some staff stated they did not feel supported in their role and felt further specialist training was required to enable them to support people effectively.

People ate and drank well and were supported to maintain a healthy and balanced diet. People were supported to maintain healthy lives and had access to health and social care professionals where required.

Staff understood safeguarding and how to keep people safe from abuse. Staff told us that they received the mandatory training to support them in their role.

Relatives feedback about the registered manager and the way in which the home was managed was positive stating that staff were kind, caring and approachable.

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

Rating at last inspection

The last rating for this service was good (published 4 July 2018).

Why we inspected

We received concerns in relation to the high number of unwitnessed accidents and incidents that had been report to the CQC and the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe, effective 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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.

We have identified breaches in regulations in relation to safe care and treatment and management oversight processes.

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 see what action we have asked the provider to take at the end of this full 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.

We last inspected the service on 10 January 2017 and found the service to be in breach of Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008. The service had not always updated people's care plans and risk assessments contained discrepancies in relation to moving, handling and mobility guidance for staff. We found accidents and incidents were not always recorded in a way that allowed for an overview of the actions taken and the outcome for the person. The service did not always follow their medicines administration policy especially around the storage of controlled drugs. In addition, we found that health monitoring documents were not completed in a robust manner leaving gaps in the recording. Care plans contained little or no evidence of people and family involvement in reviews and there was a lack of written evidence that people's consent had been sought and mental capacity assessments or best interest meetings had been considered and undertaken.

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 key question ratings to at least good. At this inspection we found that the service had made significant improvements in each of the key questions. However, we did note that some further improvements were required to ensure sustainability.

Nazareth House 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 accommodates a maximum of 84 people in one adapted building. At the time of this inspection there were 74 people living at the service. The home is split over two floors, lower ground floor and ground floor with each person’s bedroom containing en-suite facilities.

There was a registered manager in post at the time of this inspection. 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 and relatives confirmed that they felt safe with the care and support that they received from the care staff at Nazareth House. Care staff demonstrated a good level of understanding about safeguarding and the steps they would take to report concerns to ensure people are kept safe from harm and abuse.

Risk assessments had been completed that identified people’s individual risks. However, where risks associated with people’s individualised and specific health conditions had been identified and assessed, very little guidance was available to staff on how to manage or mitigate the risk in order to keep people safe.

The service monitored and documented people’s weights, food and fluid intake and repositioning where this was an identified need. However, noted that the service did not always clearly record a person’s minimum and maximum fluid intake and the actions taken where a person had not met the required amount.

The area manager, registered manager and head of care carried out a number of audits and checks to oversee the quality of care delivery and identify issues so that improvements and learning could be implemented. However, where we found some minor issues with the completion of individualised risk assessments, robust completion of food and fluid charts, and lack of documented action plans these issues had not always been identified through the service’s internal monitoring processes. We have made a recommendation to the provider about this.

The provider had policies and processes in place to ensure the safe administration of medicines. People received their medicines as prescribed.

There were sufficient numbers of care staff available to meet the needs of the people living at Nazareth House. Recruitment processes ensured that only care staff assessed as safe to work with vulnerable adults were employed.

People were supported to have maximum choice and control in their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Care staff were supported in their role through regular training, supervision, appraisal and team meetings.

People ate well. They enjoyed the food that was presented to them and they were always given a choice of what they wanted to eat. Drinks and snacks were available to people throughout the day.

Care plans were detailed and person centred which gave specific information and guidance to care staff on how to meet people’s identified needs and wishes. Care staff knew the people they supported very well and had developed positive caring relationships with them which were based on mutual trust and respect.

The provider had displayed their complaints policy which gave guidance on how people and relatives could lodge a complaint. People and their relatives knew who to speak with if they had any concerns or issues to raise.

Further information is in the detailed findings below.

Nazareth House - East Finchley is a care home providing personal care to a maximum of 84 older people. At the time of our visit 67 older people lived at the service.

People, relatives and staff spoke positively about 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 our last inspection in November 2015 we found two breaches of regulations. The service had not consistently provided staff with supervision and training to equip them to undertake their role. In addition the service had not ensured that care plans were up to date and had not captured changes in people’s care delivery.

During our inspection in January 2017 we found four breaches of the regulations these included that the service again had not always updated people’s care plans. We found some care plan documents and risk assessments contained discrepancies, in particular the moving and handling and mobility guidance for staff. Further more accidents and incidents were not always recorded in a way that allowed for an overview of the actions taken and the outcome for the person.

We found that the service medicines administration policy was not being followed, in particular the storage of controlled drugs. In addition we found that health monitoring documents were not completed in robust manner leaving gaps in the recording. These concerns had not been identified and addressed by the management team in an effective manner.

People had person centred care plans that contained a pen profile and contact details. Guidance for staff was specific and stated what people wanted however there was little or no evidence of people and family involvement in reviews.

The service undertook Deprivation of Liberty (DoLS) applications appropriately and we saw a number were authorised by the statutory body. Staff could tell us how they got people’s consent before offering care and support and people spoken with confirmed they were supported as they wanted to be. There was no evidence that the Mental Capacity Act 2005 (MCA) was being considered in written documents as there was a lack of written evidence that people’s consent had been sought. We were told records of consent were archived. This meant staff did not have access to people’s decisions and we saw no evidence of mental capacity assessments or best interest meetings in people’s records. The registered manager told us records were being placed on the electronic system for staff reference.

People, relatives and staff had mixed views about the staffing levels but we found the management team requested agency staff to cover staff absence. There was a robust recruitment procedure to ensure staff were safe to work with vulnerable adults.

People told us they felt safe in the service, there were posters displayed to support people to raise concerns and staff could tell us they would report any concerns to their senior staff.

Staff had received training to assist them in their role and confirmed they received regular supervision sessions. People were supported to eat and drink well and there was a good variety of nutritious meal choice. People who required support to eat were given the support they required.

The service had been refurbished and was fully accessible, well maintained and clean. Staff could tell us the measures they took to avoid cross infection this included the use of personal protective equipment and colour coded equipment.

People and their relatives told us staff were caring and kind. We saw sensitive and gentle interactions between staff and people. Staff could tell us how they maintained people’s privacy and dignity and people confirmed staff were respectful.

There was a good variety of activities for people to attend if they wished to. People’s diversity support needs were identified and met.

People and relatives told us they felt able to complain to the registered manager who was visible in the service and would respond by addressing the issue.

The service sought the views of people, relatives and staff and there were good lines of communication. The service undertook audits to assure the quality of the service but these had not always captured the concerns raised in this report.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 12 Safe Care and Treatment, Regulation 17 Good Governance, Regulation 9 Person Centred Care and Regulation 11 Need for Consent.

You can see what action we told the provider to take at the back of the full version of the report. Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there.

Staff understood the importance of obtaining the consent of the person before any care or treatment took place. People we spoke with confirmed that staff communicated well with them and asked for their permission before they offered any assistance. One person commented 'they do what I want them to do.' People told us they had good access to health care professionals such as doctors, dentists and chiropodists. One person commented 'he's a very good doctor.' People told us they were satisfied with the support they received to take their medication.

Effective recruitment and selection processes were in place and appropriate checks were undertaken before staff began work.

People who use the service confirmed that the management and staff often asked them for their views about the quality of care they received and if there were any suggestions for improvements. One person told us 'it's a very well-run and organised place.'

People were able to express their views and were involved in making decisions about their care and treatment. People told us that they were offered choices in relation to how they wanted to be supported. The manager sent out quality questionnaires throughout the year, covering a range of issues such as food, staffing and activities. These were then discussed in regular meetings with people using the service.

We saw that people's spiritual, cultural and religious needs were being assessed and there were daily religious services held at the home. People told us that it was important for them that the home had a strong Catholic ethos. One person commented, 'I go to Mass every day.'

People told us they had good access to health care professionals and that they were satisfied with the support they received to take their medication.

People told us that they had no concerns or complaints about their care but would speak with their relatives, the manager or the care worker if they needed to. One person told us, 'I wouldn't be afraid to say if there was anything wrong.'

Staff told us they felt supported by the management and that there were good training opportunities available within the organisation.