Archived: Nazareth House - Southend

Nazareth house is a care home supporting people who required residential and nursing care for up to 64 people over the age of 65. At this inspection, 30 people were living at the service.

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

At the last inspection in April 2019, we found that people were at risk of harm and the service was placed in special measures. At this inspection we found that whilst there had been some improvement, people remained at risk of harm because systems, processes and staff, failed to identify people’s needs and presenting risks and take timely action.

Staff did not always adequately handover to other staff, people’s needs. Missing important information about risks and actions to prevent and mitigate these.

Medicines were managed safely, although for those on covert medications (Given without the person’s consent or knowledge and hidden in food or drink) staff had not always followed best practice guidance. We made a recommendation about this.

Staffing had improved because the scale of the service had reduced to three floors of one wing of the building. This meant staff were more responsive.

External stakeholders had expressed continued concerns about meal time experience for people. We saw that the registered manager had made efforts to improve this and remained a work in progress.

People were not always supported to have maximum choice and control of their lives. However, staff supported them in the least restrictive way possible and in their best interests.

Staff had not received a values-based interview and opportunities were missed at the point of interview and within supervisions to identify additional training to ensure staff had the correct skills and values. We made a recommendation about this.

Although efforts had been made to ensure that all safety checks on potential staff had been carried out prior to employment there were missed opportunities at the recruitment stage to put in place training to meet potential staffs identified weaknesses. We made a recommendation about this

Staff were caring in how they supported people, but support was task orientated rather than person centred. People were not always asked how they would best like to live their lives.

Care plans had improved but continued to need improvement to ensure that they were person centred. We made a recommendation about this.

Oral hygiene care was sometimes poor for those who were not able to manage their needs without support. We made a recommendation about this.

People with access to communal areas had good opportunity for engagement and activity. But for those people cared for in their bedrooms this was poor. We made a recommendation about this.

People at the end of their life did not receive care in line with gold standards, which aims to ensure people are supported to plan ahead to live as well as possible right to the end of their lives.

The new registered manager had begun to make improvements at the service and had identified some of the concerns we found at this inspection.

People, relatives and staff were engaged with the service and the registered manager was visible. Staff told us they felt supported by managers.

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 inadequate (Published 5 June 2019).

Previous breaches

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection whilst some improvement had been made to the well led domain, enough improvement had not been made/ sustained in the safe domain and the provider was still in breach of regulations. The safe remains rated as Inadequate and therefore the service remains in special measures.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see all sections of this full report.

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.

Special Measures:

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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.

People’s experience of using this service:

We inspected this service in September 2018 following concerns received about the service and the standard of care and treatment of people using it. At that time, we found that the service had deteriorated from being good and required improvement in each key question.

This inspection was prompted by information of concern from relatives and the local authority that people’s needs were not being safely met. During this inspection, we found that people were not receiving safe care and treatment.

There was poor managerial oversight of staff competencies and practice and this left people at risk of neglect. This was complicated by the poor layout of the building. Whilst the provider had identified this as an issue, processes to rectify this had been delayed and enough measures were not put in place to manage this risk in the interim.

Where people had complex physical and mental health needs, these were not monitored and managed in a manner that could inform staff of deterioration or improvement. Risk assessments and care plans did not adequately address people’s needs and care staff did not refer to them. Where external professionals had provided guidance for care interventions, these were not always followed.

A significant number of staff members were supplied from local care agencies as the service had struggled to recruit regular staff. These members of staff were not always inducted to the service in line with the providers own policies and procedures. On the day of inspection, we observed this led to unsafe and neglectful care practices.

There was a poor level of leadership across both the residential and nursing units. Senior care staff and nurses had either not completed or completed quality audits poorly. This meant risk to the quality of care was not identified and left people at significant risk.

These failings resulted in people being placed at risk of harm. As a result of this, we have placed the service into special measures.

Rating at last inspection: At the last inspection in September 2018 the service was rated as Requires improvement in all key questions and had breached The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected: This was a focused inspection of Safe and Well led key questions, following information of concern about risk to people at the service.

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

Follow up: The service has been placed in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Nazareth House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 provides nursing care in St Joseph’s unit and residential care in Marie Stella unit. It is registered for up to 64 older people. At the time of our inspection there were 58 people living in the service, many of whom were living with dementia.

There was a manager in post who was in the process of registering with us. 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.

There was a safeguarding system in place which staff knew and understood. However, the number of safeguarding issues raised recently were of concern. While some people told us they felt safe, some of their relatives did not feel that Nazareth House was currently providing a safe service. Risks had not always been well managed. Essential risks such as for diabetes, weight loss and nutrition had not always been fully assessed and managed.

The service was using many agency staff to support the permanent staff whilst recruiting to vacant posts. The building was very large, spread over three floors on both sides and throughout our visits we saw how difficult it was to staff to respond to people’s needs in a timely manner. Relatives were particularly worried about the level of agency staff on Marie Stella (residential) unit. They said that team leaders were left in charge of agency staff and this meant that people’s care needs were falling short, as the agency staff did not know or understand their relative’s needs. Recruitment at the service was not robust, a number of staff files had shortfalls in important documentation as required by law. Essential paperwork had not been fully completed for all staff.

There were issues with medication management, and covert medication (disguised), however, we found that the service had an action plan in place to minimise any future risks to people. Although there were infection control policies in place, we found issues around cleaning the service. There were no cleaning schedules available and we found some kitchen floors to be sticky, and there were stained carpets in the hallways. We also saw there were a number of broken wall and floor tiles around the service. The provider had also not ensured that property was refurbished regularly to ensure a pleasant living environment.

People received a full assessment of need prior to a receiving a service. Staff said they felt supported by the new manager, and they had received supervision recently, and had attended staff meetings. However, the records showed that very few supervisions, and staff meetings had been recorded. The provider had identified that no appraisals had taken place in the past year and training needed to improve. People’s views on food varied, some felt it was okay, others felt they would like more choice. Mealtimes needed to improve to ensure that everyone received enough to eat and drink and enjoyed their food.

People were generally well supported to access healthcare services. However, some relatives told us the service did not always respond quickly to their loved one’s healthcare needs. They said their relative did not receive appropriate foot care, as their nails were long and the skin around them very dry. And the inconsistency of records made it difficult to ascertain what care people had received.

The service had Mental Capacity assessments in place. Staff had received training and demonstrated an awareness of the Mental Capacity Act. We heard staff asking people for their consent during our visits. However, we found that some people’s relatives, and a staff member had signed documents on behalf of people who had been assessed as having capacity.

People mostly told us that staff were kind and caring. But also said staff were usually very busy but they did not have to wait too long for staff to support them. People had mixed views about involvement in their care. People did not always have personalised care plans that reflected their individual preferences and social history. Staff provided group activities but there was a need to also explore activities for individuals to make engagement more person centred.

Relatives and people living in the home were aware of the complaints procedure and felt that their concerns were listened to. Some people felt more could be done to rectify their concerns. People had end of life care plans in place, detailing their wishes.

Although the new manager in post was working towards improving the service, the quality assurances processes of the service and day-to-day monitoring and observations of care and support within the service was not effective.

The service requires improvement in all five key questions and there were several breaches of regulation. We also made recommendations which you can read in the main body of the report. As a result of our findings, and recent provider audits, the management of the service have developed an action plan to address all the concerns we found and share progress of this with the commission on a weekly basis.

Further information is available in the detailed findings below.

At the last inspection, the service was rated good and at this inspection, we found the service remains good.

The registered manager left in February 2017 and a temporary manager and the head of care managed the service until April 2017. The new manager was appointed in April 2017 and is in the process of registering with CQC. 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 were very positive about feeling safe and secure. There were systems and processes in place to protect people from the risk of harm and to keep them safe. The service employed enough suitable safely recruited staff to help keep people safe and to meet their needs. Medication was well managed, staff were trained and competent and people received their medication as prescribed.

People were cared for by supported, experienced and well-trained staff. The service ensured that people had the support they needed to have as much choice and control over their lives in the least restrictive way possible. People received sufficient food and drink to meet their needs and preferences and their healthcare needs were met.

Staff knew the people they cared for well and were kind, caring and understanding in their approach. People were supported to remain as independent as possible. Staff ensured that people were treated with dignity and respect and their privacy was maintained at all times.

People were fully involved in the assessment and care planning process. Their care plans had been regularly reviewed to reflect their changing needs. People were offered a range of activities that suited their individual preferences and interests. People had confidence in the service when it comes to complaints and the service had dealt with any complaints in an appropriate well-timed way.

People were positive about the quality of the service and told us they would recommend it to others. The new manager and staff were committed to providing people with good quality person centred care that met their needs and preferences. There were systems in place to monitor the quality of the service and to drive improvements. The service met all relevant fundamental standards.

Further information is in the detailed findings below.

Nazareth House – Southend is registered to provide accommodation and care with nursing for up to 64 people some of whom may be living with dementia. The service consists of two units St Joseph’s and Maris Stella. St Joseph’s unit provides nursing care and Maris Stella provides residential care. There were 62 people living in the service on the day of our inspection.

At our last inspection on 5 October 2015 we checked to see if the service had complied with the breaches found at the February 2015 inspection. We found that the provider had taken steps to mitigate the risks to people and address the shortfalls. This included implementing systems to monitor the quality and safety of the service. However, these measures needed to be embedded and sustained over time so we did not change the overall rating of the service at the 5 October 2015 inspection.

At this inspection we found that the improvements made in the October 2015 inspection had been sustained. People received their care and support in a way that ensured their safety and welfare. There were sufficient numbers of staff on duty who had been safely recruited, were well trained and supported to meet people’s assessed needs. People received their medication as prescribed and there were safe systems in place for receiving, administering and disposing of medicines.

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.

Staff had a good understanding of how to protect people from the risk of harm. They had been trained and had access to guidance and information to support them with the process. Risks to people’s health and safety had been assessed and the service had care plans and risk assessments in place to ensure people were cared for safely.

The registered manager and staff had a good understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and had made appropriate applications when needed.

People had enough food and drink to meet their individual needs and preferences. Their care needs had been assessed and the care plans provided staff with the information needed to care for them safely. People’s healthcare needs were monitored and staff sought advice and guidance from healthcare professionals when needed.

People were cared for by kind and caring staff who knew them well. Staff ensured that people’s privacy and dignity was maintained at all times. People expressed their views and opinions and they participated in activities and pastimes of their choosing. People were able to receive their visitors at any time and their families and friends were made to feel welcome.

People were confident that their concerns or complaints would be listened to and acted upon. There was an effective system in place to assess and monitor the quality of the service and to drive improvements.

We looked at six people's care records. Other records viewed included staff training records and rotas, health and safety checks and staff and resident meeting minutes.

If you want to see evidence supporting our summary please read our full report.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

When we arrived at the service our identification was checked and we were asked to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that they would speak with the staff if they had concerns. We found that the service was open and transparent. If any safeguarding incidents were reported by people using the service or others we saw that they were reported to the safeguarding team and the service cooperated with any investigations. Staff were trained in safeguarding and knew their responsibility to report any concerns. This helped to ensure that people were cared for safely.

The Care Quality Commission, (CQC,) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager was aware of changes in guidance with regard to DoLS. One application had been submitted and authorised to safeguard the person's rights. However, more work was needed in this area to ensure that people's capacity needs were assessed appropriately and that staff were trained to have the knowledge and skills to apply the law consistently and effectively.

We saw that appropriate general arrangements were in place in relation to the management of people's medicines. However, we found that some improvements were needed to staffs' practices and monitoring in relation to medication management. Improvements were needed to ensure that people could be confident that they were protected from the unsafe management of medicines.

People told us that the staff were generally available when they needed them. Improvements in the service were however needed to reduce the dependency on agency staff who may not be as familiar with people's needs. The provider also needed to consider how staffing levels were calculated to ensure that there were always sufficient staff available to people.

Is the service effective?

Most people told us that they felt that they were provided with a service that met their needs. People made comments such as, "I like it here, the food is good and the staff are kind," "Everything here is fine, the staff are marvellous," and, "There is always something going on."

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met. People using the service were encouraged to express their views, contribute to and agree their care plans and risk assessments.

Staff told us that they had a good induction, received a good level of training and felt supported. However, records detailing staff induction, training and supervision were not adequate. This meant that we could not be sure that people were supported by appropriately trained and skilled staff.

Is the service caring?

We saw that staff interacted with people who lived in the service in a caring, and respectful manner. We saw that staff treated people with respect. Staff had undertaken training in dignity in care and were encouraged to understand and operate to core values such as privacy and hospitality.

Staff had a knowledge and understanding of people's care and support needs, including recognising and supporting people as individuals.

People's preferences and diverse needs had generally been recorded and care and support was provided in accordance with people's wishes.

Is the service responsive?

We saw that staff consulted with people and offered them choices in their daily lives. People's choices were taken in to account and listened to.

We saw that staff were responsive to people's changing wishes and needs and that they supported people well.

People told us that they felt able to raise any issues they might have and felt that the service would act upon their concerns.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor, the tissue viability team and speech and language therapists.

Is the service well-led?

The management team at Nazareth House were new, and had not worked at the service for long. They were honest with us in our discussions. They had recognised the areas that needed development and were working to improve the service.

People's care was organised through adequate care planning and recording which was kept under review and monitored. Staff had lead areas to monitor practice in aspects such as health and safety and infection control. The provider had arrangements in place to assess and monitor the quality of the service provided. Audits were undertaken to assess various aspects of the service and actions were taken where shortfalls were identified. This showed us that the provider sought to provide a good and consistent service.

People had the opportunity to express their views about the service through a complaints process, meetings and one to one discussions.

We saw that people's care needs were assessed and planned for with any risks associated with their care being minimised as far as possible.

We saw that people were supported to follow their own interests. Opportunities for activity and occupation were available. Some people felt that there could be a better level of choice in daily routines such as getting up and going to bed.

People were happy with the environment which was well maintained and safe for them to live in. People liked being able to personalise their rooms and have their own things around them.

Staff said that they were supported and had opportunities for training. We saw that staff were trained in essential areas such as moving and handling. We found that levels of staff supervision needed to be improved to ensure that staff were fully supported and their practice monitored.

We found that people felt able to raise complaints or concerns about any aspect of the service. People's complaints were looked into and resolved where possible.