The inspection took place on Thursday 31 August and Friday 1 September, 2017 and was unannounced.Nazareth House is a large care home, registered to provide personal care for older people. The care home can accommodate up to 66 people, at the time of the inspection there were 51 people living at the home. The care home has accommodation over three floors and is situated in extensive grounds. Facilities include four lounges, three dining rooms, 64 single bedrooms, 24 bedrooms with en-suite facilities, one large function room and a large garden area. A car park is available to the front of the building.
At the time of the inspection there was a registered manager in post. A manager was in post and they had applied to the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the previous comprehensive inspection which took place in July 2016 the home was rated ‘Requires Improvement’. We found the registered provider was not meeting legal requirements in relation to person centred care, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and staffing. Following the inspection the registered provider submitted an action plan which outlined how they were improving the standards of care and quality of service.
During this inspection we found a number of improvements had been made however the registered provider was found to still be in breach of safe care and treatment, person centred care, good governance, staffing and fit and proper persons employed. We are taking a number of appropriate actions to protect the people who are living in the home.
During this inspection we found that the systems and processes which were in place to maintain the quality and the standard of care were not effectively being used. Care records were not being maintained, risks were not appropriately being assessed, audits were not being used effectively, and action plans were not being completed. This meant that the delivery of the care being provided was not effectively being monitored or reviewed meaning that people were exposed to unnecessary risk.
Recruitment was not safely and effectively managed within the home. Staff personnel files which were reviewed during the inspection demonstrated unsafe recruitment practices. This meant that some staff who were working at the home had unsuitable and insufficient references and had not had the appropriate criminal record checks.
During the inspection we found that the area of ‘staffing’ had not improved. Routine supervisions and appraisals had not been taking place, the completion of training had not improved and staff were not being provided with specialist training such as dementia awareness training.
Accidents and incidents were being recorded on an internal database system however there was little evidence to suggest they were being analysed or if lessons were being learnt.
Medication processes and systems were not effectively managed. During the inspection we found that routine medications audits were not being conducted, medication administration records were not being appropriately completed, people living in the home were not receiving the appropriate medication as prescribed by the GP and medication was not safely stored away.
Person centred care was not always being provided. People’s care records were found to be very basic, contained minimal information and didn’t offer staff important or significant detail about the people they were caring for.
There was evidence to suggest the home was operating in line with the principles of the Mental Capacity Act, 2005 (MCA) When able, people must be involved with the decisions which are taken in relation to the care and treatment which is provided, records we reviewed suggested that the principles of the MCA were being routinely followed. The registered provider was no longer in breach of the regulation in relation to the ‘need for consent’
The MCA requires that as far as possible people make their own decisions and are helped to do so when needed. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. We found that the registered provider was suitably submitting the necessary DoLS application forms and conducting the necessary best interest meetings in accordance with the principles of the MCA. The registered provider was no longer in breach of the regulation in relation to ‘Safeguarding service users from abuse and improper treatment’.
There was evidence during this inspection that improvements had been made and the environment. The environment had been adapted to support people who were living with dementia.
The day to day support needs of people living in the home was being met. External healthcare professionals we spoke with on the second of the inspection were positive about the level of care and support which was being provided. The appropriate referrals were taking place when needed and the relevant guidance and advice which was provided by professionals was being followed accordingly.
People told us that their privacy and dignity was respected. Staff were able to provide examples of how they ensured privacy and dignity was maintained and relatives felt that the care being provided was done so with the utmost respect and dignity.
On the second day of the inspection a Short Observational Framework for Inspection tool (SOFI) was used during the lunch time period. SOFI tool provides a framework to enhance observations; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at the home who could not express their experiences for themselves. Staff provided support to people with care, compassion and kindness, staff spoke in a friendly, sincere and warm manner when they were engaging with people and people appeared to be happy and content.
There was a part time activities co-ordinator in post who was responsible for organising a range of different activities. The feedback about the activities was mixed. People we spoke with said that the range of different activities had improved however other people we spoke with, staff and visitors explained that the range of different activities needed to be improved.
There was a formal complaints policy in place and people knew how to make a complaint. There was evidence of how complaints were being responded to which were in accordance to the organisational procedures. At the time of the inspection there were no formal complaints being investigated.
Staff morale appeared to be positive. Staff did express that due to the recent changes which had taken place in relation to the management the morale had been affected however, staff also expressed that the morale of the home was improving and staff felt supported by the new registered manager.
The registered manager was aware of their responsibilities and had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with the CQC’s statutory notifications procedures. The registered provider ensured that the ratings from the previous inspection were on display within the home, these were also available for the public to review on the provider website, as required.
Specific policies and procedures were available such as whistle blowing, safeguarding and equality and diversity and staff were able to discuss them with us.
We are taking a number of appropriate actions to protect the people who are living in the home. The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in ‘special measures’ must be inspected again within six months. If insufficient improvements have been made we will take the necessary actions in line with our enforcement procedures which is to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.