Nazareth House - East Finchley

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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

We rated this key question as - requires improvement. During our assessment, we found concerns around how medicines were managed. There were shortfalls in this area which was a breach of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. People's risk assessments and care plans provided sufficient guidance to help staff keep people safe. Staff were recruited appropriately and trained to support people. There were systems to control and protect people from infections.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were quality assurance processes in place to help continuously improve the service. We saw examples of learning in the service following incidents or complaints that were raised. However, we did not see much evidence of how the provider developed creative ways of helping to improve the quality of life for people. The management team of the home maintained a culture of safety based on openness and honesty. Incidents and accidents were reported and investigated. Staff confirmed they knew how to respond to incidents and accidents involving people they supported. A staff member said, "We have a process to report incidents. We log them in the system."

People that had been referred to the home through the care pathway, for example from hospitals or the community, were initially assessed by senior staff to determine their needs could be met in the home. The management team used a joined-up approach to safety that involved people, their relatives and professionals, such as doctors, occupational therapists and social workers. The regional manager told us and records showed systems were in place to maintain people's safety through their transition to the service. The management team and staff told us they supported people through their care journey, for example if they transferred to another service or were admitted to hospital. They told us relevant information about people's needs was shared between them and partner agencies in a timely manner.

There were processes and systems established for care to be provided to people in a way that was safe and for their needs to be assessed and understood. People's needs, risks and preferences were assessed and people were involved in the process. The provider had procedures in place to ensure safe care was carried out and people received care from staff that was appropriate and delivered as required. People admitted to the home were supported to settle and transition into their new home environment. We received positive feedback from professionals on how the service worked collaboratively with them. Staff and managers communicated with key partners who were also involved in people’s care journey through the health and social care system. Risks to people's safety and health were assessed so that the right level of care could be provided and risks could be mitigated. However, some people's care plans lacked consistency to ensure continuous care could be provided to people. For example, some care plans had missing information such as capacity assessments and some lacked detail around areas such as skin integrity, sleep, falls, oral hygiene or sleep patterns, or had not been updated. This meant there was not always an effective process to ensure people were supported within a safe system of care and their needs were monitored and managed to keep them safe.

People and relatives said the home was safe because they were well-looked after and the staff were kind and caring. A person said, “The staff are kind and helpful to me.” Relatives told us they felt their family members were safe in the home and with staff. They also told us they knew who to contact if they had any concerns about people’s safety. A relative said, “[Family member] is safe. I have been really impressed; the staff spotted a problem which I was really happy about.” Staff kept people safe and knew how to respond if people expressed distress or signs of abuse. Staff followed safeguarding guidance and risk assessments from people's care plans to provide safe care and support to people.

Leaders and staff ensured safeguarding processes were followed. Staff understood and completed safeguarding training. They told us they knew how to identify possible abuse, for example what signs to look out for. They notified the Local Authority about safeguarding concerns. Staff told us they would be confident to escalate safeguarding concerns internally and to the local authority or the CQC. There was recognition from the management team that more prompt action should have been taken to identify a person with a developing pressure sore following a safeguarding concern but they worked with safeguarding teams to ensure improvements were implemented. Staff were trained in safeguarding during their induction and had annual refresher courses. A staff member told us, “If we have any concerns that people may be at risk of abuse we would report it immediately to management. I have no trouble in reporting people if I feel I need to do so. There are policies in the office for safeguarding and whistleblowing which we were required to read as part of our induction.”

The service worked with people to understand and manage risks. This enabled staff to deliver care that met people’s needs and enabled people to do the things that mattered to them. People told us they had assessments of risk specific to them to minimise the risk of injury. People's consent to care was sought and their capacity to make decisions around their care was assessed. People's relatives were also involved to ensure the right level of care was delivered and people's needs were assessed and understood by the staff supporting them.

Staff supported people safely. For example, they followed people’s risk assessments when assisting them to mobilise, ensuring they had the correct equipment and number of staff specified in their care plans and risk assessments. People had risk assessments covering all aspects of their care and support needs. These were written in partnership with people and relatives where possible. Risk assessments were regularly reviewed and updated when people's needs changed.

People told us the environment of the home was a safe place for them. On the day of our inspection, we noted some electrical works were being carried out by maintenance, which involved machinery that could at times be loud. We asked some people if they had been made aware of the work in advance and they told us they were not. However, any equipment was kept at a safe distance from people and it did not interfere with the delivery of care. There was signage in place for areas that were considered a safety hazard risk. The home had implemented adaptations to support people with their needs, for example for those that required a dementia friendly environment. This included signage which supported people to find their way around. People's bedrooms had been personalised with items, photos or pictures that meant something to them and there was easy access to outdoor areas. However, we did note that some parts of the home contained stained carpets and occasional odours but these did not have significant impact on people's daily routines or quality of life. The provider told us improving the home environment this was also part of their improvement plan.

Staff told us there were always enough staff on shift and people's one to one support was always staffed correctly. There were enough staff on duty to meet people’s needs. When people needed care and support staff provided this promptly. Staff were kind and caring in all their interactions with people and competent in meeting their needs. The staff team had the right skills mix to ensure people received safe, good quality care. Staff were well-trained and used their knowledge to provide good quality care. There were systems for staff to be appropriately and safely recruited. The management team carried out recruitment checks prior to staff working with people to ensure they had the right level of qualifications, skills and character to meet the needs of the people using the service. Police checks were also carried out to check for previous convictions and references and proof of eligibility to work in the UK were obtained. The management team pursued professional references for new staff and their work history and experience was explored. This enabled the management team to make safe decisions about their suitability to work with people in the home. There was a policy and procedure in place to ensure that staff receive regular supervision, appraisal and support to develop their skills and qualifications continuously. Records showed staff received ongoing supervision and yearly appraisals. Staff were provided opportunities to learn and improve their skills.

Staff told us there were enough staff in the home and to meet the needs of people. They told us the home was always staffed correctly, although some staff told us they felt they needed more support to carry out their roles. The management team and provider assessed the numbers of staff required each day. A staff member said, "There used to be two people do my job and this is just too much work for one person." We looked at staffing rotas to check there were enough staff on duty to meet people’s needs. We saw that there were enough care staff and when people needed care and support staff provided this promptly. However, other departments within the home such as the cleaning, laundry and kitchen services would require staffing assessments to ensure staff had enough support to carry out their roles effectively. A staff member said, “We are adequately staffed here I think. We cover for each other and work well.” Staff told us they had the relevant training to do their job well and received good support from the management team. A senior member of staff said, "Staff receive the training they need to be competent in their roles." People and relatives were positive about the staff and told us they were caring and friendly. A relative said, “Yes [family member] is safe and there seem to be enough staff, but there could always be more”. Another relative told us, “I think there enough staff for her needs.” People said staff came as soon as they could when responding to their call bells to request assistance. A person told us, “I think the staff are responsive.” Some people and relatives thought the staff did not always have the time to respond to them. A person said, "They are probably short of staff, otherwise I wouldn’t have to wait." We saw that care staff numbers were assessed and extra staff were recruited when needed, for example if people needed additional support for their needs.

There were systems for staff to be appropriately and safely recruited. The management team carried out recruitment checks prior to staff working with people to ensure they had the right level of qualifications, skills and character to meet the needs of the people using the service. Police checks were also carried out to check for previous convictions and references and proof of eligibility to work in the UK were obtained. The management team pursued professional references for new staff and their work history and experience was explored. This enabled the management team to make safe decisions about their suitability to work with people in the home. There was a policy and procedure in place to ensure that staff receive regular supervision, appraisal and training to develop their skills and qualifications. The staff team had the right skills mix to ensure people received safe, good quality care. Staff were well-trained and used their knowledge to provide good quality care.

Staff received training as a continuous process to help them maintain good standards of infection control. We found the home to be cleaned, odour free and well sanitised. Staff told us they followed procedures to protect people from the risk or spread of infection. They confirmed they wore PPE when needed. These included gloves, aprons, shoe covers and hand gels. People told us staff washed their hands and followed hygiene protocols. They also told us the home was well maintained to help prevent the spread of infection. A person said, “They keep the place is very clean and tidy.” We viewed people's rooms with their consent and found them to be very clean.

Infection prevention and control procedures were in place. On the day of our inspection, a floor within the home was closed to external visitors due to a COVID-19 outbreak. The provider had ensured they followed their process for outbreaks to help contain the spread of infection. The area was appropriately used for zoning and self isolation so that people and staff were sufficiently protected. Staff had access to sufficient supplies of personal protective equipment (PPE). One staff member said, “We always have a good supply of PPE.” Observations and audits of staff at work were carried out to check their competence in following the infection control policy in people's homes. Staff demonstrated how to work in a safe and clean way.

People and relatives were satisfied with how staff managed medicines in the home. A person told us, “I take my medication every day at the same times.” Another person said, “Medication here is good and it is at same time every day.” A relative said, “I have no concerns regarding medications.” However, we found some issues with how medicines were being counted and recorded. When we raised concerns about these shortfalls with the nursing staff and the management team they agreed to investigate and make improvements as necessary. We saw medicines being administered on the day of the inspection safely and efficiently. This was carried out in a way that was careful, considerate and with attention to detail. People received their medicines in a timely manner, and staff told us that unless there was an emergency, the senior staff gave people their prescribed medicines at a suitable time in the morning so that it was not too close to the lunchtime medicine round.

We spoke with nursing staff who were responsible for medicines administration. They said they were well-supported by senior staff in managing medicines safely. They told us they had regular staff meetings, and training which covered their skills and competency regarding medicines. They told us they were able to use technology to record medicine they administered to people on medicine administration records (MARs). We saw that electronic MAR sheets were mostly accurate and up to date. Unused medicines were disposed of appropriately using the electronic system. There were some PRN protocols in place for some people on medication prescribed ‘as required’. These provided the necessary information to give people medicines safely when it was required. However, these were not always person centred. For example, for a person who could be given paracetamol for pain relief when they requested or needed it, the protocol did not specify the type of pain and location of the pain that may occur. There was not enough information on the signs and symptoms or what to look out for in that person on how they could express they were in pain. There was not much information on other solutions for pain such as homely remedies, which are over the counter medicines used for mild pain relief.

Processes to review the stock levels of medicines were not effective. We found medicines were mostly kept in their original packaging if they were not part of a blister pack. The MARs showed the stock and balance levels after each use but we found 5 lots of medicines where the stock levels were incorrect. There were 4 records for paracetamol and another was for a medicine that helps with symptoms of certain mental health conditions. The MAR record had recorded there were 90 tablets remaining but there were actually 78. Similar errors were found for four people who took paracetamol as a PRN. This meant there was risk of medicines being unaccounted for. We brought this to the attention of the regional manager who attended due to the absence of the registered manager. They took action to investigate and told us these were recording errors by staff that had not been identified. This meant systems were not effective in ensuring the safe management of medicines. Although we found medicines were stored in secure trolleys in a locked room in medicine fridge or cupboards, these concerns could put people at risk of not receiving their prescribed or 'as required' medicines, or there was risk that medicines were being removed or taken without authorisation. This put people's health at risk or at risk of avoidable harm. The refrigerator temperature was checked and recorded daily by staff who monitored that it was within the minimum and maximum range. The temperature in the medicine rooms were also checked to make sure they were in the acceptable temperature range for the safe storage of medicines. We saw that allergies people had were made clear for each person in medicine records.