Nazareth House - East Finchley

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment, we found concerns with the provider’s governance systems as they were not always effective in identifying or addressing shortfalls. This was a breach of Regulation 17 (good governance) 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. Staff were well-supported by the registered manager who was approachable and committed to continually improving the service. Some of the ways risks were managed had improved.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. The management team and staff understood regulations around transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. People, relatives and staff all told us they felt supported by the management team and treated as individuals. They respected the challenges and the needs of people within their community in order to meet these qualities.

Processes were in place to deliver a service that embodied the shared vision, strategy and culture of the organisation. However, we found that more work and development was needed to help improve the service. Leaders in the service had not effectively promoted a safe culture within the home or displayed the knowledge and skills in identifying and driving improvements, due to some of the shortfalls we found.

The registered manager was supported by unit leads and senior staff to monitor the day to day running of the home. The regional manager, who we spoke with in the absence of the registered manager, also visited the service frequently to offer additional support and oversee the management of the home. They told us they worked well with the registered manager and was pleased with the progress of the service. They said, "We are working through some issues but there has been good progress. We know there are areas for improvement and we have ongoing actions to do this." This meant there was a culture of openness, integrity and honesty in the home. However, there had not been enough improvement in the home since our last inspection and we were not assured that leaders always demonstrated the skills, knowledge and experience to lead effectively. Staff told us they respected people's privacy and dignity. They bought into the culture of the service and said that managers were capable, caring and compassionate in their work. This ensured people were treated well.

Leaders in the home, such as the deputy manager, unit leads and senior healthcare assistants worked with the registered manager to support staff in their roles to deliver care that met people's needs. Staff were provided with ongoing supervision. They were able to discuss their performance and any issues with the leaders in the service. They were provided the tools and skills needed to carry out their work effectively. Feedback from people and relatives was positive about the staff, who they said were kind and compassionate towards them.

Staff told us they understood how to report concerns about the home and felt able to approach the management team with them. A staff member said, "The registered manager is nice. They are approachable and I feel they would listen and take action if I was concerned about something." A whistleblowing policy was in place should staff not feel able to approach the management team or wider organisation. Staff knew they could contact other external agencies such as the local authority, police or the CQC if they wanted to raise concerns about the safety and culture of the home.

The service did not place restrictions whereby people and staff felt they could not speak up and their voice would not be heard. People and relatives stated they felt able to raise concerns about anything they felt was important and felt able to compliment or criticise the service openly. People were supported with regular reviews of their care and support plans and with residents or relatives meetings. People felt their views were valued by the registered manager and other members of the management team. We saw a range of compliments received by the home from people and relatives, praising the hard work of the staff and caring for their loved ones with dignity and respect.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. All staff we spoke with told us they were treated fairly and respectfully by the management team and the provider. There was a policy to ensure all staff had access to equal opportunities and reasonable adjustments to ensure their needs could be accommodated in the work place. Staff told us they were treated well and were supported in their role. The management team ensured equal opportunities for staff were maintained. Recruitment and disciplinary processes were fair and ensured there were no disadvantages based on staff's specific protected equality characteristics. Staff told us they were able to take breaks and were able to ask for reasonable adjustments to be made to their working patterns if needed. Most staff felt their health and wellbeing was taken seriously by managers, although some staff felt they needed more support from the management team in this area.

The manager and staff team were aware of their roles and responsibilities. We saw records of audits to monitor and improve the home. These included audits of people’s care plans, medicines, the environment and infection prevention and control procedures. Following our visit the regional manager told us they investigated the medicines errors and raised a safeguarding alert, they went through weekly stock check reports with staff and allocated further training as part of learning lessons to prevent reoccurrence of similar errors in future. This meant they were addressing this issue. At the time of our visit, the service had improved some of the ways risks were managed, care plans were more personalised and activities were taking place more frequently. This demonstrated a commitment to continually improving the service.

The provider’s quality assurance audits and checks were not always effective. Medicines audits failed to identify the concerns we found in relation to medicine stock checks. The service’s medicines audits had not identified these shortfalls. Risks to the health and safety of people were not being effectively assessed and monitored. We noted from records that there had been previous issues with ensuring people were repositioned at regular intervals. However, we found these issues had yet to be resolved as we saw that some people were not being repositioned at the intervals required. People were at risk of not having their nutrition and hydration needs met. We reported our findings around monitoring people's fluid intake to ensure they were meeting the amounts recommended daily to keep hydrated and healthy. For a person identified as being at risk of dehydration the recorded fluid intake was very low and there was no clear target in place. Another person who was bedbound did not have a fluid target and on some days records showed no amount had been recorded and on another day it was only 200mls. For another person the recording had not reached 100mls on any day. At our last inspection in December 2022, we recommended the provider ensured that all improvements and developments implemented in relation to medicines, risk and accident/incident management are sustained and fully embedded within current care practices and processes, so that people continued to receive safe care and treatment. We found that these improvements had not been sustained to a consistent level. The regional manager acknowledged further improvements were needed and they would work through an action plan to ensure progress.

The management team understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated with them to keep people safe and well. People benefited from the provider working in partnership with other health care services in the local area. For example, collaboration with GP’s, district nurses, the local authority and physiotherapy services. We received positive feedback from partners. We spoke with with the community matron who had been supporting the service for many years. They told us, "The staff are listening to the multi disciplinary teams (MDT) and follow up on the advice I give. They are aware they can refer directly to the community matron and they have got there now with referrals to me and the MDT. Staff are becoming more confident and concerns are now acted on quickly." MDT meetings for people which could include professionals such as psychiatrists, geriatrician, physiotherapist, occupational therapists and district nurses, were attended by care staff and managers. Partners told us staff had improved in identifying problems, such as weight loss and people’s needs were being met.

There were processes for the provider to work in partnership with the local community and various services. The regional manager told us, "We work with other health professionals that come into the service by referrals we make, residents they see, attending manager's network meetings, attending MDT meetings. We also have the community come in such as local schools and community groups. In terms of how we support people to access the community some residents go to clubs outside the home and staff also take residents out shopping or where they want to go, accompanying them via taxi. We also do activity outings as well."

Staff and leaders told us that learning, innovation and improvement took place in the home through discussions. There were meetings for staff where information was shared and views were encouraged, listened and responded to. Staff meetings included topics such as training, recording, dignity in care and following safety protocols. Lessons were learned when things went wrong in the service but these systems were not robust to ensure these lessons were sustained. People could also express their views in annual satisfaction surveys and meetings. Relatives had opportunities to meet managers in groups to discuss updates about the service. A relative said, “When I visit [family member] she is how I would expect her to be, no surprises”

Despite the work done by the service since our last inspection, the service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. This is the third consecutive inspection where the provider has failed to achieve and maintain an overall rating of good. This meant their overall governance systems required further work to ensure good care and continuous improvements.