About the service: Nazareth House Birkenhead is registered to provide accommodation for up to 51 older people who require nursing or personal care, and for the treatment of disease, disorder or injury. The service is divided into two separate units; the ground floor unit providing nursing care and the first floor unit providing personal care. At the time of the inspection there were 37 people living in the home.

People’s experience of using this service: At the last inspection in February 2018 we found that the registered provider was in breach of Regulation 12 regarding risk management. During this inspection, we found similar concerns. The building, equipment and utilities were checked regularly, however not all identified risks had been addressed.

Systems in place to assess and monitor the quality and safety of the service were not always effective as they did not check all areas of the service and actions were not always taken to address concerns identified.

Although there were usually sufficient numbers of staff on duty, the high use of agency staff impacted on the consistency and quality of the care people received. Staff recruitment was underway, which the registered manager hoped would reduce the use of agency staff.

Recruitment checks were completed; however dates of the initial checks were not always clearly recorded to evidence checks had been made prior to employment. We made a recommendation regarding this in the main body of the report.

Records regarding the management of medicines were not always adequately maintained. We made a recommendation regarding this in the main body of the report.

At the last inspection we found the registered provider to be in breach of Regulation 17 as care plans did not reflect people’s needs accurately and planned care was not always evidenced as provided. Since then, care plans had been reviewed and rewritten and were detailed and person centred, providing information regarding people’s needs and preferences.

People and their relatives felt they were safe in the home. Individual risks to people had been assessed and measures were in place to mitigate those risks. Staff were knowledgeable about safeguarding and how to raise any concerns they had.

Consent was sought and recorded appropriately for some people, but this was not always consistently recorded. People told us staff asked for their consent and when people had their liberty restricted lawfully, any conditions attached were met.

Staff told us they were well supported, they received regular training and supervisions and were able to raise any concerns with the registered manager.

People told us they were treated with kindness and compassion by staff and their family members agreed. We observed familiar, warm interactions between staff and people living in the home.

People told us their dignity and privacy was always respected by staff, that they were able to make choices regarding their care and they were encouraged to be as independent as they could be.

Systems were in place to manage complaints and we saw that they were investigated and responded to appropriately.

Feedback regarding the management of the home was positive. Staff told us they had seen improvements since the registered manager had been in post. The registered manager worked with other agencies to help provide joined up care.

Rating at last inspection: Requires improvement (Report published March 2018). This is the third consecutive time the service has been rated as requires improvement.

Why we inspected: This was a planned comprehensive inspection based on the previous rating.

Enforcement: Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

We will also meet with the provider and registered

This inspection took place on 21and 23 February 2018 and was unannounced.

Nazareth House- Birkenhead 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 is registered to provide accommodation, nursing and personal care for up to 51 people. At the time of the inspection there were 39 people living in the home.

At the last inspection in December 2016, we found that the provider was in breach of regulations and the service was rated as requires improvement. The breaches were in relation to the safety of equipment and care planning. 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 service and ensure regulations were met. The provider told us that all improvements would be completed by the end of March 2017. During this inspection, we looked to see whether the provider had followed their plan and necessary improvements had been made.

We found that concerns identified at the last inspection had been addressed. For example, windows had appropriate window restrictors fitted to prevent accidental falls from height, fire doors were not wedged open, appropriate bed rails were in use and systems were in place to ensure air mattresses were set at the correct settings. However, we found that other areas required improvement.

At the last inspection we identified concerns as care plans did not always reflect peoples’ current needs. During this inspection we found that although many care plans were detailed and person centred, not all had been updated when peoples’ needs had changed. We also found that planned care was not always evidenced as provided. The provider was in breach of regulations regarding this.

Checks to monitor the quality and safety of the service were regularly completed, but were not always effective in identifying areas that required improvement. Not all risks previously identified had been addressed by the provider. The provider was in breach of regulations regarding this.

Not all risk assessments accurately reflected the risk people faced, however we found that appropriate action had been taken to address risks. Personal emergency evacuation plans did not provide sufficient information to ensure people could be safely evacuated in the event of an emergency and not all identified risks had been addressed. The provider was in breach of regulations regarding this.

We found that medicines were not always managed safely and we made a recommendation regarding this.

A registered manager was 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. Feedback regarding the management of the service was positive.

Systems were in place to ensure safe staff recruited procedures were followed. We received mixed feedback regarding staffing levels, but found that there was sufficient staff on duty to meet peoples’ needs at the time of the inspection.

All people we spoke with told us they felt safe living in Nazareth House. People told us, “I have nothing to be afraid of” and “Staff are around so I never have any worries.” There were systems in place to help ensure that lessons could be learnt from incidents and accidents were recorded and reported appropriately. Internal and external checks were completed to help maintain the safety of the environment.

Applications to deprive people of their liberty lawfully had been made appropriately to ensure people received care with least restrictions. Consent to care was gained in line with the principles of the Me

We carried out this comprehensive inspection on 28 and 30 December 2016. During our last inspection of Nazareth House Birkenhead on 8 July 2015, we found breaches of three regulations of the Health and Social Care Act 2008. These were because: the staff employed by the service did not receive appropriate support, training, professional development, supervision and appraisal to enable them to carry out their duties; the provider did not have suitable arrangements in place for people to consent to their care or follow legal requirements when people could not give their consent; complaints received had not been investigated nor had necessary and proportionate action been taken.

During this visit we found that improvements had been made in all of these areas, however further improvement was needed in order for the service to be fully compliant with the Mental Capacity Act. We found breaches of Regulation 12 of the Health and Social Care Act because people did not always have in place equipment that was safe and suitable for their needs and care plans did not always contain up to date, relevant information which placed people’s health at risk.

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Nazareth House Birkenhead is a care home registered to accommodate up to 51 people who require nursing or personal care. It is situated in a residential area of Birkenhead. There were 43 people living at the home when we visited.

The service had a 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.

People who lived at the home told us they felt safe. Policies and procedures were available for safeguarding vulnerable adults and for whistle-blowing, and nearly all of the staff had received recent training about safeguarding. Information about who to contact to report safeguarding concerns was displayed in the entrance area.

Maintenance contracts were in place for equipment and services. The premises were clean and tidy with no unpleasant smells and a programme of refurbishment was underway. We saw unsafe bedrails in place on some people’s beds. Pressure mattresses were not all on the correct weight setting to protect people from pressure damage. Window opening restrictors had been over-ridden in two bedrooms. We saw no systems in place to check any of these.

Applications for a Deprivation of Liberty Safeguard had been made on behalf of some people living at Nazareth House, however this was inconsistent and further work was needed to ensure full compliance with the Mental Capacity Act.

People’s medicines were managed safely and people told us they had their medicines at the right time.

On the day we visited there were enough staff to meet people’s needs and staff rotas showed that these numbers were maintained. However, members of staff thought there should be one more care assistant on duty because the people living at the home had a high level of dependency. Safe recruitment processes had been followed before new staff were employed.

Training records showed that there was an annual programme of training and most staff were reasonably up to date with all of this training. A new system of on-line training was being introduced. In the absence of a manager during 2015/16, staff supervision and appraisal had lapsed, however we saw evidence that this had now recommenced.

We observed that people were provided with a variety of nutritious meals and had the support they needed to eat their meals.

People we spoke with said the staff were kind and caring. People received the support they needed to maintain a good standard of personal care. People were able to receive pastoral support from the nuns who lived in a separate part of Nazareth House.

Records in people's care files showed us th

We carried out this comprehensive inspection on 28 July 2015. Nazareth House Birkenhead is a care home registered to accommodate up to 51 people who require nursing or personal care. The service did not have a registered manager because the registered manager had resigned shortly before our visit. 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 who lived at the home told us they felt safe. Policies and procedures were available for safeguarding vulnerable adults and for whistle-blowing, and nearly all of the staff had received training about safeguarding. Maintenance records showed equipment and services were checked regularly and kept in safe condition. The premises were clean and tidy with no unpleasant smells. Actions were being taken to address the findings of an infection control audit. People’s medicines were managed safely and people told us they had their medicines at the right time.

On the day we visited there were enough staff to meet people’s needs and staff rotas showed that these numbers were maintained. However, a number of people told us they thought the staff were rushed and did not always have time to spend with them. Safe recruitment processes had been followed before new staff were employed, however records did not show us that new staff completed induction training or that they had been supported in their new employment. Training records showed that there was an annual programme of training and most staff were reasonably up to date with all of this training. Records indicated that most staff had an appraisal in 2014 but only a small number so far in 2015. Staff supervision meetings were very infrequent.

Some of the people living at the home had a diagnosis of dementia. Where people are living under constant supervision and are unable to decide if they wish to live at the home, consideration should be given to making a Deprivation of Liberty Safeguard (DoLS) application. This helps to make sure the person’s best interests have been taken into account and their legal rights protected. Nobody living at Nazareth House had been assessed to see if a DoLS application should be made on their behalf.

People told us they got a menu to choose from every day. Most of the people we spoke with thought the food was good, hot and tasty. We looked at a sample of care plans and found that nutritional risk assessments were recorded and plans put in place where a risk was identified. People at high risk were weighed weekly. Records in people's care files showed us that people had received support to access a range of health professionals. This included podiatrists, dentists, GP, district nurses and attendance at medical appointments.

People we spoke with said the staff treated them with dignity and respect. Staff were aware of barriers to communication that may affect people and put measures into place to support them. We saw that people had been supported to take a pride in their appearance. People were able to receive pastoral support from the nuns who lived in a separate part of Nazareth House and the nuns were available to sit with people who were reaching the end of their life.

During our visit people told us they were happy with the care they received but they would like to have more to do. Before our visit we received information of concern regarding the care of people who were at risk of pressure damage and who had developed a pressure sore. Care staff we spoke with were aware of pressure care and that they should observe for skin breakdowns when assisting with personal care. Appropriate equipment was in use to prevent pressure damage and we saw that pressure care mattresses and cushions were working correctly and were on the correct setting. People at risk were repositioned every two hours, however we found that repositioning charts were not completed consistently. Pressure ulcer dressings were changed every two to three days as advised by the NHS wound care specialist nurse and as stated in detail in the care plans. We found that care plans were a little repetitive and generic rather than person-centred, however the pressure care plan was detailed and care plans contained some information about the choices people could make in their everyday lives.

We found that complaints we were aware of had not always been logged and there were no records to show how they had been addressed. The registered manager had recently left the home and the area manager was spending two to three days a week at the home with additional support being provided by another manager from within the organisation. The area manager had held meetings with staff on 2 July 2015 and 20 July 2015 and the organisation’s chief executive officer had visited. From speaking with staff, visitors, and people who lived at the home, we considered that people’s views had not always been listened to, and the monitoring audits carried out had not always identified and addressed improvements needed. The area manager had written a detailed action plan and was working with the local authority to ensure that this was implemented.

You can see what action we told the provider to take at the back of the full version of the report.

We gathered evidence against the outcomes we inspected to help answer our five key questions.

Is the service safe?

Medicines were stored, administered, and recorded safely and consistently by qualified staff. Records showed that staff received regular training, supervision and appraisal. No Deprivation of Liberty Safeguards were currently in place but the service had appropriate policies and procedures.

Is the service effective?

People told us that they were happy with the care and their needs were met. Staff had a good understanding of people's care and support needs. One person told us “I love it here, I couldn’t be in a better place.”

Is the service caring?

Staff were kind and patient to the people who lived at the home. One person told us “The girls are brilliant to me, I couldn’t have nicer carers.” The Sister Superior based at the service carried out a monthly ‘core values’ audit.

Is the service responsive?

People's needs were assessed before they moved into the home. Care plans recorded people's personal preferences and interests, and care was provided in accordance with people's wishes. People had access to activities and to pastoral support.

Is the service well led?

The manager was a registered nurse and had been in post for five years. He was supported by a deputy manager and a unit manager. The home was part of the Nazareth Care Charitable Trust and senior management provided support in all areas of the service.

Care plans we looked at contained assessments of people's needs, plans for their care, and monthly updates to ensure that any changes were documented. The Sisters of Nazareth were able to provide pastoral care for example sitting with people nearing the end of their life. The home had a full-time activities organiser and a minibus was available for trips out. People we spoke with all told us that they felt well cared for by the staff and one person said “they do everything you need, they are marvellous”. A letter received recently from the family of a person who lived at Nazareth House read “Thank you for all your kindness and hard work and love you showed towards my [relative]. Thank you for making her time at Nazareth House so warm and welcoming, she really felt at home here.”

Everyone who lived at the home was weighed monthly and a nutrition risk assessment was recorded for everyone and reviewed monthly. People we spoke with told us “It’s very good food”, “I always have plenty to eat” and “They are very good cooks”.

The home employed a full-time maintenance person who carried out regular health and safety checks including a weekly fire alarm test, checks of equipment safety including bedrails and wheelchairs, and a checklist for the minibus.

Many staff had worked at the home for twenty years or more and all except one of the care staff had a national vocational qualification in care at level 2 and more than half at level 3.

People we spoke with said that they were very happy living at Nazareth House. One person told us how important it is for her to be able to practice her religion and she attends mass every day. A person we spoke with said “the carers are all marvellous”.

The home is visited monthly by a Sister Superior and she writes a report for the home manager. During her last visit, people she spoke with told her:

‘Staff help us, there is nothing that they would not do for you; I am very happy here; everything is fine here, we are waited on hand and foot.’

On a recent questionnaire, one person commented: ‘My mother is very content in her surroundings, care is excellent and I am always made to feel welcome.’ Two people commented that they would like a better choice and quality of food and one person would like more regular meetings. One person considered that towels were poor and there were a number of negative comments about the décor of the home.

One of the comments we saw was ‘standard of nursing care is excellent’, and another person wrote ‘The staff are really friendly and helpful and interact very well with family and residents.’