This inspection took place on 4 April, 2018 and was unannounced.

Nazareth House is a large ‘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.

The service is registered to provide accommodation with personal care for up to 66 older people. At the time of the inspection there were 39 people living in the home. Accommodation is located over three floors and 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 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. During the inspection we found the registered manager to be open and transparent and receptive to the feedback provided.

At the last inspection which took place in August, 2017 we identified breaches of Regulations 9, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection we issued a warning notice regarding Regulation 12 and 17 and asked the registered provider to complete an action plan to tell us what changes they would make and by when. During this inspection, we looked to see if the registered provider had made the necessary improvements.

At the last inspection we found that the registered provider was in breach of regulations in relation to safe care and treatment people were receiving. We found that medicine processes and systems were unsafe and information regarding people’s medication support needs was inconsistent and conflicting. We also identified that people’s health and well-being was not safely being supported and areas of risk were not being safely managed. During this inspection we found that the registered provider was no longer in breach of regulation in relation to ‘safe care and treatment’.

We have made a recommendation that the registered provider consults best practice in relation to improved medicine management systems.

At the last inspection we found that systems to monitor and assess the quality, standard and safety of the service were not effective. During this inspection we looked at the audits completed and found that improvements had been made. Audits were routinely completed, the quality and standard of the care being provided was being assessed and improvement action plans were in place. The registered provider was no longer in breach of regulation in relation to ‘good governance’ although further improvements are required.

At the last inspection, we found that care plans were not person centred and did not always provide sufficient information to ensure staff could meet people’s needs. During this inspection we found that care plans were detailed, reflected people’s individual needs and preferences and were reviewed regularly. We found that improvements had been made and the registered provider was no longer in breach of this regulation regarding ‘person centred care’.

At the last inspection, we found that staff were not receiving adequate supervision or being supported with training which would enhance their skills and knowledge. During this inspection we found staff received regular supervisions and annual appraisals. The registered provider was no longer in breach of this regulation regarding ‘staffing’.

At the last inspection, we found that the registered provider did not have effective systems in place to ensure ‘fit and proper persons’ were employed to support peopl

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 abl

This inspection took place on 18 and 19 July 2016 and was unannounced.

Situated close to shops, local facilities and public transport links, Nazareth House is a residential care home that can support up to 66 people who require accommodation and personal care. Located in spacious grounds, the accommodation is arranged over three floors. During the inspection, there were 61 people living in the home.

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.

A safe environment was not always maintained. We observed chemicals around the home that were not stored securely. There were windows that were observed to have broken or no window restrictors on them in order to maintain people’s safety. Vulnerable people had access to boiling water putting them at risk of potential injury.

We looked at people’s care files and found that not all identified health needs were assessed and reflected in their care plans. This meant that staff may not have access to sufficient information to support people safely.

The care files we looked at showed staff had completed some risk assessments to assess and monitor people’s health and safety. However not all risk assessments provided sufficient detail, such as some personal emergency evacuation plans.

We looked at the systems in place for managing medicines in the home. A medicine policy was available for staff and staff had completed training in relation to safe medicine administration. Medicines were stored safely and records showed they were administered as prescribed. We found that people’s allergies were not always clearly recorded.

People we spoke with told us they felt safe living in Nazareth House and staff and visitors to the home agreed that care was provided to help keep people safe. We found that there were adequate numbers of staff on duty to meet people’s needs.

Staff had a good understanding about adult safeguarding. We found that appropriate safeguarding referrals had been made and a system was in place to monitor the outcomes of referrals.

We looked at accident and incident reporting within the home and found that this was reported and recorded appropriately. There was a system in place to report any maintenance work required and this was signed off when completed to ensure the home was kept in a good state of repair.

One person had an authorised Deprivation of Liberty Safeguards (DoLS) in place, however records showed and the manager confirmed, that there were other people who required a DoLS application but these had not been submitted at the time of the inspection.

We observed staff gaining people’s consent during the inspection. We found that when people were unable to provide consent, the principles of the Mental Capacity Act 2005 were not always followed.

Staff completed an induction when then commenced in post. The manager told us that approximately 50% of staff required refresher training in what they considered to be mandatory training. Not all staff we spoke with had received regular supervisions to help support them in their role. No staff had received an annual appraisal, though staff we spoke with felt supported in their role.

People told us they received enough to eat and drink but we received mixed feedback regarding the choice and quality of the food.

No changes had been made to the environment to support people living with dementia since we made a recommendation regarding this during the last inspection. The environment had not been adapted to meet people’s individual needs. There was no secure area for people to sit outside and the communal areas of all three

Nazareth House - Crosby is a residential care home that provides accommodation, care and support for up to 66 adults. The home has been adapted to provide accessible accommodation for people who are physically disabled. Accommodation is provided over three floors. The service is situated in the Crosby area of Sefton, Merseyside.

We found that people living at the home were protected from potential abuse because the provider had taken steps to minimise the risk of abuse. Procedures for preventing abuse and for responding to allegations of abuse were in place. Staff told us they were confident about recognising and reporting suspected abuse and the manager was aware of their responsibilities to report abuse to relevant agencies.

Each of the people who lived at the home had a plan of care. These provided a sufficient level of information and guidance on how to meet people’s needs. Risks to people’s safety and welfare had been assessed as part of their care plan. Guidance on how to manage identified risks was included in the information about how to support people. People’s care plans included information about their preferences and choices and about how they wanted their care and support to be provided.

Staff worked well with health and social care professionals to make sure people received the care and support they needed. Staff referred to outside professionals promptly for advice and support when required.

Medicines were safely administered by suitably trained care workers. The medicines administration records were clearly presented to show the treatment people had received and prescriptions for new medicines were promptly started. We found that medicines, including controlled drugs, were stored safely and adequate stocks were maintained to allow continuity of treatment. Medicines audits had been completed to help ensure that any medication errors could be promptly identified and addressed.

The manager had knowledge of the Mental Capacity Act 2005 and their roles and responsibilities linked to this and they were able to tell us what action they would take if they felt a decision needed to be made in a person’s best interests.

During the course of our visit we saw that staff were caring towards people and they treated people with warmth and respect. People we spoke with gave us good feedback about the staff team and the support they provided.

There were sufficient numbers of staff on duty to meet people’s needs. Staff were only employed to work at the home when the provider had obtained satisfactory pre-employment checks.

Staff told us they felt supported in their roles and responsibilities. Staff had been provided with relevant training, some of this was a little out of date but training in the required areas had been booked for the staff team. Team meetings had been taking place and staff supervision meetings had commenced since the new manager took up post.

The home was clean and people were protected from the risk of cross infection because staff had been trained appropriately and followed good practice guidelines for the control of infection.

The home was fully accessible and aids and adaptations were in place to meet people’s needs and promote their independence. The premises were well maintained, however, there were a number of areas which needed to be made safe or improved upon for the benefit of the people who lived at the home.

People were well supported with their nutritional needs and people generally told us that the quality of the food and meals was good.

There was no registered manager at the service at the time of our inspection. 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. The manager informed us that they had submitted an application for registration and they have since become registered.

Systems were in place to check on the quality of the service and ensure improvements were made. These included surveying people about the quality of the service and carrying out regular audits on areas of practice.

You can see what action we told the provider to take at the end of this report.

During our inspection we invited people to share with us their views and experience of living at Nazareth House care home.

The people we spoke with were positive about the care and support they received. One person said, “The staff are nice and friendly. They will do anything for you.” Another person told us, “I like it here and am well looked after.”

People told us they could make choices about how they spent their day. They said they could get up in the morning and go to bed at times that suited them.

We heard from people that there was enough staff available to support them at all times. They said they did not have to wait long if they needed help as staff came along promptly when they called for assistance. One person said, “It is alright here. There are plenty of staff to help you.”

Assessments and care plans were in place for each person and they were reviewed each month with the person and/or their representative to take account of the person’s changing needs.

A complaints procedure was established and this was made available to people and their relatives/representatives in the ‘Service user guide’ which was located in each person’s bedroom.

An effective process was established for the recruitment of new staff.

During our inspection of Nazareth House we spent time talking with people about their experience of living at Nazareth House. The feedback from people was positive. One person told us, “It [the home] is a lovely place to live.” Another person said, “The staff are always there for you”.

We also spent time with relatives who were visiting the home at the time of our inspection. They told us they were happy with the care provided. We heard the communication from staff was good and they were contacted by staff if there were any changes to their dependent relative’s care needs.

Throughout the inspection we observed people were relaxed and were engaging in conversation with each other, and with staff. We noted staff supported people with their personal care needs in a discrete and dignified way.

Effective arrangements were in place for monitoring the quality and safety of the service provided.