This inspection took place on 24 and 25 May 2018 and was unannounced.

We last inspected the service on 10 January 2017 and found the service to be in breach of Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008. The service had not always updated people's care plans and risk assessments contained discrepancies in relation to moving, handling and mobility guidance for staff. We found accidents and incidents were not always recorded in a way that allowed for an overview of the actions taken and the outcome for the person. The service did not always follow their medicines administration policy especially around the storage of controlled drugs. In addition, we found that health monitoring documents were not completed in a robust manner leaving gaps in the recording. Care plans contained little or no evidence of people and family involvement in reviews and there was a lack of written evidence that people's consent had been sought and mental capacity assessments or best interest meetings had been considered and undertaken.

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 key question ratings to at least good. At this inspection we found that the service had made significant improvements in each of the key questions. However, we did note that some further improvements were required to ensure sustainability.

Nazareth House 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 accommodates a maximum of 84 people in one adapted building. At the time of this inspection there were 74 people living at the service. The home is split over two floors, lower ground floor and ground floor with each person’s bedroom containing en-suite facilities.

There was a registered manager in post at the time of this 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.

People and relatives confirmed that they felt safe with the care and support that they received from the care staff at Nazareth House. Care staff demonstrated a good level of understanding about safeguarding and the steps they would take to report concerns to ensure people are kept safe from harm and abuse.

Risk assessments had been completed that identified people’s individual risks. However, where risks associated with people’s individualised and specific health conditions had been identified and assessed, very little guidance was available to staff on how to manage or mitigate the risk in order to keep people safe.

The service monitored and documented people’s weights, food and fluid intake and repositioning where this was an identified need. However, noted that the service did not always clearly record a person’s minimum and maximum fluid intake and the actions taken where a person had not met the required amount.

The area manager, registered manager and head of care carried out a number of audits and checks to oversee the quality of care delivery and identify issues so that improvements and learning could be implemented. However, where we found some minor issues with the completion of individualised risk assessments, robust completion of food and fluid charts, and lack of documented action plans these issues had not always been identified through the service’s internal monitoring processes. We have made a recommendation to the provider about this.

The provider had policies and processes in place to ensure the safe administration of medicines. People received their medicines as prescrib

This inspection took place on 5 and 10 January 2017 and was unannounced.

Nazareth House - East Finchley is a care home providing personal care to a maximum of 84 older people. At the time of our visit 67 older people lived at the service.

People, relatives and staff spoke positively about 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 our last inspection in November 2015 we found two breaches of regulations. The service had not consistently provided staff with supervision and training to equip them to undertake their role. In addition the service had not ensured that care plans were up to date and had not captured changes in people’s care delivery.

During our inspection in January 2017 we found four breaches of the regulations these included that the service again had not always updated people’s care plans. We found some care plan documents and risk assessments contained discrepancies, in particular the moving and handling and mobility guidance for staff. Further more accidents and incidents were not always recorded in a way that allowed for an overview of the actions taken and the outcome for the person.

We found that the service medicines administration policy was not being followed, in particular the storage of controlled drugs. In addition we found that health monitoring documents were not completed in robust manner leaving gaps in the recording. These concerns had not been identified and addressed by the management team in an effective manner.

People had person centred care plans that contained a pen profile and contact details. Guidance for staff was specific and stated what people wanted however there was little or no evidence of people and family involvement in reviews.

The service undertook Deprivation of Liberty (DoLS) applications appropriately and we saw a number were authorised by the statutory body. Staff could tell us how they got people’s consent before offering care and support and people spoken with confirmed they were supported as they wanted to be. There was no evidence that the Mental Capacity Act 2005 (MCA) was being considered in written documents as there was a lack of written evidence that people’s consent had been sought. We were told records of consent were archived. This meant staff did not have access to people’s decisions and we saw no evidence of mental capacity assessments or best interest meetings in people’s records. The registered manager told us records were being placed on the electronic system for staff reference.

People, relatives and staff had mixed views about the staffing levels but we found the management team requested agency staff to cover staff absence. There was a robust recruitment procedure to ensure staff were safe to work with vulnerable adults.

People told us they felt safe in the service, there were posters displayed to support people to raise concerns and staff could tell us they would report any concerns to their senior staff.

Staff had received training to assist them in their role and confirmed they received regular supervision sessions. People were supported to eat and drink well and there was a good variety of nutritious meal choice. People who required support to eat were given the support they required.

The service had been refurbished and was fully accessible, well maintained and clean. Staff could tell us the measures they took to avoid cross infection this included the use of personal protective equipment and colour coded equipment.

People and their relatives told us staff were caring and kind. We saw sensitive and gentle interactions between staff and people. Staff could tell us how they maintained people’s privacy and dignity

People who use the service were very positive about the care and treatment they received from staff at the home. One person commented “I’m very happy here. The staff are lovely.” We observed staff supporting people in a friendly, patient and professional manner. Staff had a very good understanding of the needs of the people they supported and the potential risks they faced.

Staff understood the importance of obtaining the consent of the person before any care or treatment took place. People we spoke with confirmed that staff communicated well with them and asked for their permission before they offered any assistance. One person commented “they do what I want them to do.” People told us they had good access to health care professionals such as doctors, dentists and chiropodists. One person commented “he’s a very good doctor.” People told us they were satisfied with the support they received to take their medication.

Effective recruitment and selection processes were in place and appropriate checks were undertaken before staff began work.

People who use the service confirmed that the management and staff often asked them for their views about the quality of care they received and if there were any suggestions for improvements. One person told us “it’s a very well-run and organised place.”

People told us that staff were kind and respected their privacy. They confirmed that staff treated them with respect and dignity. One person commented, “the staff are very caring and supportive.”

People were able to express their views and were involved in making decisions about their care and treatment. People told us that they were offered choices in relation to how they wanted to be supported. The manager sent out quality questionnaires throughout the year, covering a range of issues such as food, staffing and activities. These were then discussed in regular meetings with people using the service.

We saw that people’s spiritual, cultural and religious needs were being assessed and there were daily religious services held at the home. People told us that it was important for them that the home had a strong Catholic ethos. One person commented, “I go to Mass every day.”

People told us they had good access to health care professionals and that they were satisfied with the support they received to take their medication.

People told us that they had no concerns or complaints about their care but would speak with their relatives, the manager or the care worker if they needed to. One person told us, “I wouldn’t be afraid to say if there was anything wrong.”

Staff told us they felt supported by the management and that there were good training opportunities available within the organisation.

The unannounced comprehensive inspection took place on 16 and 19 November 2015.

Nazareth House is a residential home that provides accommodation and nursing with personal care for up to 84 older people with physical ill health or learning disabilities. The service is run by a charitable trust connected to the Catholic Church. Divided into units the service is on a lower and upper ground floor. There are communal lounge areas, an activities room and a chapel for daily mass. At the time of our inspection 53 people lived there.

There is a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Extensive refurbishment was taking place to upgrade the accommodation and communal areas. Although there was unavoidable noise at times the registered manager had worked closely with the contractors to ensure there was minimal disruption to people.

The service was well-led with an approachable and committed registered manager. We found improvements in the delivery of the service since the last inspection in the administration of medicines, staffing levels and activities. Staff demonstrated an understanding of safeguarding adults from abuse.

We found improvements with supporting people to access appropriate medical care and treatment. Changes to the environment had facilitated a designated clinical room and centrally placed staff stations. Liaison had taken place to improve key working relationships with medical services. However the routine training of staff in some topics was not taking place. The care staff and supporting staff team were praised by people and their relatives as caring and respectful to people, and received monthly training in the core values.

There was a wide range of varied and interesting activities available to people. We found some people were involved in their care planning but care plans did not address all people’s support needs.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 Regulation 9 Person-centred care and Regulation 18 Staffing.

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