We carried out this inspection on 02 and 04 July 2018. The inspection was unannounced on the first day, which meant the people living at Nazareth House Lancaster, their relatives and staff working there didn’t know we were visiting.

Nazareth House Lancaster 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 accommodate 43 people in need of personal care. Accommodation is provided over four floors with 43 single rooms, all with en-suite facilities.

Established in 1899 by the Sisters of Nazareth, the home is set in landscaped gardens, which

includes a wildlife pond. There is also a greenhouse for people who like gardening and a sensory

garden area for people to relax in. On the days of the inspection there were forty people living at

the home.

There was a registered manager in place. 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 last comprehensive inspection of the service took place in June 2017. At this time, we found the service was not meeting all the fundamental standards. The registered provider failed to ensure sufficient numbers of suitably experienced persons were deployed to meet the needs of people who lived at the home. This was a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014, and enforcement action was taken.

We also found people were not consistently treated with dignity and respect. This was a breach of Regulation 10 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered provider had failed to ensure the proper and safe management of medicines. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

At the last inspection, we found the registered provider failed to ensure systems or processes were established and operated effectively to ensure compliance. They failed to maintain accurate records in respect of each person, including a record of the care and treatment and decisions taken in relation to the care and treatment provided. These were breaches of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

After the last inspection on 22 and 28 June 2017, we asked the provider to act to make improvements and this action has been completed.

At this inspection, we looked at staffing levels at Nazareth House Lancaster. Staff were effectively trained and able to deliver care in a compassionate and patient manner. However, we have made a recommendation the registered provider review staffing levels at busy times.

Care plans we looked at highlighted risk, however, not all care plans we looked at detailed how to minimise the risk. We have made a recommendation about this.

The service had systems to record safeguarding concerns, accidents and incidents and acted as required. The service carefully monitored and analysed such events to learn from them and improve the service. Staff had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices. The registered provider had reported incidents to the commission when required.

Staff we spoke with confirmed they did not commence in post until the registered manager completed relevant checks. We checked staff records and noted employees received induction and ongoing training appropriate to their roles.

We looked around the building and found it had been refurbished, maintained, was clean and a safe place for people to live. We

This unannounced inspection took place on 22 and 28 June 2017.

Nazareth House is registered to accommodate 43 people in need of nursing and personal care. Accommodation is provided over three floors with 43 single rooms, all with en-suite facilities. Established in 1899 by the Sisters of Nazareth, the home is set in landscaped gardens, which includes a wildlife pond. There is also a greenhouse for people who like gardening and a sensory garden area for people to relax in. On the days of the inspection there were forty people residing at the home.

There was a registered manager in place. 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 last comprehensive inspection of the service took place on 04 June 2016. At this inspection we found the service was not meeting all the fundamental standards. The registered provider did not consistently treat people with dignity and respect and people’s nutritional needs were not always suitably managed. We carried out a focussed inspection on 08 December 2016 to check if the required changes had been made and found suitable improvements had been made.

At this comprehensive inspection visit carried out on 22 and 28 June 2107, we found breaches relating to staffing, dignity and respect, safe care and treatment and good governance.

The service was not meeting all the fundamental standards. People who lived at the home and relatives told us they did not think staffing levels were adequate to meet people's needs. From our observations we found this was the case and staff were not always suitably deployed. Deployment of staffing in communal areas was inconsistent and people were left unsupported despite us being there was a staff member in communal areas at all times. Similarly, at meal times deployment of staffing was poor. This resulted in people having to wait and not always receiving the meal of their choice. We found errors in paperwork. Staff told us they had not been able to fulfil all their duties due to the workload pressures. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) 2013 as the registered provider had failed to ensure suitable numbers of staff were deployed to meet the needs of people who lived at the home.

People were not always treated with dignity and respect. We observed one person trying to leave a communal lounge in their wheelchair. Staff intercepted the person and brought them back into the lounge. They did not speak with the person to find out their wishes and left them in the lounge without any stimulation. This was a breach of Regulation 10 of the Health and Social Care Act 2008, (Regulated Activities) 2014 as the registered provider failed to ensure people were consistently treated with dignity and respect.

Arrangements were in place for managing and administering medicines. Medicines were secured in line with current guidance. Regular audits of medicines took place. However we observed that good practice guidelines were not consistently followed. This was a breach of Regulation 12 of the Health and Social Care Act 2008, (Regulated Activities) 2014 as the registered provider failed to ensure suitable systems were in place for the administration of medicines.

People who lived at the home were consulted with on a regular basis. However we found evidence to suggest people’s views were not always listened to and acted upon. We have made a recommendation on effective communication and consultation.

People who lived at the home told us that person centred care was not always provided. We looked at care records to establish if this was the case but were unable to make any judgement as care records were not fully completed and accu

We carried out an unannounced comprehensive inspection of this service on 04 May 2016, at which two breaches of legal requirements were found. This was because the provider had failed to ensure staff were treated people with dignity and communication was respectful. They failed to ensure food was maintained at the right temperature for the whole mealtime.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We carried out this unannounced focused inspection on 08 December 2016 to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Nazareth House on our website at www.cqc.org.uk'.

Nazareth House is registered to accommodate 41 people who require nursing and personal care. Accommodation is provided over four floors with one double room and 39 single rooms, all with en-suite facilities. Established in 1899 by the Sisters of Nazareth, the home is set in landscaped gardens, which include a wildlife pond. There is also a greenhouse for people who like gardening and a sensory garden area where people can relax. Amenities are within easy reach, such as shops, pubs, library, cafes, museums, leisure facilities and public transport links. At the time of our focused inspection, 38 people lived at Nazareth House.

The service had a registered manager in place. 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 home had a Sister Superior, who is in charge of delivering spiritual support to people who live at Nazareth House. However, the home accepts people from all religious backgrounds. The home holds a daily Catholic Mass and other services are held by visiting clergy. There are several nuns who live at Nazareth House who provide social care and spiritual guidance.

At our focused inspection on the 08 December 2016, we found improvements had been made. We observed people being supported and treated with dignity and respect. Staff had received training that had helped them reflect on how they engaged with people.

We observed lunchtime at Nazareth House. We noted staff provided effective support to people. There was a variety of food available, which was checked and served at the appropriate temperature.

We could not improve the rating for effective and caring from requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

The inspection visit at Nazareth House took place on 04 May 2016 and was unannounced.

Nazareth House is registered to accommodate 41 people who require nursing and personal care. Accommodation is provided over four floors with one double room and 39 single rooms, all with en-suite facilities. Established in 1899 by the Sisters of Nazareth, the home is set in landscaped gardens, which include a wildlife pond. There is also a greenhouse for people who like gardening and a sensory garden area for people to relax in. Amenities are within easy reach, such as shops, pubs, library, cafes, museums, leisure facilities and public transport links.

The service had a registered manager in place. 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 home had a Sister Superior, who is in charge of delivering spiritual support to people who live at Nazareth House. However the home accepts people from all religious backgrounds. The home holds a daily Catholic Mass and other services are held by visiting clergy. There are several nuns who live at Nazareth House who provide social care and spiritual guidance.

At the last inspection on 23 September 2014, we found the provider was meeting the requirements of the regulations that were inspected.

During this inspection, we observed people being supported with their lunch. People did not always receive the appropriate support at mealtimes.

This was a breach of Regulation 14 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Meeting nutritional and hydration needs.) You can see what action we told the provider to take at the back of the full version of the report.

During our lunchtime observation staff did not always treat people in a caring way that ensured their dignity and respect was maintained.

This was a breach of Regulation 10 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Dignity and respect.) You can see what action we told the provider to take at the back of the full version of the report.

We found there were concerns regarding staffing levels to meet the needs of people who used the service.This was in relation to people being supported on the residential side of the home.

We have made a recommendation that the provider reviews staffing levels at the home.

We saw staff had received training in abuse and understood their responsibilities to report any unsafe care or abusive practices. Staff we spoke with told us they were aware of the safeguarding procedures. One person told us, “ I feel happier here because I’m never on my own at night. I'm safe.”

The provider had recruitment and selection procedures to minimise the risk of inappropriate employees working with vulnerable people. Checks had been completed prior to any staff commencing work at the service. This was confirmed from discussions with staff.

Staff received training related to their role and were knowledgeable about their responsibilities. They had the skills, knowledge and experience required to support people with their care and support needs.

Staff responsible for assisting people with their medicines were trained to ensure they were competent and had the skills required. Medicines were safely kept and appropriate arrangements for storing medicines were in place.

People and their representatives told us they were involved in their care and had discussed and consented to their care. We found staff had an understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Comments we received demonstrated people were satisfied with the care they were given. The registered manager and staff were clear about their roles and responsibilities

This inspection was undertaken to review improvements made by the registered provider following the previous inspection undertaken on 17th June 2014. Areas of non-compliance found at the last inspection included issues relating to information in care plan records. We found the information recorded was not always accurate and up to date to reflect people`s assessed needs. Also of concern was the management of medication.

We asked the registered provider to provide us with an action plan demonstrating what they were doing to address the issues of non-compliance. We received their action plan in June 2014. This detailed the procedures put in place to address the shortfalls. We used this inspection to see what actions had been taken to address the areas of non-compliance.

Is the service safe?

At this inspection we found the service had made improvements in their care planning processes. We found that the service was safe because people were protected against the risks associated with use and management of medicines. People received their medicines at the times they needed them and in a safe way. Medicines were administered and recorded appropriately, and were kept safely.

Is the service effective?

We found that care plans for managing medicines were much improved and staff had guidance available to them to make sure that people received appropriate care.

Is the service well led?

We saw that audits, or checks of medicines, were done to assess the way medicines were managed. Care plans were being reviewed by a specialist clinician and staff were receiving training in care planning and record keeping.

At our inspection of this service on 13th March 2014 we found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage them safely. This was a follow up inspection to check the provider`s progress towards meeting their safe management of medicines. We also combined their annual scheduled inspection at the same time. We looked at care plan records, safeguarding measures to protect people from harm or abuse, safe recruitment of new staff and quality audit systems.

This helped to answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found.

Is the service safe?

We saw that staff had attended safeguarding training. Safeguarding was discussed at staff meetings. All newly appointed staff received safeguarding training as part of their induction training. A copy of the local safeguarding policy and procedure was available for staff for guidance and information. There were financial systems in place to protect people from risks of financial abuse.

Is the service effective?

We spoke with several people who lived at the home and their relatives. Relatives told us they valued being involved in care plan reviews and felt that they were listened to. If they felt improvements or changes could be made with the care and support, they saw that action was taken. The relatives we spoke with also said that they had good communication with the staff team and were always informed of any changes or concerns. This helped to reassure them regarding their family`s welfare

Is the service caring?

We spent time with people in the communal areas of the home. This helped us to observe the daily routines and gain an insight into how people`s care and support was being managed. We observed staff to be caring and responsive to people who required support.

Is the service responsive?

The service worked well with a range of health professionals to make sure that people received their care in a joined up way. We spoke with several visiting professional(s) to the home. They told us they felt the home was responsive to people`s health care needs. When they spent time in the home they observed people to be well cared for. They told us staff took action when advice was given and specialised equipment was provided.

Is the service well led?

Since the last inspection a new manager was in post and she had submitted her Registered Mangers application to the Commission. During her time in post she told us she had developed a new management team and they were working to support their staff team to develop their skills and knowledge. A range of routine audits were in place including care plan records, medication, financial records and staffing levels within the home. People using the service and their relatives had been given opportunity to complete a satisfaction survey. Regular staff and resident meetings took place.

We spoke with five people about their medicines. They told us that they were very well cared for and they had no complaints. They told us:

“I get it [their painkiller] when I need it, I get it pretty regularly”.

“I am well cared for. I get my eye drops and tablets every morning and every night”

“The place is lovely and the carers are very good. I have a special carer who knows all about me. I sometimes get aches in the night and I ring my bell and the girls come quickly to give me painkillers”.

“I have problems with my eyes and get drops every night. The carers do it for me”.

“I get my painkillers twice a day and my blood pressure tablets in the morning. The girls give them to me in a little pot and stand with me while I take them”.

“I have cream on my feet every morning before they put my socks on. They rub it in nice and softly”.

Whilst people who we spoke with were happy with the way their medicines were managed, we saw that medicines were not always handled safely. Overall, we found that the handling of medicines had improved since our last inspection. However, further improvements in medicines handling was needed in order to fully protect the people who use the service.

We spoke with two people about their medicines. They told us:

“I get my tablets regularly”.

“I have no pain. We have a good system. I have painkillers four times a day”.

“The nurses come no problem in the night for pain-killers”.

“I have my own eye drops. They change them every 28 days”.

“My legs are dry. I am supposed to have my cream twice a day but I only get it

as and when. Sometimes I don’t get it at all”.

Overall, we found that medicines were not managed in a safe way. Whilst people who we spoke with were mostly happy with the way their medicines were managed, we saw that medicines were not handled properly. In particular we saw records and care plans relating to medication that were poor. This meant that the care that was provided was not always safe or appropriate.

We looked at five care plan records to see how the home was planning the care and support they provided to meet people`s assessed needs. We saw that pre assessments were undertaken prior to people moving into the home. The care plans were detailed and contained information that reflected people`s individual needs, preferences and choices.

We observed the care and support at lunchtime. The dining room was set out to a high standard with crockery and condiments on the tables available. People were supported to eat a healthy and nutritious diet.

We looked at the staffing rotas over a four week period to see if there were sufficient staff on duty to meet the needs of people who lived at the home. We saw there was a skill mix of qualified nurses, experienced and newer members of the staff team on the duty rota.

The home had a range of audits and systems in place to monitor the quality of the service being provided. We saw that people were encouraged to give their feedback regarding living at the home in a variety of ways. People we spoke with told us they felt they could raise any concerns they had.

We spoke with several people who lived at the home and members of the staff team. We spent time with people over lunch and in the lounge. We saw people were treated with respect and dignity. We observed people were well cared for in a patient and sensitive manner. People we spoke with said they felt safe and secure. They were happy with their care and staff were responsive to their needs. Comments we received were,” They are lovely, they are absolutely wonderful”.

“I go out to the hairdressers and the Deepdale centre and have lots of visitors”.

“We checked out a few homes and this was the best. I like it here, it is very quiet”.