The inspection took place on 07 and 10 January 2019 and was unannounced.

Nazareth House – Plymouth 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.

CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. The service provides care and accommodation for up to 46 people. On the days of the inspection 43 people were staying at the service. Some people were living with dementia and some people had both physical and mental health needs.

The service is owned and operated by Nazareth Care Charitable Trust. They also own 19 other care homes across England, providing residential and nursing care to older people.

The service had 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.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service remained good, with the caring key question improving to outstanding.

Why the service is rated good.

The care home, and people who lived in it, formed part of the community. People lived in a service which had been adapted to meet their individual needs. People’s health and social care was co-ordinated with external professionals to help ensure they got the support they needed.

People lived in a service that truly respected and valued people as individuals, and they were empowered in their care.

People were cared and supported in a service which had a strong, visible and person-centred culture. People’s privacy and dignity was at the heart of the service’s culture and values.

People were empowered to be in charge of their own care and had their views listened to and respected. People’s religious needs were known.

Staff, were incredibly respectful of everyone’s individual beliefs, as well as those living at the service. People were supported at the end of their life with compassion. There were good links with the local GP practices and the local palliative care team.

People were protected from abuse, because staff received safeguarding training and knew what action to take if they suspected someone was being abused, mistreated or neglected.

People told us they felt safe living at the service. People did not face discrimination or harassment and their individual equality and diversity was respected.

People were supported to stay safe whilst still respecting their freedom. People lived in a building that was assessed for safety. Overall, people who had risks associated with their care had them assessed and managed to help ensure that they were supported safely. But whilst documentation was not in place, risks to people were low because knew how to support people safely, and those living with diabetes were managing their own health, because they had the mental capacity to do so.

People received their medicines safely and people were encouraged to manage their own medicines where possible.

People were supported by sufficient numbers of staff. However, whilst staff were recruited safely, gaps in people’s employment history had not always been fully sc

This unannounced comprehensive inspection took place on 2 August 2016. The last inspection of Nazareth House took place on 8 May 2014. The service was meeting the requirements of the regulations at that time.

Nazareth House is a care home which offers nursing care and support for up to 44 predominantly older people. At the time of the inspection there were 42 people living at the service. Some of these people were living with dementia. The service occupies a detatched building over three floors.

The service had 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.

We looked at how medicines were managed and administered. We found it was mostly possible to establish if people had received their medicine as prescribed. There were some gaps in the medicine administration records (MAR) and records were not always completed when prescribed creams were applied by staff. People told us they did receive their prescribed medicines appropriately. Regular medicines audits were consistently identifying when errors occurred. The audit outcomes were raised at staff meetings and at supervision with individual staff. However, this had not been entirely effective in addressing this concern. The registered manager assured us that this issue would be closely monitored over the coming weeks and the individual staff who were not always completing medicine records would be identified and supported to improve.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness, compassion and respect. There were no malodours experienced throughout the service at the time of this inspection.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. People and staff told us they felt there were enough staff to meet their needs. Consent was sought from each person before care was provided. People who were not able to consent had their rights protected, by staff who were knowledgeable about their responsibilities as laid down in the Mental Capacity Act 2005 legislation.

Staff were supported by a system of induction training, supervision and appraisals. Staff knew how to recognise and report the signs of abuse. Staff received training relevant for their role and there were good opportunities for on-going training and support and development. More specialised training specific to the needs of people using the service was being provided. For example, care of people living with dementia. Staff meetings were held regularly. These allowed staff and management to communicate information and air any concerns or suggestions they had regarding the running of the service.

People’s views on the food provided at the service were varied. People were offered a choice in line with their dietary requirements and preferences. However, some people we spoke with had raised issues about the food with the kitchen staff. We saw these had been listened to and changes had been made. Where necessary staff monitored what people ate to help ensure they stayed healthy.

Care plans were held electronically. However, the service also held a paper copy for people and their families, if appropriate, to review and sign in agreement with the contents. The care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs recorded.

Activities were provided by an activity co ordinator who worked at the service Monday to Friday. The care staff were supported to provide relevant activities for people at the weekends. People who wished to take part told us they enjoyed

Our inspection team was made up of a single inspector. We considered all the evidence we had gathered under the outcomes we had inspected. We used the information to answer the five questions we always ask: 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. The summary is based on our observations during the inspection, speaking to people using the service, staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with dignity and respect by the staff. People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure that the managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. The home had proper policies and procedures in relation to the Mental Capacity Act, Deprivation of Liberty and Safeguards applications had been submitted in a timely fashion proving that the manager was protecting the service. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people were safeguarded as required.

The deputy Manager set the staff rotas, they took people’s care needs into account when making decisions about numbers, qualifications, skills and experience required. This helped to ensure that people’s care needs were always met.

Recruitment practice was safe and thorough. A staff member was currently suspended and subject to a disciplinary action. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

People's healthcare needs were assessed with them and they were involved in writing their care plans. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said they had been involved in writing them and they reflected their current needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. People commented, “The staff couldn’t be better, they are so patient and caring. Nothing is too much trouble for them”.

People using the service, their relatives, friends and other professionals involved with the service completed annual satisfaction surveys. Where shortfalls or concerns were raised these had been addressed.

People’s preferences, interests, aspirations and diverse needs had been recorded and care support had been provided in accordance with people's wishes.

Is the service responsive?

People regularly completed a range of daily activities within the home which they helped to organise and arrange through committee meetings. One service user liked to be responsible for organising the clubs and entertainment. Everyone within the home was able to choose their level of involvement.

People knew how to make a complaint if they were unhappy. No one we spoke to felt the need to make a complaint as they were very happy with the service they received. We looked at how complaints had been dealt with and found that the responses had been open, thorough and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service worked well with other agencies and services to make sure that people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls had been addressed promptly. As a result the quality of the service was continually improving.

Staff told us they were clear about their roles and responsibilities.

On the day of our visit we were told that there were 38 people living at Nazareth House. We spoke to six staff members, which included the registered manager, spent time observing the care people were receiving, talked to six people living in the home, three relatives and looked at four people’s care files in detail.

We observed staff supporting people in a friendly and respectful manner. One person told us "They are very good when they help you with things like that.” “

We saw that anyone who moved into the home had their needs assessed before a place was offered. We looked at four care plans and found that they were detailed and personal to the individual to ensure their needs were met.

We spent time observing the people who lived at Nazareth House, we saw that they were relaxed and able to make their own choices. We saw two people sat in the lounge talking and two people enjoying recreational activities during the morning, for example we saw people enjoying the completion of a crossword. One person told us “they let you do what you like.”

The people living at Nazareth House were supported by staff members that were trained and supported, by the organisation. Staff were able to speak confidently about the care practices they delivered.

Staff monitored the service on a regular basis and involved people that lived at Nazareth House in this process.