Nazareth House - Cheltenham

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people. The service provides support to people aged 65 and over. At the time of our inspection there were 48 people using the service.

People’s experience of using this service and what we found

People’s care records were current and reflective of their needs. They were working towards ensuring all care plans contained the same level of detail and personalisation.

People’s communication needs had been identified, assessed and recorded in care plans. Where required, communication aides and provision were sought to support people to communicate their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager was working towards further consistency for people by increasing permanent staff and reducing reliance upon agency staff. The improvements already made in staffing had positively impacted upon personalised care for people.

The registered manager was committed to ensuring improvements underway at the service were completed. Increased oversight and leadership, investment in staff and the recruitment of more permanent staff were all having a positive impact on the service's culture.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 June 2022)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 12 and 13 May 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Responsive and Well-led which contain those requirements.

For those key questions not inspected or inspected but not rated, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nazareth House - Cheltenham on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people aged 65 and over. At the time of our inspection there were 51 people using the service.

People’s experience of using this service and what we found

The registered manager was committed to providing care that met people's needs. However, our observations and the feedback we received, meant we could not be assured everyone in the home experienced person-centred care where choices and preferences were respected.

The provider had systems in place to monitor quality and risk in the service. However, these systems had not been effective in identifying the shortfalls we found on inspection. We found staff had not always followed the provider’s systems, including policies and procedures.

People were protected from the risk of abuse as staff were aware of their safeguarding responsibilities and how to report any concerns. Staff were recruited safely and received an induction and training to ensure they could meet people's requirements.

People's medicines were managed safely and systems were in place to ensure that people received bespoke medication in accordance with their needs and preferences.

We were somewhat assured the service was following all safe and correct infection control processes. We have signposted the provider to resources to develop their approach and the registered manager took immediate action.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 28 May 2021).

Why we inspected

We received concerns in relation to person centred care, assessing risk, safety monitoring and management. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nazareth House – Cheltenham on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, person centred care and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people aged 65 and over. There were 50 people living at the home at the time of our inspection.

People’s experience of using this service and what we found

We found the registered manager and provider had made improvements to the service. One professional told us, “The service provided at Nazareth House - Cheltenham has improved significantly since the new manager has arrived.”

The service was well-led by a management team who were passionate about improving care and achieving the best possible outcomes for people at Nazareth House – Cheltenham. Quality assurances systems were effective in monitoring the safety and quality of the home through audits and checks. People, relatives, staff and professionals spoke positively about the leadership of the service. One professional told us, “I have had frequent conversations with the registered manager in the last few months, she has been very supportive of my work and [peoples] needs.”

At the time of our inspection the service had a number of staffing vacancies and relied on agency staff. People told us that it meant they did not always receive care that reflected their preferences as staff did not always know them. The registered manager had already identified staffing as a high priority in the service development plan. They had recently completed a staff rota consultation to engage staff and were taking steps to promote person centred care whilst developing a more consistent staff team. Time was needed for these planned improvements to be completed so that people could be confident that their wishes and preferences would always be met.

People were supported by staff who received regular training and supervisions. The registered manager had a good understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. People had access to a balanced diet and were supported to eat and drink in a safe way. Referrals to health professionals were made when required. The environment was appropriately designed and adapted to meet people's needs.

The provider had infection control processes in place to protect people and prevent the spread of infection. There was plenty of personal protective equipment (PPE) for staff to use. Staff accessed PPE, and staff followed the providers guidance and expectations.

Rating at last inspection and update

The last rating for this service was requires improvement 2nd September 2020 and there were two continued breaches of regulation. We required the provider to submit monthly reports to CQC to show improvements were being made. The provider submitted these reports as required.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This focused inspection was carried out to follow up on action we told the provider to take at the last inspection.

We carried out an announced comprehensive inspection of this service on 28th July 2020. Breaches of legal requirements remained in place from 9 January 2020 to monitor their improvement in relation to Regulation 17 (Good Governance) and Regulation 9 (Person Centred Care).

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Effective, Responsive, and Well-led which contain those requirements.

We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nazareth House - Cheltenham on our website at www.cqc.org.uk.

Follow up

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

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people aged 65 and over. There were 46 people living there at the time of our inspection.

People’s experience of using this service and what we found

The provider and registered manager had made improvements to the service. This had included improvements to how people’s prescribed medicines were managed. Staff had received training and support to administer and manage people’s prescribed medicines and told us they felt comfortable with managing this. Management systems had enabled the service to identify any concerns and take remedial action. The provider was arranging a meeting with their supplying pharmacist with an aim to improve how people’s medicines are managed.

The provider and the manager had taken steps to develop good governance systems to monitor the quality of care people received. Further improvements had been planned to start shortly after this inspection. The service had implemented a service improvement plan however representatives of the provider spoke openly about the impact Covid-19 had on the development of these systems. Further improvements were required to ensure that quality assurance systems were effective at driving improvements.

People and their representatives told us they felt the home was safe and discussed improvements they had identified. Some relatives and healthcare professionals felt that communication needed to improve within the home. People's views were being sought about the quality of the service they received and systems being developed by the provider were aimed at driving improvements.

The provider had infection control processes in place to protect people and prevent the spread of infection. There was plenty of personal protective equipment (PPE) for staff to use. Staff accessed PPE, and most staff followed the providers guidance and expectations.

The provider ensured staff were of good character to work in the service. Where concerns had been identified with staff conduct, they took appropriate action. Staff received training, however the provider expressed that training plans had been impacted by the Covid-19 pandemic and plans were in place to address this.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 20 September 2019).

Following our last inspection, we served a warning notice on the provider. We required them to be compliant with Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 30 September 2019. The service is now meeting the requirements of this regulation.

We also imposed conditions on the provider from 9 January 2020 in relation to Regulation 17 (Good Governance) and Regulation 9 (Person Centred Care). These conditions still remain in place at this time.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met the legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for (service name) on our website at www.cqc.org.uk.

Follow up

Following this inspection we will arrange a meeting with a representative of the provider and the registered manager as part of our regulatory duties. We plan to arrange a meeting with relevant stakeholders and the provider to discuss the service with an aim to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people aged 65 and over. There were 40 people living there at the time of our inspection.

People’s experience of using this service and what we found

The provider had made some improvements to the service. However, not all the requirements of the warning notice had been met. The provider and the manager had taken steps to ensure people’s medicines were available as needed, and had implemented a system to manage the stock of people’s prescribed medicines. A daily auditing system was in place to address any errors and ensure people’s health was not impacted by these mistakes.

However, the requirements of the warning notice in relation to the safe management of people’s medicines had not been fully met. People were still not receiving their medicines as prescribed as care staff had not always administered people’s prescribed medicines.

Where changes to people’s prescribed medicines had been made by their GP or relevant healthcare professional, care staff had now ensured this was documented and shared, which reduced the risk of people not receiving their medicines as prescribed.

Staff responsible for administering people’s prescribed medicines had received training and competency assessments. The manager had arranged for further training and had taken action to address any staff medicine administration errors.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 20 September 2019).

Following our last inspection, we served a warning notice on the provider. We required them to be compliant with Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 30 September 2019.

Why we inspected

This was a targeted inspection based on the warning notice we served on the provider following our last inspection. CQC are conducting trials of targeted inspections to measure their effectiveness in services where we served a warning notice.

We undertook this targeted inspection to check if they now met legal requirements. This report only covers our findings in relation to the safe care and treatment of people, including people’s prescribed medicines. The overall rating for the service has not changed following this targeted inspection and remains requires improvement. This is because we have not assessed all areas of the key questions.

Follow up

Following this inspection we had a discussion with a representative of the provider to discuss their continued action. We will work with the local authority and local clinical commissioning group to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Nazareth House - Cheltenham is a residential home which provides personal care to 63 older people and people living with dementia. The home consists of a home contains, a range of communal areas, including lounges, dining rooms and a café and reception area. At the time of our inspection 40 people were living in Nazareth House - Cheltenham.

People’s experience of using this service and what we found

Since our last inspection the management of the service had changed. The interim manager, head of care and provider had identified a number of the concerns we had found prior to our inspection. However, actions at the time of our inspection were still ongoing and had not been fully implemented and evaluated to ensure people would always receive safe and effective personalised care. We continued to identified breaches of regulations at this inspection. The provider had not demonstrated that they were able to consistently meet the requirements of their registration and operate effective systems to ensure that Nazareth House – Cheltenham met the requirements of the Health and Social Care Regulations. Therefore, we have rated the key question ‘Is the service Well-led?’ as ‘Inadequate’.

People and their relatives told us their views had not always been sought and listened to. They told us that due to the changes in the management of the home they were not confident the service was managed well. Healthcare professionals, senior care staff and agency staff told us that communication was not always effective, which impacted on people’s wellbeing when requests had not been acted upon.

People did not always receive care which was personalised to their needs. People told us they did not always receive care which made them comfortable or maintained their wellbeing. Staff told us they did not have the time to spend with people and promote their wellbeing. Staff did not always take opportunities to engage with people and ensure care was tailored to their needs.

People did not always receive their medicines as prescribed. Senior care staff did not always follow recognised good practice to ensure people received their medicines as prescribed. Staff did not have effective systems to ensure people’s prescribed medicines were in stock and effectively replenished. People could not be assured that they would be safe if an emergency evacuation was required. Fire evacuation practices had not taken place regularly and people’s personal evacuation plans were out of date.

People were not always protected from the risks associated with their care as staff did not always follow their assessed plan of care.

There were enough staff deployed to keep people safe. People, their relatives and staff told us that staffing was an issue and impacted the quality of care people received. The provider was heavily reliant on agency care staff to ensure safe staffing levels. People told us how this impacted on the care they received.

Care staff followed recognised infection control procedures. We observed, and people and their relatives told us that the home had not always been cleaned. The interim manager was aware of these concerns and was taking actions to improve this. People were protected from the risk of malnutrition or choking. The interim manager was taking action to improve the quality and variety of food people received.

Care staff required further support to enable them to meet people’s day to day needs. Not all staff had received effective supervision and staff told us they would benefit from more training in relation to dementia care. People spoke positively about the caring nature of permanent staff.

People told us they generally enjoyed their time at Nazareth House – Cheltenham. A new activity co-ordinator had started to work at the home, and previously the Sisters of Nazareth had provided a range of activities whilst the service were recruiting. People were supported to maintain their personal relationships. However, there was limited record of the activities people enjoyed, particularly those who were cared for or chose to remain in their own rooms.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 4 April 2019) and we identified two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, we found that improvements had not been sustained and the provider was still in breach of these regulations as well as other regulations. We have used the previous ratings of the service and enforcement action taken to inform our planning and decisions about the rating at this inspection. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the service from healthcare professionals and people’s relatives. These concerns related to the quality of care people received, staffing skills and communication from staff at the service. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the ‘Is the service Safe?’; ‘Is the service Effective?’; ‘Is the service Responsive?’ and ‘Is the service Well-led?’ key question sections of this full report.

Enforcement

We have identified breaches in relation to the safe care and treatment people received, including the administration of people’s prescribed medicines at this inspection. We identified that people did not receive care and support which was tailored to their individual needs. Staff did not have access to effective supervision and did not have the training or skills they required to meet the needs of people living with dementia. The service did not have effective systems to monitor the quality of the service people received.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will meet with and work alongside the provider to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Nazareth House – Cheltenham is a residential care home providing accommodation and personal care for up to 63 people aged 65 and over. There were 40 people living there at the time of our inspection.

People’s experience of using this service and what we found

The provider had made some improvements to the service. However, not all the requirements of the warning notice had been met. The provider and the manager had taken steps to ensure people’s risks were assessed. Care staff followed guidance to ensure people were protected from these risks.

However, the requirements of the warning notice in relation to the safe management of people’s medicines had not been met. People were still not receiving their medicines as prescribed as care staff had not always administered people’s prescribed medicines. Staff did not always accurately check the stock of people’s medicines to ensure people’s medicines would be available when needed.

Where changes to people’s prescribed medicines had been made by their GP or relevant healthcare professional, care staff had not always ensured this was documented and shared, meaning people were placed at risk of not receiving their medicines as prescribed.

Staff responsible for administering people’s prescribed medicines had received training and competency assessments.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 20 September 2019).

Following our last inspection, we served a warning notice on the provider. We required them to be compliant with Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 30 September 2019.

Why we inspected

This was a targeted inspection based on the warning notice we served on the provider following our last inspection. CQC are conducting trials of targeted inspections to measure their effectiveness in services where we served a warning notice.

We undertook this targeted inspection to check if they now met legal requirements. This report only covers our findings in relation to the safe care and treatment of people, including people’s prescribed medicines. The overall rating for the service has not changed following this targeted inspection and remains requires improvement. This is because we have not assessed all areas of the key questions.

Follow up

Following this inspection we met with the manager and a representative of the provider to discuss the inspection and understand the plans they had in place to improve the service and ensure legal requirements are met. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our previous comprehensive inspection in June 2018 we found the provider was not meeting five of the regulations. We found people’s risks had not always been assessed and they had not always received their medicines as prescribed. Additionally, staff did not have access to training and support. People did not receive person centred care and access to stimulation which would have benefitted their wellbeing. People’s dignity and privacy were not always respected. The provider did not have effective systems to monitor and improve the quality of service people received.

Following the June 2018 inspection, we met with the provider and the previous registered manager to discuss the actions they were planning to take to improve the service.

We completed a focused inspection in October 2018 to follow up on enforcement actions we issued against the provider following our June 2018 inspection. We found improvements had been made in relation to the concerns we identified at our June 2018 inspection. The management of people’s prescribed medicines and risks had improved, the governance systems were increasingly effective and staff had received some support and training. However, further improvements were required to the safe management of people’s medicines and the training and support staff received.

At this inspection in February 2019, we found continued improvements had been made to the safety of the service, staff training and support and the provider’s quality assurance systems. However, we identified concerns where staff had not followed the guidance and expectations of the manager and the provider when managing people’s medicines. This placed people at risk of not receiving their medicines as prescribed. The provider and manager were aware of these concerns and informed us of the immediate actions they planned to take.

A registered manager was not in place at the service. The provider had recruited a manager, who had previously been the registered manager of the service. The manager was in the process of registering with CQC. This manager was supported by representatives of the provider and a head of care. 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 provider and manager had systems in place to drive the quality of care people received. While these systems had led to improvements, they were not always consistently being monitored and implemented by senior care staff. Senior staff did not always complete and update records when people’s care was delivered, such as topical cream charts. Senior staff did not always provide all staff with a detailed shift handover. During and following our inspection the manager provided us with an action plan of how they were planning to address these concerns and ensure quality was maintained within the home.

People, their relatives and staff felt staffing had improved at Nazareth House - Cheltenham. There was a high level of agency staff usage to ensure people’s needs were met however the manager and provider ensured agency staff were block booked to maintain consistency. The provider was taking action to address staffing concerns through ongoing recruitment. Care and nursing staff felt they were supported by the manager and head of care. However, further improvements were required to ensure staff received effective supervision (one to one meetings with their manager) and training.

People were now receiving person centred care and meaningful engagement from care staff. Care staff were attentive to people’s needs and supported people’s wishes and preferences.

People were cared for in a clean, safe and well-maintained home. The provider and manager carried out effective checks to ensure the service remained safe and met people’s needs. Significant refurbishment work was being carried out at the home. Care staff followed recognised infection control procedures.

People were protected from the risks associated with their care. Care staff knew how to assist people with their needs and ensure their health was maintained. Staff understood their responsibilities to protect people from harm and to report any safeguarding concerns. Staff provided people with choice and worked to protect and maintain their legal rights.

People had access to a variety of food and drink. Care staff treated people with dignity and ensured they had any nutritional support required. Catering and care staff were aware of and met people’s individual dietary needs.

People’s relatives felt their concerns and views were being listened to and acted upon and spoke positively about the approachability of the new manager and head of care.

The provider had systems in place to drive the quality of care people received. There was an action plan in place to drive these improvements. Time and consistency was required to ensure the provider’s action plan was completed, evaluated and improvements were effectively sustained and embedded.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have not escalated our action as we had identified improvements at this inspection following our inspections in June 2018 and October 2018. You can see some of the action we told the provider to take at the back of the full version of this report.

At the time of our inspection, 46 people were living at Nazareth House - Cheltenham. Nazareth House - Cheltenham is based in Charlton Kings in Cheltenham. Nazareth House is a large building based on three floors. The home is attached to a chapel and accommodation used by the Sisters of Nazareth. The home has large grounds which people could enjoy, included a wooded pathway and extensive patio. Many of the people living at Nazareth House, chose the home to enable them to continue meeting their religious needs.

We last inspected in June 2018, following concerns about the service raised by healthcare professionals. At the inspection in June 2018 we found the provider was not meeting a number of the regulations. We found people did not consistently receive safe care and treatment, because staff had not always assessed their risks and people had not always received their medicines as prescribed. Additionally, staff did not have access to training and support. People did not have access to person centred care and stimulation which would benefit their wellbeing. Care staff did not always ensure people’s dignity and privacy were respected. The provider did not have effective systems to monitor and improve the quality of service people received.

Following our inspection in June 2018, we issued the provider with three warning notices in relation to safe care and treatment, staff training and support and their good governance systems. We also met with the provider and asked them to provide us with weekly action plans regarding how they planned to improve the service people received. We rated the service as “Requires Improvement” and ‘Is the service well led?’ as “Inadequate.” At this inspection on 30 and 31 October 2018 we found significant improvements had been made, however further work was still required to ensure the service was safe, effective and well led. Following this inspection, we rated the service as “Requires Improvement” in all areas.

At our inspection on 30 and 31 October 2018 there wasn’t a registered manager in place. The previous registered manager left the service shortly after our June 2018 inspection. The provider had an interim manager in place and they had also recruited a permanent manager who intended to register with CQC. The new manager was due to start work at Nazareth House – Cheltenham on 5 November 2018. This manager had previously managed the service. 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 provider had implemented systems to monitor and improve the quality of service people received. We found these systems had been effective in identifying shortfalls in the service and driving improvement. Staffing numbers had improved and risks to people’s health and wellbeing had been assessed and were understood by staff. Although some improvements were being made in relation to medicine management and staff training and supervision, at the time of this inspection, the provider’s planned improvements were still to be completed before all the required regulation standards could be met.

People and staff spoke positively about the improvements made at Nazareth House - Cheltenham since our last inspection. Care staff felt they received more support and were hopeful for the future of the home and were improving the quality of care people received.

People were generally positive about the home. They felt safe and well looked after. People enjoyed the food they received, stating the quality had improved and they had access to food and drink when they wanted it.

People were receiving care and treatment which kept them safe and promoted their health and wellbeing. People’s care plans and risk assessments had been reviewed and were now reflective of their needs. Care assessments gave care staff clear information in relation to people’s needs. The provider and area operations manager had focused on ensuring people’s care plans were person centred and detailed, with further improvements planned.

Staff were deployed effectively to ensure people were kept safe and their basic needs were met. All staff were receiving training to meet people’s healthcare needs. However, while staff now felt supported, consistent arrangements around staff supervision and appraisals, training and professional development, were being implemented. Further time was required to ensure these systems were effective.

We found two repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As improvements have been made, we have not considered further enforcement action at this time. The provider will continue to keep us updated of progress made through their monthly action plan submissions. You can see what actions we told the provider to take at the back of the full version of this report.

At the time of our inspection, 55 people were living at Nazareth House - Cheltenham. Nazareth House - Cheltenham is based in Charlton Kings in Cheltenham. Nazareth House is a large building based on three floors. The home is attached to a chapel and accommodation used by the Sisters of Nazareth. The home has large grounds which people could enjoy, included a wooded pathway and extensive patio. Many of the people living at Nazareth House, chose the home to enable them to continue meeting their religious needs. This was an unannounced inspection.

We previously inspected the home on 17 August 2017 and rated the service as “Good”. At the inspection in August 2017 we rated the key question ‘Is the Service Responsive?’ as “Requires Improvement” as we found additional improvements were required to ensure people's care plans were person centred to their needs. At our June 2018 inspection we found improvements had not always been made and sustained. We found multiple concerns relating to; the quality of care people received.

This is the fifth inspection of Nazareth House - Cheltenham where the service has been rated. At four of these inspections the service had failed to meet all the requirements of the relevant regulations. The registered manager and provider had not demonstrated that they were able to consistently meet the requirements of their registration and operate effective systems to ensure that Nazareth House – Cheltenham met the requirements of the Health and Social Care Regulations. Therefore we have rated the key question ‘Is the service well-led’ as ‘Inadequate’.

There was a registered manager in place at Nazareth House - Cheltenham. The registered manager left the service shortly after our inspection, however was available on all three days 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.

People told us they were safe living at Nazareth House - Cheltenham. However, we identified shortfalls that impacted on people receiving safe care. People had not always received their medicines as prescribed. Care staff responded to people’s changing needs and health and worked closely with people's GPs. However, they did not always document the support they provided people and did not always follow care plans to ensure people would always receive care that met their needs and kept them safe.

There were enough staff deployed to ensure people’s health needs were being met but staff sickness had led to shortages which impacted on people receiving person centred care, including access to baths when they wanted. We recommended that the service seek advice based on current best practice, around how to use staff most effectively.

People’s privacy and dignity was not always respected and protected. Care staff did not always ensure people were cared for in private, by closing their bedroom doors. Care staff did not always effectively communicate with people living with dementia and did not always speak to people in a caring and compassionate way.

Staff felt they had the skills they needed to meet people’s needs. The registered manager had no overview of the training their staff required. Staff told us they had not always received effective support including one to one meeting with their line manager, and there was no clear record of the support staff had received to aide their professional development. Care staff felt they had all the training and support they required to meet people’s needs, however some care staff expressed concerns about staff practices.

The registered manager and provider had systems to monitor the quality of care people received at Nazareth House – Cheltenham however these had not always been effective. Audits were not always effective at identifying concerns in relation to staff performance, the support and training staff received and the management of medicines that we found. Following our inspection, the area manager and registered manager provided us with a list of actions they were planning to implement to drive improvements.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This was a focussed inspection and was prompted in part by information of concern we had received about the service. The information shared with CQC indicated potential concerns about safe care and treatment and the leadership within the service. This inspection examined those concerns and reported on the findings in the safe, responsive and well led domains. During our inspection in November 2016 we found the care provided to people was not always person centred and tailored to their individual needs and preferences. At this inspection we also checked whether the provider had taken action to address this shortfall.

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’. The last comprehensive inspection was carried out on 22 and 23 November 2016. At that inspection the service was rated overall as “requires improvement.” Our findings at this inspection have not changed the current rating of ‘good’ for the key question Safe or for the ‘requires improvement’ rating for the key question Responsive because we did not look at all the areas related to these two key questions. We will review these two domains in full at our next comprehensive inspection. We have reviewed the rating of the Well-Led question and have changed this to ‘good’ And as a result we have reviewed and changed the overall rating for this service to ‘good.’ .

Nazareth House provides care to predominantly older people. Some live with dementia and others have physical needs which they require support with. It can accommodate up to 63 people in total and at the time of the inspection there were 53 people living there. The provider adopts the core values set by the Sisters of Nazareth which are love, justice, hospitality, respect, compassion and patience.

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 and associated Regulations about how the service is run.

People felt safe living at Nazareth House. Staff had received training around safeguarding people from harm and abuse, and demonstrated a good understanding of safeguarding principles. The registered manager had carried out the relevant checks to ensure they employed suitable people at Nazareth House. There were regular health and safety checks of the property to ensure it was safe for the people living there.

Following our previous inspection in November 2016 improvements had been made to the recording of people’s care needs. Care plans were person centred and had been developed in partnership with the people receiving care. People needs and preferences in relation to their care were clearly recorded. Where people used their call bells to request staff support, we found the response times to these had improved and people received support in a timely manner.

The registered manager and staff were aware of the vision and values of the service and worked hard to provide a service which was person centred for each individual. There was a positive culture within the service. The registered manager offered strong leadership throughout the service. The staff and people living at Nazareth House spoke positively about the registered manager. The registered manger carried out quality assurance checks and audits regularly and where issues had been identified, action had been taken to address them.

On 12 and 17 May 2016 we carried out another inspection after receiving information of concern which included: not enough care staff to meet people’s needs, issues arising from a high dependency on agency care staff, poor staff practices relating to people’s safe moving and handling, unsafe medicines management and a lack of consistent and effective day to day management. We had also received several notifications from the provider reporting incidents of poor moving and handling practices which we had difficulty establishing whether they had been fully investigated and acted on. At this inspection we had checked on the progress made by the provider on some areas of the breaches found in January 2016, which the provider had told us would be met at the end of April 2016. We looked at some aspects of risk management, staff training and the recording of some people’s food and fluid intake.

During the inspection in May 2016 we were concerned about the lack of suitable arrangements to ensure the safe evacuation of people in the event of a fire. We requested that the local fire safety office carry out an urgent visit. They carried out a fire safety assessment on 13 May 2016. Immediate guidance and advice was given to the management team in place at the time by the fire safety officers, on how to improve staffs’ awareness on what to do in the event of a fire. A notice of non-compliance was issued by the fire safety department under relevant requirements of the Regulatory Reform (Fire Safety) Order 2005. This was subsequently met by the provider.

Nazareth Care Charitable Trust is a Charity which works closely with the Sisters of Nazareth. Nazareth House - Cheltenham is one of the Charity’s care homes. It can accommodate up to 63 people who require support and care. During this inspection 53 people were receiving care. Although many people who followed the Catholic faith chose to live at Nazareth House all faiths’ and backgrounds were welcomed. Care was provided predominantly to older people by staff who were employed by the Charity. A group of Sisters and one Catholic Father lived on site and provided pastoral support and guidance to those who lived there. The Sisters were involved in some decision making and had some financial input in the up keep of the building. They were very visible within the care home.

A new manager had been employed since the last two inspections. They had been in post since May 2016 and were now 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.

People told us they felt safe. They were looked after by staff who had received support to access necessary training since the last two inspections. This had included update training in areas that were considered not safe in May 2016 such as fire safety, the safe moving and handling of people and medicine management. People’s medicines were now managed safely. Further on-going training had also been booked.

Risks to people’s health had been identified and these were managed and monitored. Risks in the environment were also assessed, managed and monitored. Staff were aware of the risks of potential abuse and of harm to people from poor practice. They had been supported to report any concerns they may have. Episodes of proven poor practice had been managed appropriately. The registered manager worked with local safeguarding professionals appropriately and took any concerns raised seriously.

There were enough staff to meet people’s needs although, the way staff sometimes worked and the decisions made around work routines did not promote or always ensure personalised care was delivered. People were receiving care but not necessarily in a way that suited them or in a way they preferred. You can read what we asked the provider to do about this at the back of the full version of this report. There were not always opportunities for people to receive the support they needed to take part in meaningful activities. However, the activities and social events provided by the Friends of Nazareth House were enjoyed by those who took part in these.

The use of agency staff had been reduced by the registered manager but staff sickness, increased admissions and the need for staff to attend necessary training had necessitated their use again more recently. This was to ensure there were enough staff on duty each day but was not at the levels previously seen. Staff recruitment was therefore on-going. Where possible the same agency staff were used so the impact of staff changes on people were reduced. Staff recruitment had been successful and safe recruitment processes protected people from those who may not be suitable.

People had access to appropriate health care professionals and there were good working relationships with local GPs and community nursing services. A lot of work had been done to ensure people’s care records were up to date but these now needed to be personalised. Work had started to involve people and/or their relatives more in the planning of their care. Care was only given if people consented to it and where they were unable to do this the principles of the Mental Capacity Act 2005 were adhered to. People were supported to make independent decisions and decisions made on behalf of people were made in their best interests.

There were arrangements for people to raise a complaint and have this addressed. The registered manager worked in a proactive way by communicating with people or relatives and making herself available so that any areas of dissatisfaction or concern could be discussed and resolved quickly. The care home had received many expressions of thanks for the care received. People received care which was delivered in a kind and caring way. Where this had previously not been the case, those staff no longer worked at the care home. Those who mattered to people were welcomed.

The registered manager had provided strong leadership and they had made improvements to the way the care home operated. They used audits and other checks to ensure the care home was meeting relevant regulations as well as the provider’s expectations. Some improvements were still needed by the managements team as we identified a breach of regulation at this inspection. Representatives of the provider were contactable when needed and visited the care home. The provider had systems in place to monitor the service’s performance, identify shortfalls and promote improvement.

The provider had sought people’s views of the service in the last year but this information had not yet been collated and shared. The registered manager was continually seeking people’s views. This helped her to gauge what they felt about the improvements made so far and to learn about what further improvements and changes they would like to see.

Nazareth House provides care and accommodation for up to 63 older people. At the time of our inspection there were 45 people using the service. Many people reside at Nazareth House because the Sisters of Nazareth provide spiritual support and guidance to those of the Catholic faith. There is a chapel attached to the care home where people can take part in daily devotions. Nazareth House however welcomes and cares for people of other faiths and those who have no particular faith.

At the time of this inspection the service was without a registered manager and had been since May 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Since May 2015 there had been other managers, both permanent and interim, but not registered with the Care Quality Commission. During this inspection the management team were different to those present at our last inspection in January 2016.

We carried out an unannounced comprehensive inspection of this service on 28 and 29 January and 1 February 2016 where we found breaches of regulations relating to the Mental Capacity Act 2005, management of risks, staff training and support and quality monitoring arrangements. The provider wrote to us to say what they would do to meet legal requirements in relation to these breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Since then we received further information with concerns relating to: not enough care staff to meet people’s needs, issues arising from a high dependency on agency care staff, poor staff practices relating to people’s safe moving and handling, unsafe medicines management and a lack of consistent and effective day to day management. We had also received several notifications from the provider reporting incidents of possible poor moving and handling practices which we were having difficulty establishing whether these had been fully investigated and acted on. As a result we undertook this unannounced focused inspection to check if people were safe. We also checked on the progress made by the provider on some areas of the breaches found in January 2016, which the provider told us would be met at the end of April 2016. This included: some aspects of risk management, staff training and the recording of people’s food and fluid intake where people needed this monitoring closely. This report only focuses on the above areas and is not a follow up on all breaches of regulation found in January 2016. These will be followed up in due course when we carry out the next planned comprehensive inspection.

During this inspection we were concerned enough about the lack of suitable arrangements to ensure the safe evacuation of people in the event of a fire, to share our concerns immediately with a local fire safety officer. They carried out a fire safety assessment on 13 May 2016. Immediate guidance and advice was given to the new interim management team by the fire safety officers on how to improve staffs’ awareness on what to do in the event of a fire. A notice of non-compliance was issued by the fire safety department. They will follow this up in due course to ensure the provider meets with the relevant requirements of the Regulatory Reform (Fire Safety) Order 2005.

During this inspection some aspects of the management of medicines were not safe. Previous and current management staff had begun to take some action to address this. However, this was still work in progress. People’s needs were not always being met in a timely way and support was not always available when people wanted or needed it. The service had continued to use high numbers of agency staff to be able to meet people’s basic needs. Some progress had been made in recruiting new staff and good recruitment practice helped to protect people from those who may be unsuitable to care for them.

Some of the provider’s processes for making sure that agency staff received the information they needed to be able to work safely had not been followed. This was found in a lack of awareness in what to do in the event of a fire and how information about people’s needs or changes in their care and health were communicated. Just prior to this inspection new and simple guidance had been prepared about people’s basic care needs which could be given to staff at the beginning of their shift in the staff hand-over meeting. We have however made a recommendation in this report that the provider take appropriate advice on how to improve staffs’ access to their electronic systems. These systems hold information about people’s risks and their plans for care.

The management of the service had altered twice since our last visit in January 2016. The then, new permanent manager had left in April 2016. Since then there had been one interim manager present for six weeks and two new interim managers had started on 9 May 2016. During this inspection the provider carried out interviews for a new and permanent manager. Subsequently a successful candidate was appointed and has started in post at Nazareth House.

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

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Nazareth House – Cheltenham on our website at www.cqc.org.uk

Nazareth House provides care to predominantly older people. Some live with dementia and others have physical needs which they require support with. It can accommodate up to 63 people in total and at the time of the inspection there were 51 people living there. The provider adopts the core values set by the Sisters of Nazareth which are love, justice, hospitality, respect, compassion and patience

A registered manager was not 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 registered manager had stopped managing the service in May 2015. Since then another manager had been appointed and had left in December 2015. The current new home manager had started employment with the organisation on 25 January 2016. They had been working in the home for four days when this inspection started. They were an experienced adult social care manager who brought with them various qualifications and skills which would benefit Nazareth House.

People’s risks had not always been well managed. This had particularly related to the management of falls where actions to avoid reoccurring falls had not always been taken. Staff were committed to those they looked after but at times were unable to meet people’s needs in a way which suited people best. Response times to call bells for example needed to improve. Staff recruitment practices were good and protected people from those who may be unsuitable. People’s medicines were administered by staff but some arrangements potentially meant some people were not getting their medicines as prescribed. Improvements to the environment had been made and continued to ne made but not all risks had been addressed. This particularly related to evacuation processes in the event of a fire. People had access to health care professionals when needed. However, confusion in applying the appropriate legislation when people lacked mental capacity meant people’s rights were not fully protected. Staff had lacked effective training and adequate support which had resulted in some of the shortfalls identified above. People were supported to eat and drink and potential risks in this area were identified and managed.

People or their representatives had not always been involved in planning and reviewing care; as a result not all care plans were personalised. Care records had not been well maintained but as from November 2015 improvements had started to take place and we saw updated records. This had not caused significant shortfalls in people’s care but had meant that staff who did not know people’s needs lacked guidance about these. This could potentially lead to inconsistent or unsafe care if not addressed. People had opportunities to partake in social activities but they wanted to be able to go on more trips. Staff worked hard to make the activities enjoyable and meaningful to people. This work was very well supported by volunteers. People had been able to raise complaints and have these taken seriously, investigated and resolved where possible. There had been an increase in complaints during the time of unsettled management but the new home manager had plans to ensure people could express any areas of dissatisfaction and have these resolved before a complaint was necessary.

The staff at Nazareth House were caring and compassionate. People who mattered to those receiving care were also welcomed and supported. The Sisters of Nazareth Convent provided additional time and pastoral support to anyone of any denomination. This was clearly appreciated by people who lived at Nazareth house and those who visited.

The service had lacked consistent management and staff told us they needed consistent management and a period of stability. The new home manager was aware of the challenges the service presented but had the support of a provider representative to address these and take the service forward. Changes were being made to the provider’s quality monitoring systems which would provide a more robust system for identifying and addressing shortfalls. The management team received strong support from the Mother Superior of the Convent. This person brought a wealth of management experience and additional time to guide and counsel the new management team. All were committed to providing a good service and people who used the service were central to achieving this.

We found breaches against four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the overall management of risks to people, the protection of those who lacked mental capacity, a lack of adequate training and support for staff and quality assurance systems which have been unable to drive improvement. You can see what action we told the provider to take at the back of the full version of the report.

As part of this inspection we spoke with the registered manager and two staff members. We reviewed care records and other relevant documents. These included policies and procedures and staff training and support records.

Below is a summary of what we found. The summary describes what staff told us and the records we looked at.

Is the service safe?

The service was safe because, since the last inspection in April 2014, appropriate arrangements had been made to ensure people's medicines were administered safely. The service was safe because checks were carried out to make sure medicine records were maintained accurately. The service was safe because individual staff competencies in medicine administration were reviewed. The service was safe because since the last inspection people's care records had been reviewed and amended so as to ensure information about people's care and treatment was relevant and updated. This was with the exception of one person's care records, which after review still did not give appropriate or relevant information. This was rectified during the inspection.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications needed to be submitted proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

The service was effective because the training and support needs of staff had been identified. Staff received support and training to enable them to deliver people's care safely. In this report the provider is made aware of one example seen during this inspection where staff lacked understanding in the completion of relevant care plans and risk assessments. The registered manager told us that additional training and support would be provided in relation to this.

The service was effective because the service had started to make improvements to how staff received training, making it more relevant and meaningful to the situations staff encountered during their work. The service was effective because it identified shortfalls in staffs' performance and put actions in place to resolve these.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

The inspection was completed by one inspector. We spoke with two people who lived in the home, one visitor and eleven members of staff. This is a summary of what we found.

Is the service safe?

Staff were aware of people's needs and were meeting them safely. Staff were also aware of people's individual risks and took action to manage these. The service worked with other health care professionals in order to meet people's needs.

Care records were not always up to date and did not give staff updated information about people's required care and treatment. People were therefore at risk of not receiving safe and effective care or treatment through a lack of accurate information about them. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The service's policies and procedures relating to what staff should do following an accident had been discussed with staff and reiterated. Training had been organised for some staff in first aid so that they could give first aid to people safely. Further training for this had also been booked. Changes to the call bell system meant that call bells were responded to correctly.

The arrangements for medicine administration had been reviewed and some staff had received additional support to ensure their practices were safe. Despite this we twice observed practices that meant some people's medicines were not administered safely. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

There were no restrictions in place. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Staff had not yet received training on the above, however, the new manager was aware of how to apply for an authorisation under the Deprivation of Liberty Safeguards. Strategies were in place to keep people safe but not deprive them of their liberty.

Is the service effective?

People told us they liked living in the home and it provided them with what they needed. Other people who were not able to share their experiences with us looked comfortable and relaxed. Both people spoken to confirmed that they were able to receive visitors when they wanted to. Both these people's bedrooms, and many more were highly personalised with private belongings making the person's personal space look like their own piece of home.

People's health and care needs were assessed and people's needs were met even though care records were not up to date. Arrangements for the administration of two people's medicines needed a review so that they could continue to have their preferences met but the safety of their medicine administration was improved.

Is the service caring?

We observed staff being very kind and patient with people who used the service. We also observed this same approach with one person who was being verbally challenging back to staff when they approached the person. One person said (about the staff): "most of them are very kind." and a visitor spoke highly of the staff and said: "they are brilliant."

People's preferences, wishes and diverse needs were respected and noted in their care records. Staff spoken with had a good understanding of how people wished to be supported and provided care in accordance with their wishes.

Is the service responsive?

People wishing to move into the home were assessed to make sure their needs could be met. When needed other social and health care professionals were involved to ensure the appropriate care and support was being provided. Increased risks to people were identified and managed.

Once concerns had been expressed about the service in November 2013 the provider had listened and had put arrangements in place to address these. Changes to how the provider and service managers were assessing and monitoring the service's performance meant that a more proactive and less reactive approach to identifying shortfalls and making improvements was in place.

One person who used the service said (in relation to how the sevice was being managed) said: "there has been a vast improvement over the last few months." This person also told us, they and others had been asked for their views of the service and where they would like to see changes. They said this approach had been new but appreciated. One visitor echoed this appreciation.

Improvements to the environment had started with some bathrooms having been refitted, resulting in areas that could be kept clean and which provided comfortable bathing facilities. Two people told us that improvements had been made to the food after people had expressed that it required improvement.

Is the service well led?

The management of the service itself has altered and senior staff were being supported to lead their individual areas more effectively. Arrangements within the service had been introduced so as to promote and encourage effective communication between the staff teams and the managers. Where needed the use of agency staff had been allowed but an active recruitment plan was also in place.

Staff were being supported to follow the provider's policies and procedures and action had been taken where this had not happened. The provider was continuing to review and adapt the way in which staff worked to make sure people's needs were met and the service ran smoothly.

Arrangements for staff training and support had been poor. Although managers had started to make improvements to staff training and how staff were informed of their responsibilities, this work was in its infancy. A compliance action was therefore set in relation to this and the provider must tell us how they plan to improve this further.

You can see our judgements on the front page of this report.

We found that people's care needs were being met and when required they were being referred to specialist health care professionals. The arrangements needed to ensure that legal requirements were being followed when people lacked mental capacity were not in place. We found no evidence that suggested the service was understaffed, although call bells were not being responded to quickly enough. The registered manager told us this would be addressed.

Staff are provided with training and support to carry out the tasks they perform. People's views on the catering and social activities had been sought. Arrangements were in place to monitor safety and to identify any needed improvements.

Plans were being discussed in how to share information with people following the annual satisfaction questionnaire. Record keeping had been satisfactory, although at times, staff needed to remember to record the action they had taken.