CQC report explained · a nursing home
What the CQC found at Nazareth House - Birkenhead
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Inadequate
- Medicines were not always administered, recorded or stored safely. People's risks, medical needs and care records were not always properly assessed, monitored or maintained.
- Effective?
- Requires improvement
- This question was not inspected during this focused visit. The report says there were no areas of concern identified in the information held about it.
- Caring?
- Good
- This question was not inspected during this focused visit. Inspectors did observe that staff were kind, caring and respectful.
- Responsive?
- Requires improvement
- This question was not inspected during this focused visit. The report says the previous comprehensive inspection ratings were used when calculating the overall rating.
- Well-led?
- Requires improvement
- Audits and management systems were not effective in identifying and reducing risks. Oversight was poor and records were inadequate, although people and staff described the manager as approachable and supportive.
What inspectors found, August 2022
Overall rated Requires Improvement, with Safe rated Inadequate because medicines, risk management and records put people at risk of avoidable harm.
The inspection began on 16 June 2022 to check infection control after a COVID-19 outbreak. Inspectors found wider environmental concerns, so they widened it to a focused inspection of Safe and Well-led.
The home had serious problems with medicines, risk assessments, care records and environmental safety. Some medicines could not be accounted for, and staff did not always have enough information about people's health conditions or risks.
There were enough staff on the days visited, and people and relatives said staff were kind, caring and approachable. The home was clean and pleasant on the inspection days, although some infection control records needed improvement.
The overall rating remained Requires Improvement. Safe fell from Requires Improvement to Inadequate, while Well-led stayed at Requires Improvement. The other three questions were not inspected during this visit, so previous ratings were used in calculating the overall rating.
Kind and respectful staff
Inspectors saw staff treating people kindly and respectfully. People and relatives also gave positive feedback about staff and the atmosphere.
“Staff were observed to be kind, caring and respectful.” from the report
Enough staff on inspection days
The home had a system for assessing staffing needs. Inspectors found enough staff on duty on the days they visited.
“On the days we visited, there were enough staff on duty to meet people's needs.” from the report
Accidents reviewed
Accidents and incidents were investigated and reviewed so staff could learn from them and try to prevent similar events.
“Accidents and incidents were properly investigated and reviewed to identify how they occurred so that staff could learn from and prevent them happening again.” from the report
Positive atmosphere
People appeared relaxed and comfortable with staff. Relatives said staff kept them informed about their family member's wellbeing.
“There was a positive culture and homely atmosphere.” from the report
Unsafe medicines management
seriousSome medicines could not be matched to the records, and guidance for some medicines was unclear or missing. This included high-risk medicines and medicines prescribed to be given when needed.
“Medication management was unsafe, did not adhere to best practice guidelines and placed people at risk of significant harm.” from the report
Risks and care records not managed well
seriousStaff did not always have enough information about people's medical conditions, warning signs or required monitoring. Records did not reliably show that people received the care needed to reduce risks.
“People's risks were not adequately assessed, monitored and managed to prevent avoidable harm.” from the report
Environmental safety risks
seriousInspectors found unsafe window restrictors, unsecured rooms containing hazardous products, an unsafe smoking shelter and accessible nursing stations. Action had started by the end of the first inspection day.
“Environmental risks had not been adequately identified and addressed.” from the report
Weak management oversight
seriousAudits were not effective in improving safety and quality. The report says the home had repeatedly been rated Requires Improvement in Well-led since 2015.
“The governance arrangements in place were not robust. Managerial oversight remained poor and record keeping was inadequate.” from the report
Incomplete infection control records
needs fixingThe home was clean and pleasant when inspectors visited, but records for cleaning, COVID-19 testing and temperature checks were not always properly maintained.
“Infection control standards were generally satisfactory but record keeping in relation to cleaning, lateral flow testing and temperature checking for COVID-19 required improvement.” from the report
- 01What has been done to make sure every medicine is given at the right time, in the right amount and recorded accurately?
- 02How are high-risk medicines and medicines prescribed to be given when needed now assessed and monitored?
- 03How will staff know about each person's medical conditions, warning signs and required monitoring?
- 04What changes have been made to the care records so they clearly show that people's needs and risks are being managed?
- 05What independent checks are now in place to make sure the action plan is being completed and the repeated Requires Improvement rating improves?
This was a focused inspection of Safe and Well-led, prompted by infection control and environmental concerns; Effective, Caring and Responsive were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 10 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2021
Nazareth House - Birkenhead was rated Requires Improvement; inspectors found some safety and management systems still needed strengthening.
This was an unannounced focused inspection on 11 February 2021. Inspectors spoke with people, relatives, staff, the manager and a health professional. They reviewed care records, medicines records, staff files, accident and safeguarding records, audits and infection control arrangements.
The home was rated Requires Improvement for Safe and Well-led. Staff were safely recruited, medicines were generally managed safely, safeguarding procedures were in place and people said they felt safe. However, staff COVID-19 testing was not always completed as often as government guidance recommended, and some end of life care records did not clearly describe people's current needs, risks or wishes.
There were mixed views about staffing levels. Rotas showed the assessed number of staff were on duty, but some staff and people said staff could be overstretched. Refurbishment was taking place, but risks had been assessed and no significant concerns were raised.
Improvements had been made since the previous inspection, and the previous breach about governance had been resolved. However, the service remained Requires Improvement and had held this rating for four consecutive inspections. The other three key questions were not inspected during this visit, so their previous ratings were used in the overall rating.
Safeguarding systems
Staff had safeguarding training, knew how to raise concerns and records showed that referrals were made appropriately when needed.
“Records showed that referrals had been made appropriately to the local authority when required.” from the report
Medicines management
Medicines were generally stored and given safely. Staff had training and their competence had been checked.
“Staff had received training in the management of medicines and had their competency assessed.” from the report
Positive care feedback
People and relatives gave positive feedback about the quality and kindness of care.
“Feedback regarding the quality of service people received was positive.” from the report
Keeping relatives informed
Relatives said they were updated about changes in the home and about their family member's health and wellbeing. The home used calls, technology and visits to support contact during the pandemic.
“Relatives told us they were informed of any accidents or incidents that occurred and were always kept updated of any changes in their family members health or wellbeing.” from the report
Staff COVID-19 testing
needs fixingNot all staff completed tests as frequently as recommended. After the inspection, the manager said they were visiting daily to improve oversight.
“However, evidence showed that staff were not all completing tests as frequently as recommended.” from the report
End of life care records
needs fixingRecords for people receiving end of life care did not always clearly set out their current needs, risks or preferences.
“Records in place for people receiving end of life care did not always provide clear information regarding people's current needs, risks or preferences.” from the report
Staffing pressure
needs fixingAlthough rotas showed the assessed staffing level was in place, feedback was mixed. Some staff and people said staff were rushed or overstretched.
“Most staff told us they felt short staffed and one said they did not have time to sit and talk to people.” from the report
Medication recording
minorInspectors found one medicines anomaly. It was dealt with immediately.
“There was one anomaly identified during the inspection, and this was addressed immediately.” from the report
- 01How do you now make sure all staff complete COVID-19 tests as often as required, and how is this recorded?
- 02Have all end of life care records been reviewed and updated to show each person's current needs, risks and wishes?
- 03How do you check that staffing levels are enough when staff are busy or people need more support?
- 04What was the medicines anomaly found at the inspection, and what change was made to prevent a repeat?
- 05What progress has been made since this inspection towards achieving a Good rating?
This was a focused inspection of Safe and Well-led only; the other three key question ratings carried over from previous comprehensive inspections. This explanation was written from the published report of 13 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Nazareth House - Birkenhead
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2022Requires improvementcurrent ratingstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2019Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Registered with the Care Quality Commission on 2 April 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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