CQC report explained · a residential care home
What the CQC found at Nazareth House - East Finchley
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found significant progress since Special Measures, but activities, privacy, medicines records and oversight still need work.
This was an unannounced comprehensive inspection on 7 and 8 December 2022. Inspectors spoke with people, relatives, staff and a healthcare professional. They observed care and checked care plans, medicines, recruitment and management records.
The home had improved significantly since its previous inadequate rating. People were generally safe, staff knew them well, care plans were person centred, and staff were kind. The Effective and Caring ratings were Good.
The home was not always safe, responsive or well-led. Inspectors found inconsistent records for some high-risk and covert medicines, some staff did not always protect privacy and dignity, and people did not always have enough meaningful activities. The home breached Regulation 9 on person-centred care.
The previous Warning Notice requirements had been met. The home was no longer rated Inadequate and was no longer in Special Measures, but CQC said improvements needed to be sustained and embedded.
Improved medicines systems
The serious medicines problems found at the previous inspection had been addressed. Records were generally complete and staff had training and competency checks.
“Medicine administration records were complete and there were no omissions in recording.” from the report
Detailed care planning
Care plans described people's needs, preferences and personal information. They were reviewed monthly and updated when needs changed.
“Care plans were detailed, person centred and gave in-depth information about the person, their life and their likes and dislikes.” from the report
Kind staff
Inspectors observed warm interactions, and people and relatives generally said staff were kind and caring.
“During the inspection we saw people being treated in a kind and caring manner by care staff.” from the report
Food and healthcare support
People were offered food choices and support to eat and drink. The home also helped people access health and social care professionals.
“People were supported and encouraged to eat and drink enough to maintain a healthy diet.” from the report
Management improvements
The management team introduced audits and action plans, responded to issues raised during the inspection and worked with the local authority.
“The management and the staff team had made significant improvements overall in the management of the home and the quality of care people received since the last inspection.” from the report
Too few meaningful activities
seriousPeople did not always have activities that supported social interaction, stimulation and mental wellbeing. Care staff initiated very little activity when the activities coordinator was unavailable.
“There was a lack of meaningful activities that people could participate in to help stimulate and fulfil their social needs.” from the report
Privacy and dignity
needs fixingSome people and relatives said some staff did not always respect privacy or provide enough interaction. CQC recommended further training and asked the provider to embed better practice.
“some staff did not always respect people's privacy” from the report
Improvements not yet embedded
needs fixingThe home had made significant progress, but CQC said further work was needed to make the changes lasting and consistent.
“further work involving embedding of learning and sustainability going forward needed to be reinforced so that people were kept safe from injury and harm.” from the report
- 01What activities are now provided on days when the activities coordinator is not working?
- 02How do you check that staff consistently protect residents' privacy and dignity?
- 03How are risk assessments for high-risk medicines kept complete and up to date?
- 04How do you record best-interest decisions and consent for covert medicines?
- 05What progress has been made with the local authority suspension on new admissions?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control, and checking action taken after the previous Warning Notice. This explanation was written from the published report of 13 January 2023 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, June 2022
Nazareth House - East Finchley is rated Inadequate and in special measures; inspectors found risks with medicines, accidents and management oversight.
This was an unannounced focused inspection on 5 and 9 May 2022. Inspectors examined whether people were safe and whether the home was well-led. They reviewed care and medicine records, spoke with people, relatives, staff and health professionals, and observed care.
Inspectors found serious problems with medicines, risk assessments, accident and incident records, staffing oversight and infection control. Some people may not have received medicines as prescribed. There had been 13 unwitnessed falls and injuries in the 28 days before the inspection, and records did not always show that risks were investigated or managed.
The home did not have effective systems to check the quality and safety of care. Care plans and medicine audits were not checked consistently, and improvement plans lacked clear dates and deadlines. Inspectors also found that people were sometimes left without staff support in communal areas.
The overall rating and the ratings for Safe and Well-led were Inadequate. The other three question ratings were not inspected and were carried over from the previous inspection. The home was placed in special measures, meaning CQC said it would continue monitoring and usually re-inspect within six months.
Kind staff
People and relatives were generally happy with the care. Care staff were seen as kind, caring and approachable.
“People and relatives told us in general they were happy with the care and support delivered at Nazareth House.” from the report
Secure medicine storage
Although medicines were not always administered safely, they were stored securely and storage temperatures were checked daily.
“Medicines were stored securely. Daily temperature checks were recorded of medicine storage areas” from the report
Emergency planning
Personal emergency evacuation plans recorded the support people would need in an emergency.
“Personal emergency evacuation plans in place outlined people's specific support needs in an emergency” from the report
Mental capacity practice
Inspectors found that the home was working within the principles of the Mental Capacity Act and that required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Medicines were not safe
seriousSome medicines were given incorrectly, ran out, or were not clearly recorded as given. One pain relief patch was given daily instead of every 72 hours, creating a possible overdose risk.
“People did not receive their medicines safely or as prescribed.” from the report
Falls and risks were not managed
seriousRisk assessments were missing or generic, and accident and injury records were incomplete. Inspectors found 13 unwitnessed falls and injuries in the 28 days before the inspection.
“There had been 13 unwitnessed falls and injuries in the 28 days prior to this inspection.” from the report
Weak management checks
seriousThe home did not consistently audit care plans, medicines, incidents or quality. Improvement plans lacked detail and clear deadlines.
“There was a lack of management oversight of care delivery in the home.” from the report
Infection control guidance was not followed
needs fixingInspectors saw staff without masks and found that regular staff lateral flow testing and entry screening were not being carried out as expected.
“The service not always working in line with current government guidance.” from the report
Inconsistent staffing and supervision
needs fixingThe home relied heavily on agency staff. Inspectors saw communal areas left unattended and staff who were meant to supervise people dozing or taking breaks without clear oversight.
“There were occasions where communal lounges were left unattended, whilst people were present in the lounge.” from the report
- 01What changes have been made to ensure medicines are given exactly as prescribed, do not run out, and are recorded clearly?
- 02How are recent falls, unexplained injuries and medicine errors now investigated, reviewed and used to prevent repeat incidents?
- 03Have individual risk assessments and care plans been updated for conditions such as diabetes, epilepsy, blood-thinning medicines and falls?
- 04Who is now responsible for daily management oversight, and how often are care plans, medicines, incidents and complaints audited?
- 05How is the use and supervision of agency staff being managed so communal areas are not left unattended?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried over from the previous inspection. This explanation was written from the published report of 18 June 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.
Every inspection of Nazareth House - East Finchley
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Nazareth House - East Finchley →
- June 2022Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
Read what inspectors found at Nazareth House - East Finchley →
- September 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- January 2013
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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