CQC report explained · a nursing home
What the CQC found at Nazareth House - Hammersmith
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Most risks were assessed and medicines, staffing, safeguarding and infection control were managed well. However, some relapse risks were not recorded, and repositioning instructions and charts were not consistently complete.
- Effective?
- Good
- People received care based on assessed needs and staff had suitable induction, training and support. Mental capacity assessments and required DoLS authorisations were in place.
- Caring?
- Good
- People and relatives gave positive feedback about staff. Inspectors saw kind, respectful interactions and support for privacy, dignity, independence and personal preferences.
- Responsive?
- Good
- Care was personalised and complaints were handled appropriately and on time. Activities were planned and reviewed, but people continued to complain that there were not enough activities they enjoyed.
- Well-led?
- Good
- The management team was visible and staff described good teamwork and communication. Audits covered many areas but did not identify problems in daily turning records or some specific medical care plans.
What inspectors found, September 2022
Rated Good overall, but inspectors found that safety records and risk assessments were not always complete.
This was an unannounced follow-up inspection. Inspectors visited on three days, spoke with people, relatives and staff, observed care, and checked care records, medicines, staffing, training and management systems.
People and relatives generally described staff as kind and caring. Inspectors saw respectful interactions, enough staff on the days visited, safe medicines practices, suitable training, and good support with food, healthcare and consent.
The main concerns were under the Safe rating. Some relapse risks were not recorded, repositioning instructions and charts were incomplete, and quality checks had not found these problems. People also said activities were not always enjoyable or sufficient.
The overall rating improved from Requires Improvement in November 2019 to Good. Effective, Caring, Responsive and Well-led were rated Good. Safe remained Requires Improvement, meaning some aspects were not always safe and there was limited assurance about safety.
Kind and respectful care
People and relatives spoke positively about staff, and inspectors saw staff showing concern for comfort and wellbeing. Staff supported privacy, dignity and independence.
“We observed familiar and light- hearted interactions between people and staff.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Staff were trained and people said they received their medicines at regular times.
“There were good systems in place for the safe management and administration of medicines.” from the report
Enough staff and suitable recruitment
Inspectors found enough suitably qualified staff during the inspection. Recruitment checks, including references, work history, right-to-work checks and DBS checks, were completed.
“At this inspection we found the provider did ensure enough suitably qualified staff were in place to support people and were deployed effectively.” from the report
Improvement since the last inspection
The service improved from Requires Improvement to Good overall. Earlier concerns about consent, premises, equipment, person-centred care and governance were no longer breaches at this inspection.
“At this inspection we found improvements had been made and the provider was now meeting these regulations.” from the report
Incomplete risk information
seriousSome people had medical conditions that could relapse, but warning signs were not recorded for staff. Inspectors recommended more comprehensive risk guidance.
“we noted that a risk of relapse still remained and there were no recorded relapse indicators for staff.” from the report
Repositioning records
seriousCare plans did not say how often some people needed repositioning, and day staff did not always complete the charts consistently. This matters particularly for people at risk of skin damage.
“people's skin integrity care plans did not include a record of how frequently they were required to be repositioned” from the report
Activities did not meet everyone's preferences
needs fixingThe home had an activities timetable and asked people for feedback, but people still complained that there were not enough activities or that they did not enjoy those offered.
“However, people we spoke with still complained about not enjoying the activities on offer.” from the report
Audits missed some problems
needs fixingThe home's quality checks covered several areas but did not review daily turning records closely enough or identify some specific medical care plan issues. Inspectors recommended more comprehensive audits.
“auditing of care records did not include an analysis of daily records such as turning charts and as a result, the issues we found were not picked up.” from the report
Building design for dementia
needs fixingInspectors found that an earlier concern about the building not helping people with dementia to orient themselves remained. Plans to redecorate and adapt the building had been delayed.
“The building was not suitable for people with dementia to orient themselves.” from the report
- 01How do you now record warning signs and action plans for people whose medical conditions could relapse?
- 02How often does each person at risk of pressure damage need repositioning, and who checks that the charts are completed?
- 03What activities are now available for my relative's interests, and how do you check whether they enjoy them?
- 04How have your audits changed so they identify missing turning records and gaps in medical care plans?
- 05What progress has been made with the planned refurbishment and dementia-friendly changes to the building?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also reviewed; the previous rating was Requires Improvement in November 2019. This explanation was written from the published report of 8 September 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, December 2020
Inspected but not rated; inspectors found good infection-control arrangements during a COVID-19 outbreak.
This was an unannounced, targeted inspection on 28 October 2020. It followed concerns about infection prevention and control. Inspectors looked only at these arrangements.
The inspectors found systems to reduce the spread of infection. These included testing, staff working in fixed areas, visitor checks, social distancing, PPE and infection-control training.
At the time, two staff members had tested positive and were self-isolating. The home was temporarily closed to visitors, although limited, socially distanced garden visits and electronic contact were available.
The service was inspected but not rated. This means the report gives assurance about infection control, but it does not provide an overall quality rating or ratings for the other areas of care.
Infection-control systems
The home had systems to reduce the spread of infection, including keeping staff in the same area of the building.
“The provider had suitable systems to minimise the spread of infection across the service.” from the report
Testing and outbreak management
The provider had a testing programme for residents and staff and had arrangements to manage positive cases.
“The provider had implemented a programme of testing for people using the service and staff.” from the report
PPE and staff training
Inspectors found that PPE was available and staff had received infection-control training.
“The provider had full access to Personal Protective Equipment (PPE) and staff had received appropriate training in infection control procedures” from the report
Visitor safety
Visitors had to use a separate entrance, have their temperature checked, clean their hands and provide infection-risk information before visiting the garden.
“Measures were also in place to minimise the risk of visitors catching or spreading illness.” from the report
Inspectors raised no specific concerns in this report.
- 01What testing arrangements are now in place for residents and staff?
- 02How do you manage visitors who may have an infection risk, and what are the current visiting arrangements?
- 03Are staff still restricted to the same area of the building to reduce the spread of illness?
- 04What infection-control training have staff completed, and how often is it updated?
- 05How can residents keep in contact with family if in-person visits are restricted?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas of care were not assessed. This explanation was written from the published report of 3 December 2020 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 - Hammersmith
4 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Nazareth House - Hammersmith →
- December 2020Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Nazareth House - Hammersmith →
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- May 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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