CQC report explained · a nursing home
What the CQC found at Nazareth House - Manchester
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe staffing, recruitment checks, safeguarding arrangements and improved risk management. Medicines were generally managed safely, but one person's creams had not been applied as prescribed and correct processes were not always followed for covert medicines.
- Effective?
- Good
- Staff training, induction and supervision had improved. Food, healthcare support and consent arrangements were effective, although clinical skills development for nurses and the creation of a dementia-friendly environment were still being developed.
- Caring?
- Good
- Staff were described as dedicated, caring and compassionate. People were treated with dignity, staff knew their preferences and people and relatives were involved in care decisions.
- Responsive?
- Good
- People had access to a varied programme of activities and were involved in planning their care. Inspectors found good support for communication, complaints and end-of-life care, but some staff were still learning how to use the electronic care-planning system.
- Well-led?
- Good
- A new leadership team had created a more positive culture. Audits, quality checks and accountability had improved, helping the home identify risks earlier and take action.
What inspectors found, March 2023
Rated Good and no longer in Special Measures; inspectors found caring staff, safer medicines and much stronger leadership, with some improvements still to sustain.
This was an unannounced follow-up inspection on 13, 15 and 16 February 2023. Inspectors spoke with people living in the home, relatives, staff and managers. They observed care and reviewed medicines, care records, safety records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, respectful care, better communication with health professionals and improved systems for managing risks and quality.
The home had previously been rated Inadequate and had been in Special Measures since April 2021. Inspectors found enough improvement for the home to leave Special Measures and no longer be in breach of regulations. They still recommended continued monitoring of medicines and better use of guidance when creating a dementia-friendly environment.
Caring staff
Inspectors saw compassionate care and heard positive feedback about staff being respectful, familiar and attentive to people's preferences.
“Care and support was provided to people by a team of staff who were dedicated, passionate and committed to their roles.” from the report
Safer medicines
Medicines were stored securely, and staff had training and checks on their administration. Audits were being used to find and correct problems.
“Medicines were stored safely and securely. Staff completed training and were assessed to ensure they administered medicines safely.” from the report
Improved leadership
The new leadership team had improved quality checks, accountability and the way risks were identified and acted on.
“Credible data was now being gathered from internal audit and quality assurance systems which meant themes and trends could be identified.” from the report
Activities and social life
People were consulted about activities, with a varied programme involving community groups, performers and entertainers.
“People were regularly involved and consulted about social activities.” from the report
Medicines processes
needs fixingOne person's topical creams had not been applied as prescribed. Inspectors also found that the correct process was not always followed when medicines were hidden in food or drink, although action was taken during the inspection.
“The correct processes were not always followed for people who were having their medicines given covertly, hidden in food or drink.” from the report
Dementia-friendly environment
minorRefurbishment was under way, but inspectors said the home should use recognised best-practice guidance to improve signs, flooring and colour choices for people with dementia or memory loss.
“We recommend the provider consults national best practice guidance for creating a dementia friendly environment.” from the report
Electronic care records
needs fixingSome staff were still learning how to use the electronic care-planning system and did not always understand all its functions. The provider was asked to make sure staff were competent users.
“Some staff acknowledged they were still learning aspects of the system 'on the job' and did not yet always understand the functionality and benefits of the system.” from the report
- 01How are you checking that topical creams and covert medicines are given exactly as prescribed?
- 02What changes are being made to signs, flooring and colour schemes to support people with dementia or memory loss?
- 03How do you check that every member of staff can use the electronic care-planning system correctly?
- 04How will staffing levels be maintained safely as new people are admitted to the home?
- 05What progress has been made with the refurbishment programme and the planned improvements to the outside space?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, carried out to check action taken after earlier inspections. This explanation was written from the published report of 7 March 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, October 2022
Rated Inadequate and still in special measures; inspectors found missed medicines and weak management checks, despite some improvements.
This was a follow-up inspection after the previous Inadequate rating. Inspectors visited over three days, reviewed care plans, recruitment files and audits, and spoke with people, relatives and staff.
The home had improved in some areas, including staff morale, recruitment checks, visiting arrangements and management engagement. However, five people had missed prescribed medicines in the four weeks before the inspection. Records, medicine storage, risk assessments and management checks were also not always reliable.
The Safe and Well-led ratings both remained Inadequate. The home remained in special measures, meaning CQC would keep it under review and normally re-inspect within six months to check for significant improvement.
Safer recruitment
The recruitment files reviewed showed that required pre-employment checks had been completed for newly appointed staff.
“Staff recruitment files showed that all necessary pre-employment checks had been completed for newly appointed staff.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment and the home's ability to manage outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Visiting arrangements
People were supported to receive visitors at a time of their choice, including visits without advance notice.
“People were supported to visit the service at a time of their choice.” from the report
Improved staff morale
Staff told inspectors that communication with management and morale had improved.
“The staff we spoke to told us that staff morale had improved at the service.” from the report
Missed medicines
seriousFive people missed some prescribed doses because the ordering system did not keep enough medicine in stock. Inspectors also found wider problems with medicine records, storage and administration.
“Five people had missed some doses of their prescribed medicines in the four-week period prior to the inspection.” from the report
Weak management checks
seriousThe provider's audits and oversight did not consistently find or address important problems. Seven accidents and incidents had not been reviewed by management since May 2022.
“Since May 2022, there were seven incidents which had not been reviewed.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. An interim manager was in place and a newly appointed manager had started, intending to apply for registration.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What has changed since the inspection to make sure prescribed medicines are always in stock and doses are not missed?
- 02How are medicine records, 'when required' medicines, topical creams and medicine storage now checked?
- 03Who is currently responsible for the home while there is no registered manager, and when will the manager apply for registration?
- 04How are accidents, incidents and risk assessments now reviewed, and how will the home show that lessons have been acted on?
- 05What action plan has been agreed with the local authority, and what progress has been made against it?
This was a focused follow-up inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were not inspected during this visit. This explanation was written from the published report of 8 October 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 - Manchester
8 rated inspections over 6 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- May 2022Inadequatestayed InadequateSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- October 2021Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- June 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- March 2014
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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