CQC report explained · a residential care home
What the CQC found at Nazareth Lodge
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- Inspectors were assured that infection risks were being managed. This included visitor testing, protective equipment, cleaning, staff training, regular COVID testing and plans for outbreaks.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Outstanding
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Outstanding
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was a targeted inspection on 24 February 2021. It was carried out as part of the CQC's response to the coronavirus pandemic and focused on infection prevention and control in the home.
Inspectors found measures to reduce infection risks for visitors, including lateral flow testing, protective equipment and scheduled visits using a visiting pod. Staff had training, supplies of protective equipment were available, and regular cleaning and infection control checks took place.
Inspectors were assured that the home was using testing, supporting safe admissions, following shielding and social distancing rules, and keeping its infection control policy up to date. The service was inspected but not rated, so this report does not provide a full overall quality rating.
Visitor infection controls
Visitors were tested, given protective equipment and used a visiting pod. Visits were scheduled so the area could be cleaned between visits.
“Measures were in place to prevent the spread of infection by visitors to the service.” from the report
Trained staff and equipment
Staff had infection prevention training and understood how to use protective equipment. Supplies such as masks, gloves, aprons and hand sanitiser were available.
“Staff had received training and were following up to date guidance in infection prevention and control, to minimise risks to people.” from the report
Cleaning and checks
The home had an additional cleaner, a cleaning schedule and regular checks of infection prevention measures.
“The provider had recruited an additional cleaner at the home to maintain the cleaning schedule put in place which included regular cleaning of touchpoints.” from the report
Testing and emergency planning
Regular COVID testing was carried out for staff and residents. Plans were in place for a COVID-19 outbreak or another emergency.
“Regular COVID testing was carried out at the service for both staff and people living there, and contingency plans were in place in the event of any outbreak of Covid-19 or other emergency.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitor testing, protective equipment and visiting arrangements managed now?
- 02How often are staff and residents tested, and what happens if someone tests positive?
- 03How often are touchpoints and shared areas cleaned, and how is this checked?
- 04What is the current plan if there is a COVID-19 outbreak or another emergency?
- 05When was the home's infection prevention and control policy last updated?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it was not a full inspection of all five areas of care and the service was not rated. This explanation was written from the published report of 9 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.
What inspectors found, August 2018
Rated Outstanding; inspectors found exceptionally caring, well-led support, with some staff practice needing improvement.
This was an unannounced comprehensive inspection on 6 and 8 March 2018. Inspectors reviewed care plans, medicines, staffing, training, complaints, safety records and quality checks. They spoke with people living at the home, relatives, staff and health professionals.
The home was rated Outstanding overall. Caring and well-led were Outstanding. Safe, effective and responsive were Good, and all five ratings remained unchanged from the previous inspection.
Inspectors found people were treated with kindness, dignity and respect. Staff knew people well, supported their choices and helped them stay connected with family, the community and their interests. End of life care was also described as responsive and compassionate.
There were some areas to improve. Medication competencies were not being reviewed annually, one staff member was unsure about fire procedures, the wrong cleaning mop was seen in use, and one staff member was unsure about supporting a person distressed by dementia. The management team had started actions to address these issues.
Kind and respectful care
People were treated with dignity and staff took time to understand their preferences, personalities and interests. Inspectors saw staff stopping to talk and provide support during everyday activities.
“Staff were observed to be very kind, caring and compassionate towards people they were supporting.” from the report
People have a voice
People were involved in care planning, activities and staff recruitment. The home also used one-to-one sessions, forums and volunteers to help people express their views.
“People were treated with respect, and empowered to have a voice in regards their care and told us they felt listened to.” from the report
Strong leadership
The management team was described as open, honest and accessible. Staff felt supported, worked well together and were encouraged to develop their skills.
“The provider and registered manager provided strong leadership, where clear and transparent processes were in place to guide staff.” from the report
Responsive end of life care
People approaching the end of life had care plans showing their wishes. The home also gave relatives information and recognised the needs of families after a bereavement.
“People could be confident that at the end of their lives they would be cared for with kindness and compassion and their comfort would be maintained.” from the report
Medication checks
seriousMedication-trained staff did not yet have their competency reviewed annually. The deputy manager put an action plan in place during the inspection.
“However, it was noted during our inspection staff did not have their medication competencies reviewed annually.” from the report
Fire procedure knowledge
needs fixingOne staff member appeared unsure about the fire procedure and where the emergency grab bag was kept. The manager said concerns would be addressed immediately.
“However one member of staff seemed unsure of the fire procedures or where the grab bag would be located in the event of a fire.” from the report
Cleaning procedure
needs fixingInspectors saw one staff member using the wrong coloured mop and bucket. The manager considered this an isolated incident and relied on audits and spot checks.
“However, we observed one member of staff using the wrong coloured mop with an incorrect bucket.” from the report
Dementia support
needs fixingOne staff member was unsure about how best to support someone showing distress linked to dementia. The home was taking steps to improve staff understanding, including appointing a Dementia Champion.
“One member of staff seemed unsure of the best approach to use if someone was showing signs of distress due to dementia.” from the report
- 01How are medication competencies reviewed now, and how often are staff checked after training?
- 02What action was taken to make sure all staff know the fire procedure and where the grab bag is kept?
- 03How do you monitor that the correct mops and buckets are used in bedrooms and toilet areas?
- 04What dementia training and practical support do staff receive when someone is distressed?
- 05What changes have been made since the inspection, and how do you check that those changes are working?
This was an unannounced comprehensive inspection covering the premises, care provided and all five CQC question areas. This explanation was written from the published report of 11 August 2018 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 Lodge
2 rated inspections over 3 years: the service has held its Outstanding rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2018Outstandingstayed OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Outstanding
- November 2015OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Outstanding
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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