Nazareth House - Lancaster

Updated 25 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by 2 inspectors.

Service and service type

Nazareth House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 4 July 2023 and ended 6 July 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, commissioners and professionals who work with the service. We also looked at information we had received and held on our system about the service, this included notifications sent to us by the provider and information passed to us by members of the public.

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.

We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service. We spoke with 4 relatives about their experience. We spoke with members of staff including the registered and deputy managers, 2 provider representatives, a cook and 4 care workers. We also obtained feedback from 2 health care professionals who regularly visit the service.

We looked at a variety of records to gather information and assess the level of care and support provided to people. We reviewed 4 care records. We looked at staff rotas, risk assessments, multiple medicine records and 4 recruitment files. We also considered a variety of records relating to the management and governance of the service, including policies and procedures.

We looked around the home in both communal and private areas to establish if it met the needs of people who lived there and if it was safe.

Updated 25 July 2023

About the service

Nazareth House is a residential care home registered to accommodate up 43 people in need of personal care. Accommodation is provided over four floors with 43 single rooms, all with en-suite facilities. On the days of the inspection there were 39 people living at the home.

People's experience of using this service and what we found

People received their medicines as prescribed by health care professionals. Some medicinal cream use and some stock holding practices required attention but these were addressed at inspection.

People were safe and protected from the risk of harm. Risks were appropriately identified, assessed and managed. Staff were safe to work with vulnerable people and appropriate safety checks had been made.

Staff were competent with safeguarding processes and knew how to protect people from the risk of abuse. People said they felt safe in the home and were trusting of staff and management. We observed good practices and interactions between management, staff and people during the inspection.

Staff supported people to have access to healthcare professionals and specialist support and the service worked with external specialists.

People and their relatives were confident in the management team at the home and praised how approachable they were. The service made appropriate notifications to CQC and other authorities of safety incidents to ensure these incidents received appropriate oversight.

Infection, Prevention and Control (IPC) processes were in place and we were assured about the service's ability to mitigate the transmission of infections.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 3 November 2021) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider improved the recording of people's care and support needs, planning of staffing levels and its engagement with people and relatives. At this inspection, we found the provider had acted on the recommendations and noted improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we carried out a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 'Nazareth House - Lancaster' on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.