Nazareth House - Cheltenham

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.
 

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The leadership team were passionate about the service and committed to strengthening the governance processes to ensure people received good quality care and improved outcomes aligned with their shared vision, strategy and culture.

Staff and relatives generally described the service as having a positive culture and environment. One relative said, “I know who is in charge and [the deputy manager is upstairs and always available]. [The management team] are very approachable and I could go to them with anything.” A staff member said, “Our care home is one of the best care homes and I love working here.”

The provider was open to feedback and responsive during the assessment, demonstrating a willingness to improve and take action where concerns were identified. They showed a commitment to developing the service and supporting staff to deliver good care.

Leaders did not always operate effective systems to consistently identify, recognise or escalate concerns within the service.

People and their relatives gave mostly positive feedback and told us leaders were visible within the service and involved in the day to day running of the home. One relative said, “[The registered manager] is supportive of me and my [family member], [they have] answered all my questions and [they are] kind and happy to have a chat with me.”

However, shortfalls in internal processes meant there was not always a clear record to show that risks had been reliably identified or acted upon. Gaps in governance meant we were not assured the service was consistently well-led, or lessons had been consistently used to drive ongoing improvements in the quality of care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a policy in place to ensure staff were able to raise any concerns. Staff were aware of the policy and mostly described feeling comfortable to raise any concerns. One staff member said, “The registered manager and deputy manager have an open door policy and are happy for us to pop in with concerns, if any.” Another staff member said, “Yes [leaders do encourage you to speak up]. I have spoken up about things and have been listened to.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and
outcomes, or share this securely with others when appropriate.

There was a governance structure in place to support the provider and management team to undertake their roles. However, the governance systems we saw at the time of assessment had not been consistently operated to effectively monitor the service and identify the shortfalls we saw in relation to records. The lack of governance placed people at risk of receiving inconsistent care.

The registered manager was aware of their responsibilities and of their duty to notify the Care Quality Commission (CQC) of significant events. The registered manager mostly submitted notifications in a timely manner. However, we identified a small number of notifications which had not been submitted. The registered manager advised this was because the system had not operated effectively in their absence and told us they would put measures in place to strengthen the process moving forward.

There was an active service improvement plan in place, supported by ongoing audits which looked at different areas of the care provided. However, these audits had not always identified the shortfalls we found during this assessment in relation to record keeping. For example, quality audits were not sufficiently detailed, and records did not provide assurance risks were consistently monitored and mitigated, with an effective system to ensure improvements were embedded.

The registered manager assured us they would be reviewing and strengthening their audit processes to ensure they were more robust, and able to identify issues promptly.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, we received mixed feedback from people and their relatives about whether they had been involved in their relatives’ care. One relative said, “Not seen [a care plan], no they don’t involve me, no meetings about [my relatives] care.” In contrast, other relatives spoke more positively about the collaboration. One relative said, “[My relative] has a care plan but I haven’t seen it or have a copy of it. I am included, very much so.”

We did not always see a record to assure us that people had been referred to other agencies when needed. For example, when people had lost weight or required input from a dietician. This meant that we could not be assured people were consistently receiving care in accordance with their changing needs. Despite this, we received from people and relatives, we received positive feedback from healthcare professionals who had worked directly with the service on an ongoing basis. One professional said, “I have found communication between the service and myself to be effective, timely, and professional.” Another professional said, “Staff communicate well with me regarding any [specific issues]. Staff know [people] well and can answer questions.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Whilst there was a service improvement plan in place, the provider had not always used their own auditing processes and procedures effectively to make consistent service improvements. As a result, there were shortfalls in the service that they were not aware of until we raised them during this assessment.

However, we also saw positive examples where the provider was developing their systems and making positive change. The registered manager told us the service was exploring new ways of working to support continuous improvement. They told us they were moving to a different electronic care management system to enhance oversight and support more efficient, accurate record keeping.

The provider was receptive to the feedback and took action to address areas of risk to minimise the potential impact to people’s safety.