Nazareth House - Manchester

Updated 7 March 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 Health and Social Care Act 2008.

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

This inspection was carried out by an inspector, a medicines inspector, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Nazareth House – Manchester 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. Nazareth House – Manchester is a care home with nursing care. 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 CQC 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.

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 and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 9 people to understand their experiences living in the home. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also telephoned 6 relatives to obtain their feedback.

We spoke with the registered manager, clinical lead/deputy manager, regional manager, interim support manager, 7 members of the care team, members of the administration team, and members of the activities team.

We reviewed medicine administration records and looked at medicines related documentation for 8 people. We also reviewed care records and records related to safety, audit and quality assurance.

Updated 7 March 2023

About the service

Nazareth House – Manchester is a nursing home providing personal and nursing care for adults over 65 years. The home is registered with the Care Quality Commission (CQC) to accommodate a maximum of 66 people. At the time of our inspection there were 27 people living in the home.

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

Care and support was provided to people by a team of staff who were dedicated, passionate and committed to their roles. Staff were caring and always sought to ensure people were treated in a dignified and respectful way.

Managers and staff had worked to address issues found at the last inspections to improve the management of medicines. We found systems in place to manage people’s medicines were safe. We have recommended the service continues to monitor the management of medicines to ensure the improvements made are sustained.

Leadership and management was effective. It was evident throughout the inspection the new registered manager and new wider leadership team had made a positive impact; this was supported by feedback which was wholly positive. Leaders now led by example, creating and embedding a culture where people felt valued, and their individual contributions recognised.

Systems for audit, quality assurance and questioning of practice had improved with clear lines of accountability now established. The provider fully understood the importance of maintaining systems and processes which support good governance. Credible data now being gathered from internal audit and quality assurance meant themes and trends could be identified early, which in turn helped managers and staff to identify risks sooner and take remedial action.

Staff understood how to protect people from poor care and abuse and worked well with other agencies to do so. There were enough appropriately trained and skilled staff to meet people’s needs and to keep them safe. We were assured any future new admissions into the home would be done on a phased basis to ensure safe staffing levels were maintained.

The provider had commenced a significant premises improvement and refurbishment programme. Improvement works included redecoration of communal areas, people’s rooms, new flooring and plans to significantly enhance the outside space. To best support people living with dementia and memory problems, we have recommended the provider consults national best practice guidance for creating a dementia friendly environment.

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.

People and those important to them were involved in planning their care. Staff evaluated the quality of care provided involving the person, their families, and other professionals as appropriate.

A desire to re-establish Nazareth House – Manchester as a valued place within the local community was a recurring theme amongst everyone we spoke with. At the heart of this, was renewed commitment made by leaders and staff to a set of shared core values. This was underpinned by the well-established and valued association with the roman catholic church. People affectionately referred to the ‘Nazareth House family’ a family that welcomed people of all faiths, and those of none, and one which embraced and celebrated people from diverse backgrounds.

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 Inadequate (published 11 October 2022). This service has been in Special Measures since April 2021.

The provider worked collaboratively with local authority and healthcare partners to implement an improvement plan, 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. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on actions we told the provider to take at the last inspection.

Follow up

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