Nazareth House – Cheltenham

“The assessment was prompted by concerns relating to safe, care and treatment.”

“We received mixed feedback from people, relatives and professionals regarding whether there were always enough staff available to support people’s needs.”

“Medicines were administered as prescribed, although we found some discrepancies with records.”

“The provider did not always have a proactive and positive culture of safety. The system to analyse incidents, themes and trends did not demonstrate that learning had been identified and improvements embedded into practice.”

“We identified inconsistencies in records such as care plans and risk assessments, which were not always updated. Some care plans lacked key information regarding the management of risk, and records did not always demonstrate how decisions had been made in relation to risk.”

“Whilst leaders had some knowledge and understanding of the issues and priorities within the service, oversight and governance of the service had not always been effective. Governance systems were not consistent in identifying and addressing risks, and the systems had not identified all of the concerns we found during this assessment.”

“Despite the concerns we identified at assessment, staff, people and relatives mostly spoke positive about leadership within the service. One relative said, “They listen to me and I can ask them things and we have conversations.””

“Infection prevention and control measures were effective, and the environment was well maintained and adapted to meet people’s needs.”

“The provider was in breach of legal regulations relating to safe care and treatment and good governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.”

“The provider was responsive to all issues raised during this assessment, and the leadership team put measures in place to make improvements where they agreed there were shortfalls.”