Updated 2 February 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
The inspection team consisted of 2 inspectors 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 - Cheltenham 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 - Cheltenham is a care home without 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 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.
What we did before the inspection
We reviewed the information we had received about the service since the last inspection. We sought feedback from a recent inspection by Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 10 people who used the service and gathered feedback from 9 relatives about their experience of the care provided. We spoke with 13 members of staff including the registered manager, deputy manager, a senior care worker, 4 care workers, 3 agency care workers, a dining room assistant, the activities co-ordinator and the regional support manager. 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 reviewed a range of records. This included a sample of 9 people's care records, and a variety of records relating to the management of the service, including a review of some policies and procedures.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at policy and quality assurance records. We sought feedback from 9 professionals who have contact with the service and received responses from 4 professionals.