Nelson House

“Since our last inspection in March 2022, we found the service had not made the required improvements to meet the breaches of regulations and improve the standard of care provided to people. We found the provider was still in breach of 2 regulations in relation to risk management and good governance. We also identified new breaches of regulations in relation to person centred care, consent, safeguarding, nutrition and hydration, safe premises and staffing.”

“The provider did not have a good learning culture and risks to people were not managed safely. The provider did not ensure people’s individual needs and preferences were met. Systems were not in place to ensure people’s rights under the Mental Capacity Act 2005 (MCA) were met. Staff had insufficient guidance for the management of people’s known health conditions and risks to ensure these were managed safely. We identified a lack of effective monitoring and mitigation in relation to risks such as dehydration, food intake, malnutrition, and skin breakdown. People’s medicines were not always managed safely. The provider did not follow their own or the Local Authority safeguarding procedures to ensure people were safeguarded from harm. The provider did not ensure the environment was safe, and risks were not being proactively identified and managed. The environment was not well maintained, and there were delays in work being completed once issues had been reported. Systems to monitor the safety of the environment were ineffective and had not identified the widespread risks and shortfalls we found.”

“The provider had not ensured enough trained staff were on duty to always meet people’s needs. The provider failed to have effective quality assurance and auditing systems to maintain oversight of the home. Systems to ensure care was provided safely and appropriately were not robust. In addition, the provider had not consistently notified the CQC of all notifiable events as required by regulation. The provider had failed to identify the issues highlighted during this assessment which meant urgent action was taken to maintain people’s safety.”

“Staff did their best to support people and provide care which met their needs. Staff felt supported by their colleagues, but did not feel valued by the provider.”

“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.”

“This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.”

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