CQC report explained · a residential care home
What the CQC found at Nelson House
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, April 2022
Nelson House was rated Requires Improvement; inspectors found infection control and management systems were not reliable enough.
This was an unannounced, focused inspection on 16 and 17 March 2022. One inspector spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was not always safe. Inspectors found missing infection risk assessments, poor arrangements for disposing of protective equipment, damaged flooring and weak checks on cleaning. Medicines were administered safely, but some records and audits were incomplete.
The home was also not well-led. Care plans were not reviewed regularly, staff supervision was often missing, recruitment checks were not always properly recorded, and accidents, incidents and people's views were not monitored well. The inspection found breaches of Regulations 12 and 17. The home had previously been rated Good in 2018, but the overall rating changed to Requires Improvement.
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to recognise and report safeguarding concerns.
“People we spoke with told us they felt safe.” from the report
Staff knew people and their risks
The staff team was consistent and knew people's needs. Staff could explain how they would recognise diabetes-related risks.
“There is a consistent staff team who know people well and people feel confident in their care skills.” from the report
Safe medicine administration
Inspectors found that medicines were administered safely, stored securely and supported by guidance for medicines given when needed.
“When people required medicines to be administered on an 'as and when required' (PRN basis, there was guidance in place for staff to follow so they would know when to give the medicine.” from the report
Approachable management
People and relatives knew who ran the home and felt able to raise concerns. The manager was open to inspectors' feedback.
“People and relatives told us they knew who the registered manager was and that they were approachable.” from the report
Infection control
seriousThere were no individual COVID-19 risk assessments for people or staff. The home also lacked suitable places to dispose of used protective equipment, and some areas were difficult to clean.
“There were no individual COVID-19 risk assessments for people living at the home or staff, and infection prevention and control policies (IPC) had not been followed.” from the report
Weak quality checks
seriousThe provider did not have effective systems to check cleaning, medicines, care plans, incidents, staff supervision or the environment. This was a breach of Regulation 17.
“The provider's failure to ensure that effective systems were in place to monitor the quality of the service was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Environmental hazards
needs fixingWorn and loose carpets had not been identified through the home's checks. Inspectors said they could harbour dirt and bacteria and create a trip hazard.
“Carpets on stairs and in front of the dining area were worn with holes in them.” from the report
Care plans not reviewed
needs fixingSeven care plans and risk assessments had not been reviewed since June 2021. Inspectors found no evidence that anyone had been harmed as a result.
“We found seven care plans and risk assessments had not been reviewed since June 2021.” from the report
Limited staff supervision
needs fixingOnly two staff had received formal supervision since December 2021, despite the provider's policy requiring monthly supervision.
“Only two staff had received formal supervision since December 2021.” from the report
- 01What has been done to complete individual infection risk assessments for every person and staff member?
- 02Where are used protective equipment items now disposed of, and how is infection control checked?
- 03How often are care plans and risk assessments now reviewed and recorded?
- 04How are cleaning, medicines, accidents and incidents audited, and how are lessons shared with staff?
- 05How are staff supervision, recruitment checks and refresher training now monitored?
This was a focused inspection of Safe and Well-led only because of concerns about infection prevention and control; the other ratings were carried forward from the 2018 inspection. This explanation was written from the published report of 29 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2022
Nelson House was inspected but not rated; inspectors found good visiting arrangements but concerns about PPE, cleaning and infection-control records.
This was an announced, targeted inspection on 24 February 2022. It focused on infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors found good arrangements for family contact, including visits in bedrooms, the garden and a separate visiting pod. The home also supported healthcare visits and had worked with public health professionals during a January 2022 outbreak.
However, inspectors were not assured that PPE was being used safely. They also found problems with waste disposal, cleaning, the condition of some areas, infection-control records and evidence of COVID-19 testing. The service was inspected but not rated, so this report does not give a Good, Requires improvement or Inadequate rating.
Family contact
People could keep in touch with relatives through bedroom, garden and driveway visits, the visiting pod and telephone calls.
“People were supported to keep in contact with their family members through physical visits, garden or driveway visits and regular phone calls.” from the report
Visiting pod
The home had created a separate visiting pod with a glass screen and intercom to reduce infection risk.
“The provider had made adaptations to the home to create a visiting 'Pod', with glass screen, voice intercom and separate access, which minimised the risk of the spread of infection.” from the report
Healthcare support
Staff supported people with healthcare appointments and arrangements for hospital visits and safe returns to the home.
“Staff supported people to access healthcare appointments and arrangements were in place when people need to attend hospital and return to the home safely.” from the report
Outbreak management
The manager and staff worked with public health and infection-control professionals during the January 2022 outbreak.
“The registered manager and staff had worked closely with public health and infection control professionals to effectively manage an outbreak in January 2022.” from the report
PPE was not used safely
seriousInspectors saw staff move between rooms without removing an apron correctly. They also saw an apron being removed in a corridor and dropped on the floor, increasing the risk of infection spreading.
“We were not assured that the provider was using PPE effectively and safely.” from the report
Waste disposal and cleaning
needs fixingThere were problems with clinical waste bins, including a household black bag used for clinical waste. Cleaning schedules did not clearly state how often areas should be cleaned or which products to use.
“Cleaning schedules lacked detail on the frequency of cleaning and products to be used, and there was no oversight in relation to these.” from the report
Infection-control policy and checks
needs fixingThe provider did not provide its infection-control policy when requested. Risk assessments and audits had not identified all the problems found by inspectors.
“We were not assured that the provider's infection prevention and control policy was up to date.” from the report
Some areas were difficult to keep clean
needs fixingInspectors found damaged flooring, gaps in sealant, broken tiles and other worn areas. Clean linen was stored next to a trolley for soiled linen, creating a risk of cross-contamination.
“In the laundry, we found clean linen was stored next to a soiled linen trolley which meant there was a risk of cross contamination.” from the report
Testing records
needs fixingThere was no system to record visitors' negative lateral flow tests. The home could not provide evidence that two recently admitted people had completed COVID-19 testing.
“Although we were asked to produce evidence of a negative LFT on arrival at the home, there was no system to record this information” from the report
- 01What has changed to make sure staff remove and dispose of PPE safely when moving between rooms?
- 02How are cleaning schedules now checked, including frequently touched areas and the products used?
- 03Have the damaged flooring, sealant, tiles and other worn areas been repaired?
- 04How are visitors' negative lateral flow tests and new residents' COVID-19 tests recorded now?
- 05What action was taken after inspectors found that the infection prevention and control policy and audits were not up to date or detailed enough?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not provide a full service rating. This explanation was written from the published report of 24 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Nelson House
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- April 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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