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CQC report explained · a nursing home

What the CQC found at Nether Place Nursing Home

Requires improvementpublished 4 November 2025, 11 months ago

Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.

The latest report, explained

What inspectors found, May 2023

Nether Place Nursing Home was rated Requires Improvement, with Safe rated Inadequate because inspectors found risks in staffing, fire safety and medicines.

This was a focused inspection of Safe and Well-led. The inspection activity ran from 25 January to 23 February 2023, with visits on 25 and 31 January. Inspectors spoke with people, relatives, staff and professionals, and reviewed care records, medicines records, recruitment files, training records and quality checks.

Inspectors found people were at risk because staffing levels were not always enough, nursing staff risks were not properly assessed and some staff lacked required training. Fire safety arrangements were not safe, medicines were not always given as prescribed, and checks on safety and quality were not reliable.

The home had been without a registered manager for more than six months. The provider began making changes during and after the inspection, but inspectors said these changes were not yet established. The overall rating fell from Good at the previous inspection to Requires Improvement. Safe was rated Inadequate and Well-led Requires Improvement. Other question ratings were carried over from the previous inspection.

What inspectors praised
  • People felt safe

    People, relatives and friends said they felt safe with the support provided.

    “I feel safe here and can get help if I need it.” from the report
  • Kind and person-centred staff

    Staff were described as caring and committed to supporting people's independence and personal needs.

    “We're well looked after, the staff are lovely.” from the report
  • Working with professionals

    Professionals gave positive feedback about staff working with them and being willing to learn.

    “Each and every visit I have made to the service has been welcomed and the staff and management were very eager to learn from me.” from the report
  • Some improvements were made

    The provider improved bedroom door locks after the previous inspection. Changes were also made to medicines arrangements after inspectors raised concerns.

    “At our last inspection we recommended the provider change bedroom door locks to enable them to be opened externally in the event of an emergency.” from the report
What inspectors were concerned about
  • Staffing and competence

    serious

    Staffing levels were not always sufficient, and risks about nursing staff competence were not properly assessed. Care staff had not received training in behaviours that challenge, despite the home providing dementia care.

    “The provider did not always ensure staffing levels were sufficient to support people to stay safe.” from the report
  • Fire safety

    serious

    Staff did not always know how to respond to a fire, fire drills were not regular and safety equipment checks had not been recorded for several months. Night staffing could also make evacuation unsafe.

    “People were at risk as fire safety was not well managed.” from the report
  • Medicines

    serious

    Some medicines were given at the wrong time, and staff applying creams did not always have suitable training or competence checks. Changes were made after the first inspection day, but further work was planned.

    “Medicines were not being administered as prescribed.” from the report
  • Weak management oversight

    serious

    Quality checks were not reliable and the provider had not identified several important problems. The home had also been without a registered manager for over six months.

    “The service had been without a registered manager since 21 July 2022.” from the report
  • Incomplete DoLS records

    needs fixing

    The home was working within the Mental Capacity Act principles, but records did not always show how conditions attached to people's authorisations were being met.

    “People's care records did not always show how any conditions given as part of their DoLS authorisation were being met.” from the report
Questions to ask them, based on this report
  1. 01What staffing levels are now in place during the day and at night, and how are they checked against residents' needs?
  2. 02What changes have been made to fire drills, fire equipment checks and overnight evacuation arrangements?
  3. 03How do you now make sure medicines are given at the correct time and that staff are trained and assessed as competent?
  4. 04Has the manager registered with CQC, and what quality checks are now completed and followed up?
  5. 05How are conditions attached to people's Deprivation of Liberty Safeguards authorisations recorded and monitored?

This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 11 May 2023 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.

An earlier report, explained

What inspectors found, December 2017

Rated Good overall, but Safe Requires Improvement because of concerns about bedroom door locks, cleaning and staffing availability.

Inspectors carried out an unannounced comprehensive inspection on 19 October 2017. They spoke with people living in the home, relatives and staff, observed care, and checked care, medicines, staffing, recruitment, maintenance and quality records.

The home was rated Good overall, with Good ratings for Effective, Caring, Responsive and Well-led. Medicines were managed safely, staff training and recruitment were suitable, people's rights were protected, and care was generally personal and kind.

Safe was rated Requires Improvement. Inspectors found some bedroom locks might not open from outside in an emergency, some equipment and areas needed better cleaning, and people gave mixed views about staffing levels. The home remained Good overall, as it had been at the previous inspection in February 2015, but inspectors made recommendations about the locks and updating policies.

What inspectors praised
  • Safe medicines

    Medicines were stored, administered and recorded appropriately. Controlled medicines were checked regularly, and suitable care plans and risk assessments were in place.

    “Medicines were being administered and recorded appropriately and were being kept safely.” from the report
  • Kind and respectful care

    People said staff were polite and caring. Inspectors saw staff knocking before entering rooms and supporting people to do as much as possible for themselves.

    “All of the people we spoke with said the staff supported them to do as much as they could for themselves so as to maintain their independence.” from the report
  • Personalised care

    Care records included people's preferences, family histories and the support they needed. People could personalise their bedrooms with their own belongings.

    “Care plans recorded people's preferences and provided information about them and their family history.” from the report
  • Suitable staff recruitment and training

    The required employment checks had been completed, and staff had induction training and regular updates, including training about dementia care.

    “When employing fit and proper persons the recruitment procedures of the provider were robust in ensuring suitable people had been employed.” from the report
What inspectors were concerned about
  • Bedroom door locks

    serious

    Some bedroom locks could not be opened from outside if locked from inside. Inspectors recommended that these locks be changed because this could affect emergency access.

    “We found that some of the bedroom door locks in use could not be opened, should it be necessary in an emergency, if they had been locked from the inside.” from the report
  • Cleaning standards

    needs fixing

    Some equipment was stained and had old food on it. Tables and floors in dining areas were not always cleaned between meals.

    “Although there were cleaning schedules in place and in the main the home was reasonably clean, we found that some pieces of equipment in use were stained and covered in old food matter.” from the report
  • Staff availability

    needs fixing

    People and relatives gave mixed views about staffing. Inspectors also saw that staff were not always readily available, and people were sometimes left unattended for short periods.

    “One person said, "There is staff about but it can be stretched sometimes, especially if people go off sick.” from the report
  • Help at mealtimes

    needs fixing

    Some people who needed help with meals were left waiting before support was given. This was raised alongside concerns about staffing at lunchtime.

    “However we observed that not all people received timely support with their meals and people were left sometime before help was actually given.” from the report
  • Policies needed updating

    needs fixing

    Some policies and procedures did not refer to current legislation or good practice guidance. Inspectors recommended that these be updated.

    “During the inspection we noted that some of the polices and procedures in use did not always refer to current legislation or good practice guidance.” from the report
Questions to ask them, based on this report
  1. 01Have all bedroom door locks been changed so staff can open them from outside in an emergency?
  2. 02What has been done to improve cleaning of equipment, tables and floors between meals?
  3. 03How do you make sure enough staff are available at night, during staff sickness and at busy mealtimes?
  4. 04How quickly will people who need help with meals receive that support?
  5. 05Have the policies and procedures been updated to reflect current legislation and good practice guidance?

This was an unannounced comprehensive inspection covering all five key questions, with the inspection team observing care and checking records including those for nine people. This explanation was written from the published report of 13 December 2017 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.

The story over the years

Every inspection of Nether Place Nursing Home

3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

  1. May 2023Requires improvementcurrent ratingdown from Good
    Safe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Nether Place Nursing Home →

  2. December 2017Goodstayed Good
    Safe: Requires improvementWell-led: Good

    Read what inspectors found at Nether Place Nursing Home →

  3. June 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. November 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. February 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. November 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. July 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. February 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. January 2011

    Registered with the Care Quality Commission on 10 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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