CQC report explained · a residential care home
What the CQC found at Nethermoor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and there were enough staff to meet their needs. Some damaged building surfaces could prevent effective cleaning, and the electronic medicines recording system had stock-checking accuracy issues.
- Effective?
- Good
- Staff were experienced, trained and supported. People's dietary needs, healthcare needs and legal requirements around consent were assessed and managed.
- Caring?
- Good
- People and relatives described staff as kind and respectful. Staff supported people's privacy, dignity, independence and choices.
- Responsive?
- Good
- Care plans reflected people's needs, preferences and routines, and were reviewed regularly. Activities had improved but were sometimes inconsistent.
- Well-led?
- Good
- The provider and manager used audits and action plans to monitor care and make improvements. There had been manager turnover, but people, relatives and staff were positive about the new manager.
What inspectors found, November 2023
Rated Good; inspectors found safe, kind and well-managed care, with some building, medicines and activities work still underway.
This was an unannounced inspection on 19 and 21 September 2023. It followed concerns about risk management, staffing, training and safeguarding. Inspectors found no evidence that people were at risk of harm from these concerns.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable training, safe safeguarding arrangements and generally safe medicines management. People and relatives spoke positively about staff, who were described as kind, respectful and supportive.
Some parts of the building needed repair so they could be cleaned effectively. Medicines recording had some stock-checking accuracy issues, and activities were sometimes inconsistent. The provider was refurbishing the home and had recently improved activities. A new manager had been in post for eight weeks and had applied to register.
Enough staff
Inspectors found enough staff to keep people safe and meet their needs, including when people needed reassurance or wanted to join an activity.
“There were enough staff to keep people safe.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed kind interactions and found that privacy, dignity and independence were respected.
“Staff are really kind and know what they are doing.” from the report
Skilled staff and healthcare support
Staff had relevant training, supervision and skills checks. The home worked positively with health and social care professionals.
“Everyone we spoke with felt confident that staff had the right skills to provide a good standard to care.” from the report
Quality monitoring
The provider and manager carried out regular audits and used action plans to identify and address improvements.
“The provider and manager undertook regular audits of all aspects of the service to review the quality of care.” from the report
Building repairs and cleanliness
needs fixingSome damaged surfaces and areas needing repair could make effective cleaning difficult. Refurbishment was underway when inspectors visited.
“Some areas of the building had damaged surfaces, which would prevent effective cleaning, and there were some parts of the service which were not particularly clean or in a good state of repair.” from the report
Medicines records
needs fixingThe electronic medicines system was not fully accurate for stock checking. The management team knew about this and was taking action, and inspectors found no negative impact on people.
“However, we identified some issues with the accuracy of the electronic medicines recording system regarding the stock checking function.” from the report
Activities were not always consistent
minorPeople and relatives said activities were sometimes inconsistent. The home had made recent improvements and was still working to widen the activities available.
“People and relatives said activities were sometimes inconsistent, but that they generally enjoyed the activities they had participated in.” from the report
Management changes
needs fixingThere had been a turnover of managers since the current provider took over. People, relatives and staff were positive about the new manager, who had applied to register.
“Since the provider took over the service in May 2022, there had been a turnover of managers, which had been challenging to people, relatives and staff.” from the report
- 01Which damaged surfaces and areas still need refurbishment, and when will this work be completed?
- 02How are you checking medicines stocks while the electronic recording system is being corrected?
- 03What activities are now offered each week, and how do you ensure they take place consistently?
- 04How will the new manager's registration application and management arrangements be kept stable?
- 05How are residents' and relatives' views being collected and shown through the planned 'You said – we did' boards?
This was an unannounced comprehensive inspection covering all five CQC questions, including infection prevention and control, and it followed concerns about risk management, staffing, training and safeguarding. This explanation was written from the published report of 16 November 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.
What inspectors found, July 2022
Inspected but not rated; inspectors found unsafe medicines management, while the new provider was putting improvements in place.
This was an unannounced, targeted inspection on 09 June 2022. The inspection focused on whether people were supported to take their medicines safely. Inspectors reviewed medicines systems and spoke with people responsible for managing the home.
The provider had taken over the home 22 days before the inspection and found serious problems. Medicine stock checks were incorrect, one person's medicines were out of stock, and systems for recording, storing, giving and disposing of medicines were not fit for purpose. There was also no guidance for staff about some medicines prescribed when needed.
The provider had introduced a new medicines policy, staff training and an action plan. The provider was still writing guidance for medicines given when needed. The service was inspected but not rated because inspectors did not assess all parts of the Safe question.
New medicines policy
The provider introduced a new policy and made it available to staff to guide their work.
“The provider implemented a new medicines policy and ensured staff had access to this to guide their practice.” from the report
Action plan
The provider had a detailed plan showing how and when it intended to make improvements.
“The provider had a detailed action plan in place demonstrating how and when they would ensure improvements were implemented.” from the report
External support
The provider sought help from healthcare professionals and a pharmacist while changing the medicines systems.
“The provider liaised with external professionals such as healthcare professionals and a pharmacist to receive their support whilst changing the systems and processes within the home.” from the report
Medicines were not safely managed
seriousInspectors found incorrect stock checks and one person's medicines were out of stock. This could put people at risk.
“For example, they found medicine stock checks to be incorrect and one person's medicines were out of stock.” from the report
Systems were not fit for purpose
seriousThe systems for recording, storing, giving and disposing of medicines were not suitable when the provider took over the home.
“The provider identified the systems used to record, store, administer and dispose of medicines were not fit for purpose.” from the report
Missing guidance for medicines given when needed
seriousStaff did not have guidance for supporting people with medicines prescribed on an as-needed basis. The provider was still writing this guidance during the inspection.
“There was no guidance for staff to follow when supporting people to take medicines that were prescribed on an 'as required' basis [PRN].” from the report
- 01Has the action plan for medicines been completed, and can we see what was changed?
- 02How are medicine stock checks carried out now, and how are out-of-stock medicines prevented?
- 03Is written guidance now available for medicines prescribed on an 'as required' basis?
- 04What training have staff completed on recording, storing, administering and disposing of medicines?
- 05How does the home check that the new medicines systems are being followed?
This was a targeted inspection of medicines safety and did not assess all parts of the Safe question, so the service was inspected but not rated overall. This explanation was written from the published report of 5 July 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 Nethermoor Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- November 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Inspected but not ratedSafe: Inspected but not rated
- May 2022
Registered with the Care Quality Commission on 19 May 2022.
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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