CQC report explained · a nursing home
What the CQC found at Netherton Green Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unclean areas, poor clinical waste arrangements, unsafe infection control practices and medicines that were not always stored or recorded safely. Staffing and safeguarding had improved.
- Effective?
- Requires improvement
- People's care needs, nutrition and hydration risks were assessed, and staff had suitable training. However, most people did not enjoy the food, some drinks were out of reach, and the environment and signage did not always meet people's needs.
- Caring?
- Good
- People and relatives said staff were kind, respectful and compassionate. Inspectors saw people treated with dignity and involved in decisions about their care.
- Responsive?
- Good
- Care plans were person-centred and reflected people's preferences and routines. Activities, communication support, complaint handling and end-of-life planning were in place.
- Well-led?
- Requires improvement
- The home had improved its audits, staffing oversight and communication, but management checks did not identify continuing infection control and medicine problems. Learning from incidents was not always shared or added to care plans and risk assessments.
What inspectors found, December 2022
Netherton Green Care Home was rated Requires Improvement; care was kind and personalised, but infection control, medicines and management systems remained unsafe, although special measures ended.
This was an unannounced follow-up inspection on 13 September 2022. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicine records, recruitment files and management checks.
The home had improved since its previous Inadequate rating. Staffing was better, care plans were more complete, and people received kind and respectful care. The Caring and Responsive ratings improved to Good.
However, inspectors found problems with infection control, medicine storage and records, learning from incidents, food and parts of the environment. Management checks had failed to spot several of these issues.
The overall rating was Requires Improvement. The home remained in breach of Regulations 12 and 17. It was no longer Inadequate or in Special Measures, but the provider was required to submit an action plan and progress would continue to be monitored.
Kind and respectful care
People and relatives consistently described staff as kind. Inspectors also observed compassionate care and respect for people's dignity.
“All the people we spoke with told us the staff in the home treated them well, with kindness, respect and compassion.” from the report
Personalised care
Care plans included people's likes, dislikes, histories and routines. This helped staff provide care suited to each person.
“Care plans contained a 'This is me' document which outlined people's likes, dislikes, personal histories and routines.” from the report
Improved staffing
Inspectors found enough staff on duty and found that the staffing assessment tool was being used accurately. Safe recruitment checks were also in place.
“During the inspection we observed enough staff were deployed within the home to meet people's needs.” from the report
Good involvement and communication
People were involved in care reviews, and relatives said staff communicated with them and listened to their views.
“People's relatives told us they felt able to approach the staff to discuss their family member's care and would be listened to.” from the report
Infection control
seriousSome areas were unclean, clinical waste arrangements were inadequate and staff did not always follow infection control rules. Inspectors said this placed people at risk of harm.
“We were not assured that the provider was promoting safety through the hygiene practices within the home.” from the report
Medicines were not always managed safely
seriousSome creams and thickeners were not securely stored, opening dates were missing, and keys were left in a medicine trolley. This could mean medicines were not kept safely or checked as in date.
“People's prescribed creams and ointments did not have a recorded date of opening.” from the report
Learning from incidents
seriousThe home investigated incidents, but learning was not always shared promptly or added to care plans and risk assessments. This left people at risk of continued harm.
“The provider had failed to ensure the learning from the incident was shared with staff to mitigate the risk of reoccurrence.” from the report
Food and mealtime experience
needs fixingMost people said they did not enjoy the food. Inspectors also saw a drink placed out of reach and found distracting noise in the dining room.
“Most people told us they did not enjoy the food prepared by the home.” from the report
Environment was not always suitable
needs fixingSome areas lacked signs and personal items to help people find their rooms. Clocks were also showing the wrong time, although this was corrected during the inspection.
“We found the home's physical environment was not always appropriate to the needs of the people living there.” from the report
Management checks missed problems
seriousAudits had been completed, but they did not identify the infection control, medicines and care record problems found by inspectors.
“The audit did not identify the same issues found during this inspection.” from the report
- 01What has been done to make sure all areas, equipment and clinical waste are kept safe and clean?
- 02How are creams, thickeners and other medicines now stored, dated and checked?
- 03How do you make sure learning from accidents and incidents is promptly shared with staff and added to care plans?
- 04What changes have been made to the food, drinks access and mealtime environment?
- 05How are your audits now checking the specific problems identified in this report?
This was an unannounced follow-up inspection covering the service's overall quality and all five key questions, including infection prevention and control; it checked improvements required after the previous inspection. This explanation was written from the published report of 7 December 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, February 2022
Rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures, alongside kind staff and some personalised support.
Inspectors visited without notice on 25 November, 2 December and 7 December 2021. They spoke with people, relatives, staff and a visiting professional, observed care and reviewed care, medicine, staffing and management records.
The home did not always have enough staff. People waited for help, including getting out of bed, using the toilet and receiving personal care. Risks involving skin damage, pain, malnutrition and moving people were not always assessed or managed properly. Medicines were not always stored or recorded safely, and some cleaning and infection control checks were missed.
People often described staff as kind and respectful. There were activities, choices about food and support for visits. However, care was not consistently meeting people's needs. The overall rating fell from Good at the previous inspection to Inadequate. Safe and well-led were Inadequate, while Effective, Caring and Responsive Requires Improvement.
Activities and personal interests
Each bungalow had an activity co-ordinator, and people were offered activities they enjoyed, including time with people who preferred to stay in their rooms.
“There was an activity co-ordinator working on each bungalow.” from the report
People could raise concerns
People and relatives said they knew how to complain and felt comfortable raising concerns. The home kept a complaints log and generally took action to resolve issues.
“People and relatives told us they knew how to complain and would be comfortable to do so.” from the report
End of life wishes recorded
The home asked people and relatives about wishes for end of life care and recorded these in care plans.
“People and their relatives were asked about people's individual wishes regarding end of life care and this was recorded in their care plans.” from the report
Not enough staff
seriousPeople waited for essential care. Some were not helped out of bed until after midday, and one person remained in bed until 3pm despite preferring to get up early.
“We observed this in two of the bungalows, and people were left in bed until after midday.” from the report
Risks were not managed
seriousThe home did not always identify or reduce risks involving skin damage, pain, malnutrition, moving people and distress. Inspectors found that some people experienced further skin deterioration.
“We were not assured that all reasonable steps had been taken to reduce risks associated with people's care which placed people at risk of harm.” from the report
Medicine safety
seriousThere were missing instructions for some medicines, incomplete administration records and medicines that were not stored securely. This created a risk that people would not receive medicines safely or as prescribed.
“Medicines were not always stored safely.” from the report
Weak management checks
seriousAudits were missing or ineffective and had not identified problems with care plans, medicines, staffing or infection control. Management changes also left staff feeling unsupported.
“There were insufficient and inadequate systems in place to monitor and improve the quality of the service.” from the report
Care did not always protect dignity
needs fixingPeople sometimes waited for personal care or could not get up at their preferred time because of staffing levels.
“Some people told us their personal care needs were not always met in a timely manner, which had an impact on their dignity.” from the report
Care records were incomplete
needs fixingCare plans did not always include professional advice or clear instructions for staff. This was particularly concerning because agency staff were used regularly.
“Care plans were not always updated with the outcome of the involvement and the professional's advice.” from the report
- 01How many staff are now scheduled in each bungalow, and how do you check that staffing matches people's assessed needs?
- 02What has changed to make sure skin damage, pain, malnutrition and moving risks are identified and acted on promptly?
- 03How are medicines now stored, administered and recorded, including medicines given through a tube and when-required medicines?
- 04Who is currently managing the home, and how often are care plans, risk assessments, medicines and infection control audited?
- 05What improvements were made after the home was placed in special measures, and what evidence can you show families?
This inspection was prompted by concerns about staffing, skin damage support and management oversight, and also examined infection prevention and control; the report compares all five key-question ratings with the previous inspection. This explanation was written from the published report of 18 February 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 Netherton Green Care Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021Inspected but not ratedSafe: Inspected but not rated
- April 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 30 November 2017.
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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