CQC report explained · a nursing home
What the CQC found at Nettleton Manor Nursing 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 good systems for visiting, admissions and responding to infection, but they also found several infection-control shortfalls. These included cleanliness problems, missing PPE supplies and incorrect use of face coverings.
- Effective?
- Requires improvement
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed in this targeted inspection.
What inspectors found, August 2022
Nettleton Manor Nursing Home was inspected but not rated; inspectors found good COVID-19 precautions but several infection-control shortfalls.
This was an unannounced, targeted inspection on 2 August 2022. Inspectors looked at infection prevention and control, visiting arrangements, and staffing pressures linked to COVID-19.
The home required staff to take a lateral flow test at the start of every shift and continued temperature checks for visitors. It also had systems for safe visiting, admissions, and managing infections.
Inspectors found several problems that increased infection risks. These included cleanliness issues, poorly sealed flooring, missing hand towels and aprons, incorrect mask use, and a staff member entering communal areas without an alternative face covering.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement for Safe.
Regular staff testing
Staff were required to take a lateral flow test at the start of every shift. Inspectors said this went beyond government guidance.
“The provider exceeded government guidance in requiring staff to conduct a lateral flow test at the start of every shift, to reduce the risk of COVID-19 entering the home.” from the report
Visitor checks
The home continued temperature checks for all visitors, which inspectors said exceeded national and local policy requirements.
“The provider also exceeded government guidance in continuing to conduct temperature checks on all visitors to the home.” from the report
Staffing response
The provider had sourced some care staff from overseas to help keep staffing levels sufficient during workforce pressures.
“The provider had proactively sourced some care staff from overseas to help address the staffing challenges created by the COVID-19 pandemic and other pressures on the social care workforce.” from the report
Safe visiting arrangements
Inspectors found an effective system for health and social care professionals, relatives and friends to visit safely.
“The provider had an effective system to enable local health and social care professionals and people's relatives and friends to visit the home safely.” from the report
Cleanliness and building surfaces
needs fixingA utility room was not fully clean. Exposed pipework and poorly sealed flooring could trap dirt and infection, increasing the risk of spread.
“Additionally, exposed pipework in the laundry and poorly sealed vinyl flooring in some bathrooms created potential traps for dirt and infection.” from the report
Missing hygiene supplies
needs fixingThe hand towel dispenser in the dining room was empty, and two PPE stations did not have aprons.
“The hand towel dispenser beside the communal washbasin in the dining room was empty, undermining the provider's commitment to safe hand hygiene.” from the report
Incorrect face covering use
needs fixingInspectors saw a staff member wearing a facemask below their nose on two occasions. This increased the risk of COVID-19 spreading.
“However, on two occasions we observed the same staff member wearing their facemask incorrectly below their nose, increasing the risk of COVID-19 spreading within the home.” from the report
Outbreak arrangements
needs fixingDuring a COVID-19 outbreak, a staff member with a medical exemption from wearing a facemask entered communal areas without an alternative face covering.
“However, despite the presence of COVID-19 in the home, a staff member who had been granted a medical exemption from wearing a facemask, was still accessing some communal areas of the home without any alternative face covering, increasing risks to themself and others.” from the report
- 01Have the utility room, laundry pipework and bathroom flooring problems all been fixed, and how are these areas checked now?
- 02How do you make sure every PPE station has aprons, gloves and masks at all times?
- 03What checks are used to make sure staff wear facemasks correctly?
- 04What alternative face covering is used when a staff member has a medical exemption during an infection outbreak?
- 05How have staffing pressures affected the home since this inspection, and are staffing levels currently sufficient?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and staffing pressures; it did not assess the other four questions or give a full service rating. This explanation was written from the published report of 24 August 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 2021
Targeted inspection found improvements, but the overall rating remained Requires Improvement and was not re-rated.
Inspectors visited on 25 January 2021. They checked infection control and whether the home had acted on earlier breaches involving safe care and treatment and good governance. They spoke with three people, six staff members and visiting health professionals, and reviewed care, medicine, training and management records.
Inspectors found that risks to people’s safety had been identified and care plans gave staff guidance to reduce those risks. Medicines were managed safely. Staff had updated training, used suitable personal protective equipment and were checked on their infection control practice.
The home had improved its audits and these were identifying issues for action. However, some audits needed more analysis and actions were not always recorded. The provider was no longer in breach of Regulations 12 and 17, but this targeted inspection did not assess the full service, so the previous Requires Improvement rating remained.
Infection control
Staff used appropriate personal protective equipment and understood when and how to put it on and remove it. Managers regularly checked their practice.
“During this visit we saw staff were wearing appropriate PPE and showed a good knowledge of when the equipment should be worn and how to don and doff their PPE.” from the report
Safer care planning
People’s safety risks had been identified and care plans included guidance for staff on reducing those risks.
“Risks to people's safety had been identified and their care was centred around managing and reducing these risks.” from the report
Medicines management
Medicine records gave staff clear instructions, including for medicines that were given only when needed.
“People were supported with their medicines administration and medicines were managed safely.” from the report
Staff training
Staff had received updated training, including specialist training for health conditions such as diabetes and chronic heart failure.
“The training matrix we viewed showed this training was being undertaken on a monthly basis to further support staff with up to date specialist training for their roles.” from the report
Audits need to be embedded
needs fixingSome audit tools were still being introduced. Some audits needed more analysis, and actions taken were not always recorded, so the improvements still needed to become established.
“However, the processes in place need time to be embedded and further improved to show the improvements found would be sustained.” from the report
- 01How are you making sure the new audit systems are now fully embedded?
- 02How do you record actions taken after an audit identifies a problem?
- 03What specialist training have staff completed recently for the health conditions represented in the home?
- 04How often are staff checked on putting on and removing personal protective equipment?
- 05When will the next comprehensive inspection assess all five key questions?
This was a targeted inspection of specific parts of Safe and Well-led, focused on infection control and earlier Regulation 12 and 17 concerns; it did not review the full key questions, so the previous ratings were not changed. This explanation was written from the published report of 20 February 2021 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 Nettleton Manor Nursing Home
5 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- August 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Nettleton Manor Nursing Home →
- February 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at Nettleton Manor Nursing Home →
- September 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- May 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- October 2012
Registered with the Care Quality Commission on 25 October 2012.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.