CQC report explained · a residential care home
What the CQC found at Nutten Stoven Residential 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
- Medicines were not always managed safely, and recruitment checks were incomplete. Inspectors found enough staff, suitable risk assessments and effective infection control.
- Effective?
- Good
- Staff received induction, training and supervision. People were supported with food, weight, health care and decisions about their care.
- Caring?
- Good
- People described staff as kind and helpful. Inspectors saw people treated with dignity and supported to make choices.
- Responsive?
- Good
- Care plans were reviewed and reflected people's needs. People were offered activities, communication support and help to maintain relationships.
- Well-led?
- Requires improvement
- The home had audits and gathered feedback, but its checks did not identify important medicines and recruitment problems. Effective systems to monitor and improve care were not fully established.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found kind care and improvements, but medicines, staff recruitment checks and quality oversight were not reliable.
This was an unannounced follow-up inspection on 9 and 10 August 2023. One inspector spoke with three people, the provider, the registered manager and three care workers. They observed care and checked care, medicines, staff and management records.
The home had improved since its last rating of Inadequate. Staff were kind, there were enough staff, risks were assessed, and people received support with food, health care and activities. The ratings for Effective, Caring and Responsive were Good.
However, the electronic medicines system was not working safely. One person's medicine had not been recorded as given for two weeks. The home also had not always checked staff members' full work history or obtained recent references from their last social care employer.
The home was still in breach of two regulations covering good governance and staff recruitment. It is no longer in Special Measures and is no longer rated Inadequate, but CQC said further improvement was needed.
Enough staff
Inspectors found enough staff to meet people's needs safely. Rotas and a staffing assessment supported this finding.
“There were enough staff to meet people's needs safely.” from the report
Kind and respectful care
People spoke positively about staff. Inspectors saw staff treat people with dignity and spend time talking with them.
“People were treated with dignity and respect.” from the report
Improvement since the last inspection
The ratings for Effective, Caring and Responsive improved from the previous inspection. The home also left Special Measures.
“At this inspection we found improvements had been made.” from the report
Risk and infection controls
People's risks were assessed and care records gave staff guidance. Inspectors were assured about infection prevention and control.
“Potential risks to people were assessed and kept under review to promote their safety.” from the report
Medicines records were unsafe
seriousThe electronic medicines system did not reliably show whether medicines had been given. One medicine was not recorded as administered for two weeks, and a stock discrepancy was not investigated.
“One person had not had one of their medicines recorded as administered for two weeks.” from the report
Incomplete recruitment checks
seriousThe home did not always obtain a full work history or an up-to-date reference from the person's last social care employer. This meant recruitment risks were not fully managed.
“Systems had not been established to get the full work history and up to date references for new staff.” from the report
Management checks missed problems
seriousAudits did not contain enough detail and failed to identify some concerns, including the medicines and recruitment issues. CQC said this placed people at risk of harm.
“Effective systems had not been fully established to assess, monitor and drive improvements to the care provided.” from the report
Food presentation
needs fixingFood for one modified diet was pureed together into a brown soup, rather than being kept separate so people could choose individual foods.
“Food was pureed altogether into a brown soup instead of being prepared separately so people could choose individual foods to eat or reject.” from the report
- 01How are medicines now recorded and checked after the electronic system was stopped?
- 02What checks are now completed on each new staff member's full work history and most recent social care reference?
- 03How often are medicines audits completed, and who reviews discrepancies or missed doses?
- 04What action has been taken to make sure management audits identify concerns before they affect people?
- 05How are people offered choice when they need pureed or other modified-texture food?
This was an unannounced follow-up inspection of action from the previous inspection, including infection prevention and control under Safe; the report gives ratings for all five key questions. This explanation was written from the published report of 11 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, May 2023
Rated Requires Improvement overall; inspectors found unsafe care systems and an Inadequate well-led service.
This was an unannounced inspection on 9 and 10 June 2022. One inspector spoke with five people, five relatives, seven staff members and one health and social care professional. They reviewed care records, medicines records, staff files, training records, complaints, incidents, audits and policies.
The home was not consistently safe. Staff training was incomplete, safeguarding concerns were not always followed up, and risk assessments and care plans did not always contain the information staff needed. Inspectors also found incomplete medicines records, unsafe infection control practices, environmental hazards and dirty kitchen equipment.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement and Well-led was rated Inadequate. The report says the overall rating had changed from Requires Improvement to Inadequate based on the inspection findings, although the ratings table records the overall rating as Requires Improvement. The other three key questions were not inspected at this visit and their previous ratings carried over.
People felt safe
People using the service and their relatives said they felt safe and were happy with the care they received.
“People using the service and their relatives told us they felt safe.” from the report
Mental capacity processes
Inspectors found that the home was working within the principles of the Mental Capacity Act, with appropriate legal authorisations in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Access to healthcare
The home supported visits from community health professionals and facilitated access to healthcare.
“Care staff and management facilitated visits by health and social care professionals.” from the report
Staff training
seriousSome staff had not completed mandatory training, including safeguarding, moving and handling, fire safety and infection control. Staff also lacked knowledge about dementia and people's individual needs.
“Care staff were not adequately trained in safeguarding.” from the report
Risk information
seriousRisk assessments and care plans were disorganised or missing information about swallowing, choking, falls and other health needs. This meant staff did not always have the guidance needed to keep people safe.
“This meant people were not always kept safe from the risks of aspiration or choking as staff did not have access to the required information or guidance.” from the report
Medicines records
seriousInformation about medicines and possible side effects was not always available to staff. Some medicine administrations were not recorded.
“Some medicine administrations had not been recorded.” from the report
Infection control
seriousSome staff did not wear masks or wore them incorrectly. Visitor COVID-19 test results were not always requested, and some kitchen areas and equipment were dirty.
“Some care staff were observed not wearing face masks.” from the report
Weak management checks
seriousAudits and monitoring systems did not reliably identify or fix problems. Inspectors found cleaning records completed before cleaning took place and no effective audit process for keeping care plans up to date.
“This demonstrated a culture of paperwork being used as a tick box exercise rather than accurately recording and improving care practices to ensure good outcomes for people.” from the report
Safeguarding follow-up
seriousA safeguarding system existed, but some concerns had not been properly addressed or followed up. This meant people were not always protected from abuse or harm.
“However, some safeguarding concerns had not been appropriately addressed or followed up by the provider.” from the report
- 01What evidence can you show that all care staff have now completed safeguarding, dementia, moving and handling, fire safety and infection control training?
- 02How are you now checking that care plans contain clear, current guidance about swallowing, choking, falls and other individual risks?
- 03What checks make sure every medicine administration is recorded and that staff understand the risks and side effects of medicines?
- 04What action has been completed in response to the warning notice about good governance, and how are audits now checked for accuracy?
- 05How are staff deployed to make sure people who need regular monitoring are not left without appropriate supervision?
This was an unannounced inspection focused on Safe and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 4 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.
Every inspection of Nutten Stoven Residential Home
7 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Nutten Stoven Residential Home →
- May 2023
Location report published without a new overall rating.
Read what inspectors found at Nutten Stoven Residential Home →
- May 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- March 2021Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 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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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.
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