Nelson House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive learning culture of safety. Staff did listen to concerns about safety, however, did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found there was limited evidence that management processes were robust enough to ensure adequate oversight of learning from incidents. The deputy manager told us they do investigate all incidents to find the root cause. However, we found there was no written evidence the incidents had been investigated, learning had taken place, or they were monitored for themes or trends. This meant we were not assured there was an effective learning culture.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems and processes in place to complete a pre-admission assessment, that involved the person and people who knew them well. A relative told us, they found the process very well organised, and the management team asked questions to find out how to best support the person. Staff told us, when someone new was moving in, the management team shared care plans and information regarding the person before supporting them.

Safeguarding incidents were recorded and where harm had occurred details of these had been recorded or photos had been taken. However, the management team did not always share reportable incidents with the Care Quality Commission (CQC) and/ or the local authority safeguarding team. For example, we found an incident where a person sustained a head injury which resulted in a hospital visit and this was not reported. This meant people could be at continued risk of harm. During our visit, we raised this, and the provider took action and told us they would report the incidents. The provider’s policies regarding safeguarding were not current and contained guidance that was no longer in use. This meant staff did not have clear information and guidance to follow to ensure people were safeguarded appropriately. Staff had received training around what to do to make sure people were protected from harm or abuse. Staff ensured Deprivation of Liberty Safeguards (DoLS) authorisations were applied for when needed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place to provide staff with clear guidance on how to manage known risks. For example, a person was diagnosed with epilepsy and staff had clear guidance to follow. The staff team knew people well and how to best support people. We found there was not always oversight in relation to people’s weight monitoring. For example, we found a person’s weight had increased over the last 6 months by 5.4%. There was no evidence to show what action has been taken. The provider told us they took action after our visit. They told us they had booked a GP appointment for a person and the GP had no concerns

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, staff had checked hot water temperatures monthly, however they had not identified the temperature was not within a safe temperature range. This meant people were at potential risk of a scalding. The provider told us after our visit they had taken action by having an external company come out to assess and the temperatures were now within safe ranges. Refurbishment had taken place and the management told us of the plan in place for people’s bedrooms to be updated without causing any disruption to their care.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did work together well to provide safe care that met people’s individual needs. Not all staff had completed the required training. For example, the training completion record showed one staff member had not completed any training courses but had been working at Nelson House for over a year. The provider used a staffing calculation tool to ensure safe levels of staffing. The management told us whilst they had a safe level, they did increase staffing numbers depending on how people want to spend their time. On days where people wanted to access the community or activities outside the home, they increased the staffing levels. Staff told us they had staff meetings and one to one supervision. Staff were safely recruited, and all pre-employment checks had been carried out prior to staff commencing in their posts. Disclosure and Barring Service (DBS) checks were completed when people commenced in post. Staff told us they were supported with skills development and had been offered to complete the level 5 health and social care course.

The provider had an infection prevention and control policy in place however it did not provide staff with guidance and information on what to do in event of an outbreak. The provider maintained a clean and uncluttered environment. There were no malodours and staff ensured all areas of the home were regularly cleaned. Staff had access to personal protective equipment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. There were effective processes in place for ordering, storage, disposal, administration recording and temperature monitoring was carried out to make sure medicines would be safe and effective. Staff had training and observational competency checks to make sure they gave medicines safely. Regular medicines checks and audits took place, and we saw that these identified areas and actions for improvement, which were recorded when completed.