Nelson House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service. Systems to audit the quality of care and safety were not always effective in identifying and addressing areas of concern, risks, or improvementswe have asked the provider for an action plan to make improvements in this area

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management team had a clear vision to provide safe and quality care to all the people in their care. There was a statement of purpose in place that detailed their strategy. The staff team were aware of the vision and told us they all worked as a team to ensure people received good care and their human rights were protected.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge or experience to ensure national guidance was always followed and the regulations. The risks we found during this assessment had not been identified by the management team prior to our visit. Therefore, we were not assured all managers had full knowledge and experience of the regulations. The management and staff team were compassionate; staff were complimentary of the management team and felt supported by the management team. Staff told us, “They have good communication skills, accurate records and strong team and always explain how to do things if we do not understand anything and good teamwork. We do a lot of activities with people and go out a lot. We receive good support from leaders.” “The managers really care about the residents and staff, and this is rare within the care sector.” The provider told us a manager and senior care staff member were in the process of completing further education in health and social care to support their ongoing development.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and people who were involved in people’s care told us they felt they could always speak up and would be listened too. One staff member told us, “Yes, we definitely have the freedom to speak, and we are listened to. For example, if we have concerns regarding the residents they, [management] value our advice.” Whistleblowing policies were available for staff with advice about who to contact if they had concerns.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider’s equality and diversity policy did not cover the 9 protected equality characteristics. This meant staff were not provided with written guidance on how to ensure people or the staff team were treated fairly and equally regardless of any protected characteristics. However, staff told us they were respected and treated equally. One staff member told us, “Absolutely no concerns, I feel welcome, and part of the team and we work as a team, fair and united as a team.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We found shortfalls in the management oversight of incidents and accidents. We found reportable incidents had not always been reported to the CQC and/or the local authority’s safeguarding team where required. This meant people could be placed at risk of harm and/or abuse due to poor reporting of safeguarding incidents. Environmental checks failed to address issues and concerns we found during our assessment. Policies and procedures such as safeguarding, infection prevention and control, equality and diversity were insufficient because they had not been updated and/or did not provide current guidance. There were regular staff meetings and meeting minutes were available. Staff were provided with the opportunity to have one to one meetings to discuss their performance. There were effective communication systems to involve people who were important to people living at Nelson House in their care and obtain their feedback.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. People were supported to access health services, and it was recorded when people had attended appointments with professionals to support with their health and wellbeing. Further work was needed to ensure all reportable incidents are reported to the CQC and/or the local authorities safeguarding team where required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. We found no evidence of systems and processes in place which gave the provider opportunities to learn and make any improvements. For example, incidents and accidents were not reviewed with the aim of learning from these. The provider was receptive to our feedback and demonstrated commitment to improvements. Throughout the assessment they took action when we fedback the risks and concerns found.