Nelson House

Updated 21 April 2026

Date of Assessment: 29 April 2026 to 13 May 2025. The site visits took place on 29 April, 5 and 6 May 2026. The assessment was undertaken in response to concerns shared with Care Quality Commission.

Nelson House is a residential care home providing support to older and younger people and people with mental health needs for up to 21 people. At the time of our assessment there were 15 people living at the home.

Since our last inspection in March 2022, we found the service had not made the required improvements to meet the breaches of regulations and improve the standard of care provided to people. We found the provider was still in breach of 2 regulations in relation to risk management and good governance. We also identified new breaches of regulations in relation to person centred care, consent, safeguarding, nutrition and hydration, safe premises and staffing.

The provider did not have a good learning culture and risks to people were not managed safely. The provider did not ensure people’s individual needs and preferences were met. Systems were not in place to ensure people’s rights under the Mental Capacity Act 2005 (MCA) were met. Staff had insufficient guidance for the management of people’s known health conditions and risks to ensure these were managed safely. We identified a lack of effective monitoring and mitigation in relation to risks such as dehydration, food intake, malnutrition, and skin breakdown. People’s medicines were not always managed safely. The provider did not follow their own or the Local Authority safeguarding procedures to ensure people were safeguarded from harm. The provider did not ensure the environment was safe, and risks were not being proactively identified and managed. The environment was not well maintained, and there were delays in work being completed once issues had been reported. Systems to monitor the safety of the environment were ineffective and had not identified the widespread risks and shortfalls we found.

The provider had not ensured enough trained staff were on duty to always meet people’s needs. The provider failed to have effective quality assurance and auditing systems to maintain oversight of the home. Systems to ensure care was provided safely and appropriately were not robust. In addition, the provider had not consistently notified the CQC of all notifiable events as required by regulation. The provider had failed to identify the issues highlighted during this assessment which meant urgent action was taken to maintain people’s safety.

Staff did their best to support people and provide care which met their needs. Staff felt supported by their colleagues, but did not feel valued by the provider.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Updated 21 April 2026

People and their relatives spoke warmly about staff, and generally said they were happy with the care they received. While people and their relatives expressed general satisfaction with the care being delivered, our assessment found care did not meet expected standards. Care records lacked important information relating to people’s care needs, which meant care was not always delivered in a way which was safe and individual to people.

People did not live in an environment which was safe, clean and well maintained. We found significant and widespread shortfalls relating to the safety of the home which had not been acted upon in a timely way to keep people protected from the risk of harm.

There was a lack of meaningful activities provided for people to engage them.We observed people sitting for extended periods with little interaction or stimulation. People had a limited choice of food and snacks, including a lack of fresh fruit and vegetables.

Relatives confirmed staff kept them informed about their relative’s wellbeing and when incidents had occurred. However, people and relatives told us they were not always involved in the planning or reviews of people’s care and had not seen people’s care plans.

People and their relatives confirmed their feedback was not consistently sought. Most people said they received care from staff who treated them as individuals and respected their privacy and dignity. People and relatives felt able to complain but did not always feel listened to.