Nelson House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was in breach of regulations in relation to gaining people’s consent, and meeting peoples nutritional and hydration needs.

This service scored 29 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

The provider did not have effective quality assurance systems in place to ensure assessments of people’s needs were accurate, consistent and up- to-date. For example, information from people’s pre-assessment records had not always been captured within their care plan, resulting in a lack of clarity about people’s actual needs. Records were not consistently reviewed following changes in need, which increased the risk of care not always being delivered in line with people’s current circumstances. For example, following people experiencing incidents and hospital admissions. As a result, staff could not always rely on care plans as an accurate source of guidance to support people consistently.

The provider did not always ensure when reviews of people’s care were undertaken this was done in consultation with people and their representatives. Records showed monthly reviews were undertaken but this was completed by staff and did not always indicate people had been involved. A person told us. “I know I have a care plan, but I have not seen it, or no one has discussed this with me for a long time.”

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

The provider had failed to ensure peoples care records were completed in partnership with people and their relatives to ensure they reflected all their needs, including health, personal care, emotional support, social interests, activities, cultural, religious, and spiritual needs. Some people’s care records did not reflect national and best practice guidance in relation to supporting people with specific health care needs, such as heart and mental health conditions. This meant staff did not always have full detailed guidance to follow.

Some people who lived in the home had dementia. Training records showed staff had received dementia awareness training. Staff confirmed this training did not equip them with the skills when supporting people with complex needs. This meant good practice standards for supporting people living with dementia were not in place. For example staff did not use pictorial aids to support decision-making in relation to food and drink.

The quality of food provision did not meet people’s nutritional needs. We observed there was a lack of fresh fruit and vegetables available. Food was not fortified to increase nutritional value, and high-calorie snacks were not routinely provided to people who required them. Where people were on a modified diet, such food prepared to pureed consistency, there was limited choice of food and snacks available to them. The staff and provider were unable to find records of guidance provided by the speech and language team of safe foods and snacks for people. This placed people at risk of being given inappropriate food placing them at risk of choking or aspiration.

Although records of food consumed for people judged as being at nutritional risk were in place, these were not completed accurately nor as part of a monitoring tool. Records did not always specify the quantities of food people were provided nor consumed. There was no oversight or monitoring of food intake to identify concerns such as low food consumption, lack of snacks, or poor food quality. This resulted in a lack of actions being taken to improve people’s nutritional intake.

There was a lack of oversight in relation to the monitoring of people’s skin integrity, to prevent sore skin. For example, records did not demonstrate people received pressure relief at required intervals. For people whose fluid intake was being monitored due to being at risk of dehydration, there was a lack of evidence to demonstrate their fluid targets were recorded and their intake was monitored. The provider failed to carry out checks or monitor the completion of these records to ensure people's care and support achieved effective outcomes.

The provider did not always work well across teams and services to support people.

The provider failed to ensure there was effective leadership in the home, which meant information was not always shared with partner agencies and health professionals in a timely way. For example, when people had experienced falls, or where people were declining personal and healthcare support and were at risk of self-neglect. Significant incidents had not always been reported to partner agencies to share known risks.

Feedback from partner agencies confirmed the provider did not always communicate effectively with them and there was a delay in the provider responding to know issues and risks. Timely action was not taken to address action plans developed by partner agencies to improve standards of care within the home.

However, we did find staff maintained regularly contact with people’s GP practice, and weekly contact was maintained with them to enable staff to discuss any medical concerns. However, records were not always completed of the discussions held nor the outcomes.

Systems were in place to support staff communication between shifts. Staff told us, and records confirmed, a handover was completed before staff started their shifts. Handovers included discussions of key information about people’s needs, including concerns staff had about people. For example, regarding people’s wellbeing and where people’s food and/or fluid intake had been limited.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. The provider did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not consistently supported to live healthier lives. The quality and quantity of food provided did not support people’s health and wellbeing. We observed people were provided with a choice of food from one menu which was repeated weekly. The main meal was a choice of frozen ready meals rather than freshly prepared meals using fresh ingredients. The provider also told us people had the option of a ‘chip shop’ tea once a week. For those people on a modified diet, a pureed menu was not provided, and staff had to puree a main frozen meal once defrosted. Options of snacks were limited, and evening meals consisted of packet or tinned foods. This meant food options were limited and repetitive. One person told us, “The food is the same each week; no choices really, and the portion sizes are small.” We saw some people purchased their own food to subside the food provided in the home due to the lack of choice, and consultation about the food provided. People who were at risk of an increase in their weight were not supported to eat healthy options as these food choices were not available in the home.

Records were not always available to support people who had access to and received regular routine health checks, such as dentist, opticians and chiropodist. The provider was unable to show us people’s last routine healthcare check-ups. A senior staff member had recently arranged for people to see a chiropodist. However, where people had declined this support, this had not been escalated, and some people were reported as having long toenails which could impact their health.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The provider failed to have systems in place to effectively monitor outcomes for people. Monitoring charts were not in place to enable staff to effectively monitor outcomes for people in relation to food and fluid intake. Staff used an electronic care planning system and recorded people’s intake as part of their daily records. Staff were unable to produce a report to see how much food or fluids people had consumed within a set timeframe, meaning there was no opportunity for meaningful oversight. This was the same regarding peoples’ weights. Staff told us, and we observed, the weights of some people had been recorded within recent weeks. However, it was difficult for staff to locate previous documented weight records so these could be compared. Due to the risks and difficulties with the system, staff had recently reintroduced a paper Malnutrition Universal Screening Tool (MUST)tool to record and, monitor people’s weight.

The lack of oversight, leaning and actions taken in other areas such as incidents and falls meant there were missed opportunities to prevent harm, monitor risks and improve outcomes for people.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider was not consistently working within the principles of the Mental Capacity Act 2005 (MCA), and people’s rights under the MCA were not always protected. Some people had equipment in their bedrooms which monitored their movements for their safety. However, a capacity assessment had not been completed to assess if people could consent to this. Where people lacked capacity, best interests meeting with their representative had not been undertaken.

Some people had Deprivation of Liberty Safeguards (DoLS) authorisations in place. Where conditions were imposed to protect people there was a lack of evidence to demonstrate how these were being monitored and met.

There was a lack of effective oversight of peoples DoLS. The homes DoLS tracker in place was incorrect, and the provider was not always able to demonstrate if peoples DoLS were in- date or if they had expired due to being unable to find relevant records. The provider could not tell us whether applications for the reassessment of people’s authorisations had been undertaken. A senior staff member contacted the Local Authority to seek clarification, and took action where needed to submit applications for people following our feedback. This meant some people were being unlawfully deprived of their liberty

People told us staff sought their consent before providing support. One person said, “Staff always ask before they do anything. They explain what they are doing and talk to me about it.” A relative said, “As far as I know staff always ask [person], they never force. I have witnessed them asking [person] if they would like to go to the toilet or to get changed, etc.”

Staff told us, and records confirmed, they had completed training in relation to the MCA and DoLS. Staff were able to provide a basic overview of the legislation and tell us what the associated principles meant for people using the service. A staff member told us, “I always ask for consent before I provide care. If someone cannot give me consent, I still ask and look at their facial gestures to check if it is okay.”