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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to safe care and treatment, safe environment, staffing and safeguarding.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety and learning from incidents that had occurred. For example, where accident and incident forms had been completed, we found limited evidence these had been reviewed by a person in charge and action taken to mitigate future risks. There was also a lack of evidence to demonstrate outcomes of any learning had been shared with staff. This meant opportunities for learning and improvements in people’s care were not always implemented and embedded.

The provider had also not fully learned lessons from their previous inspection, with repeated issues in relation to risk and the overall governance of the service.

Relatives told us staff did keep them informed about incidents that had occurred. A relative told us, “The staff do call me if anything happens.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider was unable to share with us an assessment of need that would be used to support a person moving into the home. Staff relied upon information being shared by partner agencies to gain information about people and their needs. We saw this information had not always been used effectively, as people’s care plans did not always contain key information about their needs and preferences.

Where people had a diagnosis of dementia, we found key information was not provided to partner agencies such as paramedics to support emergency or planned hospital admissions. Limited information was shared such as medicine requirements. This meant key information was not always shared to ensure continuity of care.

We sought feedback from partner agencies who told us the provider was not ‘proactive’ in implementing recommendations from action plans. The provider failed to listen and improve systems in the home to monitor people’s safety and improve records in place to support people’s continuity of care.

These inconsistencies demonstrated ineffective assessment processes and poor information-gathering, which increased the risk of people receiving inappropriate or unsafe care.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider had failed to ensure they consistently followed safeguarding procedures or responded appropriately to potential abuse. They had failed to protect people from potential harm and report concerns. For example, where people placed themselves at risk of self-neglect this had not been identified as a risk and shared with partner agencies such as the Local Authority and CQC. We also found there had been potential safeguarding incidents in the home which had not been shared with Local Authority or CQC.

Although systems were in place for the safe management of people’s finances, these were not being followed. For example, we found 1 member of staff managed people’s money, and checks and audits were not undertaken. This was not in accordance with the providers finance policy. We found discrepancies with the balance of people’s money which had not been identified.

Staff confirmed they had completed safeguarding training and shared the action they would take should they have any concerns. One staff member said, “I would always report any abusive practices.”

People and their relatives told us they felt safe with the staff supporting them. One person said, “I feel safe with the staff; they are a decent bunch.” A relative told us, “I have no concerns about [person’s]’ safety; I think the staff treat them well and keep them safe.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider failed to manage risks effectively to ensure people received safe care. We found multiple aspects of the home were unsafe which placed people’s health and safety at risk. For example, we found people experienced falls and limited action had been taken to prevent further incidents. Some people accessed the kitchen and made their own drinks, but risk assessments had not been completed to assess the risks associated with this. Where people used equipment to aid their mobility, this had not always been assessed to ensure this was safe for them to do. Some people were at risk of issues with their skin integrity, such as sore skin; however, records did not reflect they had received support with repositioning at the frequency detailed in their care plans. We found risks assessments had not been completed for people who smoked to ensure they were supported appropriately. Additional risks, such as the use of flammable prescribed creams, had not been explored with people and associated risks managed.

Where people had known health conditions which placed them at risk of harm, staff were not always provided with clear information and guidance on supporting such people in relation to these conditions and managing associated risks. Risk assessments lacked clear guidance for staff to follow regarding how identified risk should be managed. For example, where people were at risk of self-harm or neglect. These failures placed people at increased risk of avoidable harm.

We found most staff knew people’s needs and told us they understood how to manage people’s care in a safe way. People were supported by a consistent staff team.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider had failed to ensure the environment was safe. We found significant widespread issues relating to the environment that placed people at risk of harm.

The provider had failed to take timely action to address requirements from a Fire Risk assessment that was undertaken in June 2021 by an external agency.This placed people, staff and visitors at risk of harm in the event of a fire.

We observed mould in some areas of the home that had not been identified and addressed. Wardrobes in some people’s bedrooms were not securely attached to walls to prevent them from falling. Window restrictors in all bedrooms failed to meet current recommended guidelines. We observed several items of broken furniture stored in communal areas accessible by people. We observed broken and loose radiator covers in people’s bedrooms. The garden, which was used by some people, was cluttered with disposed items of furniture such as a mattress. The garden was unkempt with long grass.

CQC took urgent enforcement action to ensure the provider acted to make the home safe for people.

The provider did not 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 not work together well to provide safe care that met people’s individual needs.

The provider failed to ensure sufficient staff were on duty to meet people’s assessed needs. During the day and night, there was 2 staff on duty to meet people’s needs. We observed 4 people required 2 staff for support with repositioning, and personal care. This meant there was no staff available for other people in the home when support was being provided to people who required the support of 2 staff. In addition to providing care to people, staff were required to undertake laundry and catering roles as there was no laundry or kitchen staff employed at the home. This reduced the time staff were able to spend with people, particularly those people with cognitive impairments who we observed walking around the home. One person told us, “The staff do their best, but we do have to wait as there is not enough of them on duty.” In response to our concerns, CQC took urgent action to ensure sufficient staffing was available to meet people’s needs.

The provider had failed to ensure staff had completed all required training for their role. We found staff did not know what the fire procedures were for the home or where essential fire equipment was stored. This placed staff, people and visitors at risk of harm in the event of a fire. Urgent action was taken by CQC to address this.

Staff supported people with mental health conditions. However, training records provided to us did not demonstrate staff had completed any mental health training. Training records showed staff had completed E- learning in all other core areas, such as safeguarding and first aid. Staff had completed face -to-face training in relation to moving and handling and their competency in this area was assessed.

We found staff had been recruited safely to ensure suitable staff supported people.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

Despite the provider having infection prevention and control policies and cleaning schedules in place, these were not followed in practice and infection prevention and control (IPC). arrangements were not effective.

The staff rota showed 1 staff member was employed for 3.5 hours a day to carry out cleaning duties (between 09:00 and 12:30), 7 days per week. Outside of these hours, there was no designated staff member responsible for cleaning high-touch areas, communal areas, or people’s bedrooms. As a result, large areas of the home were not kept clean. We observed stained carpets, and furniture which were also worn, including tables.

We identified multiple cleanliness concerns in people’s bedrooms. These included, stained bedding, torn fabric on commodes, unclean and worn bed rail covers, stained flooring, and smells of urine.

One staff member told us, “We do our best, but we don’t always have time to clean in the afternoon and evenings.” A relative told us, “The home is dated and the environment needs some work, wall paper is peeling, it’s just not nice.”

These failures demonstrated a lack of effective infection prevention and control systems and placed people at increased risk of infection and avoidable harm.

The provider did not make sure medicines were consistently managed safely. People were not involved in planning.

People’s pain was not always managed effectively due to the lack of written guidance for staff to follow. We found where people were prescribed ‘as required’ medicines, information about how to administer these was not always in place. This impacted on a person not receiving effective pain relief.

We found numerous prescribed topical creams in people’s bedrooms had not been stored safely. Risk assessments were not in place for these. When these medicines had been opened, the dates of when this had occurred had not been documented. Manufacturer’s guidance states prescribed creams should be discarded after 3-months. This meant we could not be assured prescribed medicines were safe for people’s use.

Medicine storage arrangements were not safe nor well maintained. We found several boxes of medicines being stored in the office which was not locked and was accessible to people and visitors in the home. The temperature of this room was not being monitored. There were no temperature checks of the fridge which contained insulin for April 2026. Therefore, we could not be assured medicines had been stored within safe temperature ranges.