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Welcome House - Nickleby Lodge Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 December 2019

About the service

Nickleby Lodge is a residential care home providing accommodation and personal care for up to 10 people with a mental health condition. People receive care in one adapted building that had a communal lounge and kitchen facility. At the time of our inspection five people were living at the service.

People’s experience of using this service and what we found

People were at risk because of a lack of staff, particularly at night, available to care for them. People told us there were times they could not go out when they wished due to staff shortages. Although people received the medicines they required, improvements were needed to medicine practices to ensure they were safe. People lived in an environment that was not well maintained or clean and as such could present a potential risk to them. People were cared for by staff who did not always feel supported or have the opportunity to discuss their role with their line manager. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, despite staff following the principles of the Mental Capacity Act 2005, they did not have a good knowledge of the code of conduct with regard to this.

Despite quality monitoring audits taking place, these were not robust and had not led to an improved service for people. The service did not give people the opportunity to achieve goals and aspirations.

People were assisted to remain healthy and access health professional involvement when needed. They told us they were cared for by kind and caring staff and this was evident to us during our inspection. People said they could attend activities outside of the service and they liked living at Nickleby Lodge. People said they felt safe and they knew who to speak to should they have any concerns. People were supported to choose their meals and had input suggestions into the general running of their home.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (report published 6 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvement. We found three breaches of regulation. Please see the Safe, Effective and Well-Led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 14 December 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 14 December 2019

The service was not always effective.

Details are in our effective findings below.



Updated 14 December 2019

The service was caring.

Details are in our caring findings below.



Updated 14 December 2019

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 14 December 2019

The service was not always well-led.

Details are in our well-Led findings below.