Netherclay 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider worked with people, relatives, and professionals to establish and maintain safe systems of care, and staff demonstrated a culture of learning and continuous improvement. Staff described improvements in communication, handover and equipment since the changes implemented by the new provider. One staff member told us, “Communication, staff meetings and the new handover have improved, we feel more supported now.” Another said, “We’re on the right path; things have definitely improved this year.”

Lessons from incidents, mock inspections and quality audits were used to make changes, such as increasing night staffing and improving medicines processes.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced coordinated care, and the management team worked effectively with external professionals. District nurses, GPs and therapists confirmed staff followed guidance and escalated issues promptly, with one professional reporting staff were “Receptive and willing to implement recommendations” and “Competent in delivering care.” A relative explained, “If anything changes, they ring me straightaway… they let me know everything.” Staff ensured safe transitions, for example identifying when people required nursing-level care and working with professionals and families to facilitate moves.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

People were protected from abuse because staff were trained and confident in raising concerns. Staff described safeguarding processes clearly, and records showed concerns were reported to the local authority and CQC where appropriate. Relatives consistently told us they had never seen unkind behaviour from staff, with one stating, “They treat mum like a human being… they have the patience of saints.” Professionals said they had confidence in the registered manager to act on safeguarding concerns.

Where people were deprived of their liberty for care or treatment purposes, legal authorisations had been sought through the Deprivation of Liberty Safeguards (DoLS). The management team, maintained oversight of all applications, authorisations, and associated conditions, ensuring that all documentation remained accurate and up to date.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and their families were involved in risk assessments, care reviews and decisions about safety. A relative told us, “We went through the care plan with (registered manager)… anytime something changes, they put our minds at rest.” Staff promoted positive risk-taking, such as supporting people to use communal areas safely or adapt mobility equipment. The service used a “resident of the day” approach to ensure holistic reviews of their care and environment. Risks were reviewed through this process along with, daily walk‑arounds and close monitoring of falls, skin integrity and hydration.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was safe, clean and undergoing continuous improvement. Relatives repeatedly described the home as “Spotless” and “Fresh with no smells.” Safety measures had been added, including keypad‑secured areas, new stair gates linked to the fire alarm, and updated external apartments which had been risk assessed before being used. Maintenance records demonstrated regular checks, and staff confirmed issues were addressed promptly. One relative told us, “They are definitely moving forward with making things safer.”

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had increased the staffing levels and people received care from staff who knew them well. Staff confirmed night staffing had increased, and relatives consistently reported there were usually enough staff, with one stating, “There are always staff about… I always get answers.”

When there were staff shortages, due to training or annual leave, staff from the providers other home or agency staff undertook shifts. Agency staff new to the home received an induction and the registered manager told us they worked alongside experienced staff.

Under the new provider all staff at Netherclay house undertook a week‑long re‑induction at the provider’s other home. Staff said morale had improved and they felt supported. One staff member said, “Having 4 staff at night means the day starts calmer, everything is better.”

Recruitment processes were robust, with interview questions being completed for each candidate, DBS checks and references were in place.

Staff were undertaking the providers mandatory training and had received regular supervisions and an annual appraisal. Staff felt supported by the new provider with their ongoing training and development.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean throughout, and staff followed safe infection prevention and control practices (IPC). Relatives repeatedly highlighted cleanliness of the home, including comments such as, “It doesn’t smell like a care home.” Staff had access to personal protective equipment (PPE), completed IPC training, and audits were undertaken with actions followed up. Laundry processes reduced cross‑contamination, and equipment was cleaned and maintained.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medicines were managed safely. A registered nurse from the providers other home was working with the management team to review and reorganise the medicine room and update, as and when required (PRN) protocols. Medicine administration records (MAR) charts were fully completed with handwritten entries double signed by staff, no missed doses and clear guidance. The registered manager told us, they had changed the morning medicine round, to have 2 staff completing the round to improve timeliness. A professional commented that staff were “Competent and responsive to changing needs.” Relatives told us staff explained medicines clearly, with one saying, “They were very good at getting mum to take her antibiotics and explained everything.”