25 January 2023
During an inspection looking at part of the service
Nether Place Nursing Home is a care home providing personal care and nursing for up to 32 older people and people living with dementia. At the time of our inspection there were 22 people using the service.
Nether Place Nursing Home accommodates people across 2 separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia.
People’s experience of using this service and what we found
People were at risk due to shortfalls in safety across the service. Risks linked to nursing staff had not been robustly assessed to keep people safe. Staffing levels were not always sufficient to meet people’s needs or for the size of the service. Staff had not always received training to enable them to support people effectively and carry out their roles.
People were at risk as fire safety was not managed safely; staff did not always know how to respond in the event of a fire. The provider was working to make improvements to fire safety.
Systems were not always in place to ensure people received their medicines properly and safely. Medicines were not always being administered to people as directed, this was addressed during the inspection.
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 did not always support this practice. We have made a recommendation about the recording of Deprivation of Liberty Safeguards (DoLS) conditions.
People were at risk of harm because of a lack of oversight of the service by the provider. The service had been without a registered manager for over 6 months. The provider did not have effective systems in place to monitor quality and safety at the service and had not identified the issues we found during the inspection. The provider had started to make improvements following our inspection, these changes had yet to be embedded.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk.
Rating at last inspection
The last rating for this service was good (published 13 December 2017).
Why we inspected
This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the Safe 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nether Place Nursing Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment, staffing and good governance. We issued a warning notice for the breach of good governance. 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 from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.