16 December 2021
During an inspection looking at part of the service
Nicholas House is a care home providing personal care to 13 people. The service provides care to adults, some of whom may live with dementia. The service can support up to 30 people. The building has three floors, and each person had their own bedroom. There were shared facilities such as bathrooms and showers, lounge and dining areas as well as staff stations and offices.
People’s experience of using this service and what we found
The prevention and management of trips, slips and falls had improved. Actions were taken to mitigate risks including regular updates of the risk assessments, care plans, working with the physiotherapist, reporting of accidents and incidents, and completion of follow up investigations. Infection prevention and control had improved, however further action was required to ensure correct use of personal protective equipment . There were sufficient staff deployed and personnel files contained the information required by the regulation. Although service users received their medicines, improvement was required to the documentation, for example ‘as required’ protocols and guidance for high risk medicines.
There was positive feedback about the home manager. Oversight of the service at local and trustee level had improved with the changes in the management team. Auditing of care documentation was taking place, and there was evidence of follow up by the management team. There were related action plans, with the actions being tracked for progress on each one. The home manager understood the duty of candour process and had applied it to notifiable safety incidents, for example serious injuries. Statutory notifications required by law were being submitted without delay.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 31 July 2021) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements were made and the provider was no longer in breach of some regulations.
This service has been in Special Measures since 11 March 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
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.
We carried out an unannounced comprehensive inspection of this service on 18 May 2021 and 19 May 2021. Breaches of legal requirements were found. We issued a warning notice and the provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, duty of candour and notifying CQC of certain events.
We undertook this focused inspection to check they had complied with the warning notice and followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those breaches of regulations.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nicholas House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.