Northcott House Residential Care and Nursing Home Also known as 1-684385445

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last inspection completed in November 2023 this key question was rated requires improvement. At this assessment this key question remains requires improvement. During our assessment of this key question, although we found some improvements had been made to particular aspects of the service, we found the provider continued to be in breach of regulations with respect of good governance. Quality and safety audit systems were not always effective and did not always identify concerns we found during this assessment. You can find more details of our concerns in the evidence category findings below. Although continued issues and concerns were identified, most people and relatives all staff members spoken with were positive about recent changes to the service and where confident improvements would be made by the new manager and new deputy manager who had been appointed in April 2024.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

In April 2024 a new manager and new deputy manager had been appointed. People and relatives spoken with said they see the management team regularly; were confident they would act on concerns and spoke positively about them. Staff were confident about the new leadership of the home and said they felt well supported in their role. Staff spoke positively about the changes the manager had made. Staff comments included, “The service had improved since the arrival of the new manager", "Since the arrival of the manager, it’s been so much more organised. Training has improved and the manager really listens and acts on any issues and concerns" and “The new manager if firm but fair, I feel much more valued that I have done in the past." Throughout the inspection the manager demonstrated a good knowledge of the people living and Northcott House, showing they had taken time to get to know them individually. Through general discussion with the manager and staff team, it was evident that they wanted to provide a good quality person centred service and safe service to people. Although there was no registered manager at the time of this inspection the manager had submitted an application to CQC to commence the process to becoming the registered manager.

There was a clear management structure in place, including senior staff responsible for quality assurance. However, the leadership team were not always effective in identifying or acting on concerns and risks in a timely way. This meant we could not be assured there were inclusive leaders at all levels of the organisation who had the skills, knowledge and experience to lead effectively. The manager understood the challenges the service had faced and ongoing actions required to ensure good quality sustainable care.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us since the arrival of the new manager there had been improvements in the service. A staff member said, "Since the arrival of the manager, it’s been so much more organised and as staff we have much more structure. Staff and people seem much happier." The staff told is they they had a clearer understood their roles and responsibilities within the team and were encouraged to make suggestions on how the service could make improvements. From discussions with the manager and staff it was clear a number of changes had been made by the new manager. These changes had been generally well received by the staff and the service users. Staff were getting used to the new ways of working however further time was needed to embed now processes.

At this assessment although we found some improvements had been made to particular aspects of the service including but not limited to, increased person-centred information in care plans and risk assessments, training and communication. We found significant concerns with the providers systems and processes for assessing, monitoring and improving the quality of the care provided which were not effective in identifying areas of poor practice, to support the implementation of improvement and ensuring people were provided with safe and effective care. The concerns found at the inspection included, significant failing in the management of medicines, ongoing environmental risks, including ineffective fire safety management, understanding of and acting in occurrence which health and safety guidance in relation to the management of legionella. This placed people at risk of injury and harm. Following the last inspection the provider provided CQC with an action plan stating how they would address the shortfalls identified at the inspection completed in November 2023. At this inspection we found we could not be assured the provider had taken action in a timely way where concerns were identified.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.