CQC report explained · a nursing home, run by Aspen Hill Healthcare

Nevis House

Church Street, Hunslet, Leeds, LS10 2AY

Goodpublished 13 December 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask

Safe?: Good; People were protected from abuse and risks to their care were assessed and managed. However, medicines records needed improvement, and one piece of equipment that had not passed required checks had been used.
Effective?: Good; Staff received relevant training and support, people were helped to eat and drink, and healthcare professionals were involved in their care. The home was found to be working within the principles of the Mental Capacity Act.
Caring?: Good; People said staff treated them with kindness, dignity and respect. People and relatives were involved in care planning, although access to care records by staff from other homes posed a confidentiality risk.
Responsive?: Good; Care was personalised and people were supported with activities, relationships and communication needs. Some care plans were inconsistent or needed more accurate detail, including records about prescribed creams and wound care.
Well-led?: Good; People, relatives and staff described the management as approachable and responsive. Regular audits and other quality checks were in place, although action on the recording of prescribed creams had not yet been completed.

The latest report, explained

What inspectors found, December 2023

Rated Good; inspectors found kind, personalised care, with improvements still needed in medicines records and some safety checks.

This was an unannounced inspection carried out on 21 and 28 November 2023. Inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They observed care and reviewed care plans, medicines records, staff files and management records.

All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, were treated with dignity and received personalised care. Relatives were also positive about the care and support.

The inspectors found some areas that needed improvement. Guidance and records for prescribed creams and some medicines given when needed were not always clear. One piece of equipment had not passed required checks but had been used, and some care records needed correcting or adding to.

This was the first inspection of the newly registered service. The report says the previous premises had been rated Inadequate in June 2022. The current home was not placed in special measures and no regulations were recorded as breached.

What inspectors praised

People felt safe
People and relatives said people were safe, and staff understood safeguarding responsibilities. Risks linked to people's care were assessed and managed.
“People told us they felt safe and enjoyed living at Nevis House.” from the report
Kind and respectful care
People described staff as helpful, kind and respectful. Inspectors found that people were involved in decisions about their care and supported to remain independent.
“Overall the staff are very good, very helpful and treat me like a man, definitely with dignity and respect and definitely kind” from the report
Personalised support and activities
Care plans included people's history, preferences and care needs. People could take part in varied activities, trips and interests, with relatives invited to join in.
“You can do any activity you want to do, there's painting, flower arranging, arts and crafts, there are enough activities and plenty of variety.” from the report
Staffing and management
People and relatives said there were enough staff and that the staff team was regular. Staff said they felt supported, while people and relatives found managers approachable.
“There are plenty of staff, it is a regular staff team here.” from the report

What inspectors were concerned about

Medicines records and guidance
needs fixing
Guidance for applying prescribed creams was not always detailed, and records of applications were not always specific. Some medicines care plans and protocols for medicines given when needed also needed clearer information.
“Overall, medicines were managed well but some areas for improvement were identified.” from the report
Equipment safety check
serious
One piece of equipment had not passed the required safety checks, but staff said it had been used. The manager asked for it to be clearly marked so staff would not use it.
“However, we identified one piece of equipment that had not passed the required checks of the Lifting Operations and Lifting Equipment regulations and staff told us this had been used.” from the report
Care record accuracy
needs fixing
Some care plans were inconsistent or needed more detail. One person's wound care information was not accurate in their skin integrity risk assessment.
“One person required additional support with wound care and details of this need was not accurate in their skin integrity risk assessment.” from the report
Confidentiality of care records
needs fixing
Staff from five other homes run by the same provider could access people's care records. The home said work was under way to address this risk.
“People's care records could be accessed by staff who did not work with them but who worked in another 5 care homes owed by the same provider.” from the report

Questions to ask them, based on this report

01What changes have been made to the guidance and records for prescribed creams since the inspection?
02How are medicines given when needed, including covert medicines, now recorded and linked to people's care plans?
03How do you make sure equipment cannot be used before it has passed all required safety checks?
04Has access to care records by staff from other homes been restricted, and how is confidentiality protected now?
05Have the inaccurate wound care information and other gaps in care plans been reviewed and corrected?

This was an unannounced inspection of the newly registered care home covering all five key questions, including the premises and care provided; the previous Inadequate rating related to the service at different premises. This explanation was written from the published report of 13 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Nevis House

Each visit the CQC has published, newest first, back to the day the service was registered.

December 2023Goodcurrent rating
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Nevis House →
February 2023
Registered with the Care Quality Commission on 14 February 2023.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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What inspectors found, December 2023

People felt safe

Kind and respectful care

Personalised support and activities

Staffing and management

Medicines records and guidance

Equipment safety check

Care record accuracy

Confidentiality of care records

Every inspection of Nevis House

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