CQC report explained · a nursing home
What the CQC found at 121 Watleys End Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2022
121 Watleys End Road was inspected but not rated; inspectors found good infection control during a COVID-19 outbreak, with some cleaning records incomplete.
This was an announced, targeted inspection on 26 January 2022. Inspectors checked infection prevention and control and asked about staffing pressures linked to COVID-19. They gave 24 hours' notice.
The home had a COVID-19 outbreak and was closed to non-essential visitors. Inspectors found suitable arrangements for visitors, testing, PPE, vaccination checks, cleaning, staff training and managing the outbreak. Minimum staffing levels had been maintained.
People were supported to keep in touch with family and friends through visits, telephone and video calls, in line with guidance. They could also use the garden or go out in the home's vehicle, with risk assessments in place.
The inspection did not give a quality rating. The Safe question was marked 'Inspected but not rated'. Inspectors noted that some cleaning schedules had not been signed as completed, especially when the housekeeper was not working.
Infection control
Inspectors found suitable arrangements for PPE, testing, vaccination checks, cleaning and managing the COVID-19 outbreak.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staffing levels
The provider said minimum staffing levels were maintained despite COVID-19-related staffing pressures.
“Minimum staffing levels had been maintained to ensure people were safe and their needs were being met.” from the report
Family contact
People were supported to stay in touch with family and friends through visits, telephone and video calls, following government guidance.
“People were supported to keep in contact with family and friends via the telephone, video calling and visits to the home in line with government guidance.” from the report
Activities and wellbeing
People could use the garden or go out in the home's vehicle during the outbreak, with risk assessments in place.
“Advice from PHE had been sought to support people to go out in the home's vehicle to reduce isolation and improve their mental wellbeing even though the home was closed.” from the report
Incomplete cleaning records
minorSome cleaning schedules had not been signed to show that cleaning was completed. This was particularly noticeable when the housekeeper was not working.
“Some of the cleaning schedules had not been signed as completed, noticeably when the housekeeper was not working.” from the report
- 01How do you make sure all cleaning schedules are signed when the housekeeper is not working?
- 02How would essential caregiver visits be arranged during a COVID-19 outbreak?
- 03How do you maintain minimum staffing levels when staff are affected by COVID-19 pressures?
- 04How are risk assessments used for trips in the home's vehicle during an outbreak?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 25 February 2022 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.
What inspectors found, May 2018
121 Watleys End Road was rated Good overall, with kind and individual care, but inspectors found some staff communication was not person-centred.
Inspectors visited without warning on 12 April 2018. They spoke with people and staff, observed care, and checked care plans, medicines records, risk assessments, complaints and quality checks.
The home was rated Good in all five areas. People were supported safely, received their medicines correctly, and had access to healthcare, suitable food, activities and community outings. Staff were described as kind and knowledgeable about people's needs.
Inspectors found some shortfalls. At times, staff moved or assisted people without explaining what they were doing, and some staff talked mainly to each other during breakfast. Some staff training was out of date, some personal electrical items had not been safety tested, and not everyone had a detailed end of life care plan.
The home had improved since the March 2017 inspection. Problems about mental capacity safeguards, person-centred care plans and notifying CQC about important incidents had been addressed. Good means inspectors found the service met the expected standard, although improvements were still needed.
Safe medicines
Medicines were stored securely, given by trained staff, and checked through audits. Records included people's allergies and preferred way of taking medicines.
“Medicines were stored securely and administered by staff who had been trained and assessed as competent to do so.” from the report
Individual care
Care plans described people's histories, preferences, communication methods and changing needs. This helped staff provide more personalised support.
“Each person now had a care plan that was individualised to them and set out their needs and how staff were to support them.” from the report
Kind and knowledgeable staff
Staff knew people's likes, dislikes, interests and histories. They supported people sensitively during an evacuation and helped people have privacy and calm when needed.
“The staff we met conveyed a good knowledge of each person's personal likes, dislikes, interests, past lives and family history.” from the report
Communication during care
needs fixingSome staff did not explain what they were doing when moving or assisting people. During breakfast, staff sometimes talked mainly to each other, which excluded people from conversations.
“Some staff spoke to each other and did not communicate with people when they assisted them.” from the report
Out-of-date training
needs fixingSome mandatory training, including infection control and health and safety, had not been kept up to date. The manager had identified this and booked refresher courses.
“Some mandatory staff training, for example, infection control and health and safety had not been kept up to date for some of the team.” from the report
Electrical safety checks
needs fixingSeveral personal electrical items in the kitchen and bedrooms had not been tested for electrical safety.
“However, we did find several personal electrical items in the small kitchen and two bedrooms, which had not been tested for electrical safety.” from the report
End of life plans
minorNot everyone had a detailed end of life care plan at the time of the inspection. Some decisions about resuscitation were recorded, but planning was not complete for all people.
“Not everyone, as yet, had a detailed end of life care plan” from the report
- 01What training has now been completed to improve staff communication with people during meals, moving and personal care?
- 02Have all personal electrical items in bedrooms and the kitchen now been safety tested?
- 03Is every person's end of life care plan now complete and regularly reviewed with their representatives?
- 04How do you check that staff explain choices and actions to people who communicate without speech?
- 05What systems are now used to make sure significant incidents are notified to CQC promptly?
This was an unannounced inspection of the premises and care provided, covering all five CQC questions and reviewing care records, medicines, risks, complaints and management audits. This explanation was written from the published report of 24 May 2018 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.
Every inspection of 121 Watleys End Road
3 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: Requires improvementWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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39 live-in carers within about an hour of South Gloucestershire
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Most charge £1,020 to £1,280 a week. 32 can care for a couple. 11 years' experience on average.
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