CQC report explained · a residential care home
What the CQC found at 159 Wensley Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine records had 11 unexplained gaps, some medicine checks and training evidence were incomplete, and important premises safety checks were missing or inconsistent. Inspectors also found that incident records did not always show what action had been taken.
- Effective?
- Good
- This key question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not identify or manage several problems found by inspectors. The home also had a manager who was not yet registered, and records about reportable incidents and duty of candour were incomplete.
What inspectors found, May 2022
159 Wensley Road was rated Requires Improvement for the second time; inspectors found caring support but repeated safety and management failures.
This was an unannounced focused inspection on 16 March 2022. One inspector reviewed care and medicine records, staff recruitment and training files, incident records, maintenance information and quality checks. The inspector also spoke with people living there, staff, relatives and the manager.
The home provided care and accommodation for up to four people with a learning disability. Three people lived there at the time. People received kind, respectful support and were helped to make choices, stay independent and take part in activities. The home was clean, staffing levels were described as sufficient, and people and relatives said they felt safe.
However, inspectors found unsafe medicine management, incomplete recruitment checks, gaps in safety checks and weak systems for learning from incidents. The home did not consistently notify the CQC about reportable events or keep the records required when something went wrong. The overall rating and the Safe and Well-led ratings were Requires Improvement, meaning there was limited assurance about safety and management, with an increased risk that people could be harmed.
Kind and respectful care
People received compassionate support. Staff protected privacy and dignity and understood people's individual needs.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Choice and independence
People were supported to make choices, manage risks and live as independently as possible. They could personalise their rooms and take part in activities.
“People had a choice about their living environment and were able to personalise their rooms.” from the report
Clean environment
Inspectors found effective infection prevention arrangements and a clean, hygienic home.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Staff knew people well
Staff understood people's needs and supported their goals and interests. Staff turnover was very low, which helped provide consistent care.
“Staff turnover was very low, which supported people to receive consistent care from staff who knew them well.” from the report
Medicine records and supplies
seriousInspectors found 11 unexplained gaps in medicine administration records. They also found an undated bottle of eye drops, a missing dose and unclear guidance for some medicines taken when needed.
“We reviewed medicine administration record charts for the people who use the service and found 11 gaps.” from the report
Recruitment checks
seriousSome staff files had gaps in employment histories, identity information and health details. Evidence of required checks, including DBS checks, was not available.
“This placed people at risk of receiving care from unsuitable staff.” from the report
Premises safety checks
seriousFire doors and escape routes were not checked consistently, and inspectors were not given evidence of several fire, water, gas and electrical safety checks. One fire risk assessment action had not been completed at the time of inspection.
“The records showed the fire doors were not checked consistently and fire escape routes were not checked at all.” from the report
Weak quality monitoring
seriousThe home's own checks had not identified several of the problems found during inspection. This meant leaders did not have a clear enough view of risks and required improvements.
“The registered person did not follow their quality assurance policy effectively so they could assess, monitor and mitigate any risks” from the report
Incident and openness records
seriousSome reportable events were not notified to the CQC without delay. Records showing that the home had followed its duty to be open and honest after safety incidents were incomplete.
“The registered person did not always notify the Commission of notifiable events, 'without delay'.” from the report
- 01What action has been taken to explain and prevent gaps in medicine records, and how are medicine supplies and staff competence now checked?
- 02Have all staff files been completed with employment histories, identity evidence, health information and DBS checks?
- 03Which fire, legionella, water, gas and electrical safety checks have now been completed, and can we see the records?
- 04How are incidents now reviewed to identify patterns, record actions and reduce the risk of them happening again?
- 05Who is currently responsible for quality monitoring, and when will the manager's CQC registration application be completed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 20 May 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, December 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but serious gaps in medicines, premises, recruitment and management oversight.
This was an unannounced inspection on 14 October 2019. One inspector spoke with people, staff, relatives and professionals, observed care, toured the home and checked medicines, care plans, recruitment files, accidents, maintenance and quality records.
People were happy and felt safe. Staff were caring and supported people to make choices, stay independent, access healthcare, enjoy activities and keep in touch with family. The ratings for Effective, Caring and Responsive were Good.
The home was not always safe or well-led. Inspectors found expired medicines, incomplete medicine guidance, gaps in staff recruitment checks and delays or missing checks relating to fire safety, water temperatures, legionella and electrical safety. The quality checks had not found these problems, and one incident was not reported to the CQC promptly.
The overall rating fell from Good at the previous inspection to Requires Improvement. The CQC found breaches of Regulations 12, 17 and 19 and said it would request an action plan, monitor progress and return for another inspection.
Kind and respectful care
People said they were happy and liked the staff. Inspectors saw that staff respected people's choices, dignity and privacy.
“People were comfortable with staff and responded well to them.” from the report
Personalised support
Support plans described people's preferences, needs and goals. People were involved in planning their care and were encouraged to become more independent.
“People's support plans had detailed guidelines to ensure staff supported them appropriately included personal care, communication, emotional and behavioural support.” from the report
Activities and relationships
People were supported to take part in activities they chose, use local facilities and maintain relationships with family and others.
“People were supported to follow their interests and take part in social activities according to their choices.” from the report
Healthcare support
The home identified people's health needs and made timely referrals to health professionals when required.
“We saw the care for people's health and wellbeing was proactive and organised well.” from the report
Medicines were not always managed safely
seriousInspectors found two boxes of expired medicine, undated eye drops and incomplete records for medicines taken out of the home. Guidance for some as-required medicines was also unclear.
“We reviewed medicine stock and we found two boxes of expired medicine.” from the report
Safety checks were incomplete
seriousChecks of fire doors, escape routes and water temperatures were not consistent. There was no legionella risk assessment, and electrical safety work had been delayed.
“The fire door and fire escape routes were not checked for the last three to four weeks.” from the report
Recruitment checks had gaps
seriousSome staff files had missing or inaccurate employment histories and identity photographs. Checks about health, previous care work and reasons for leaving were not always completed.
“This placed people at risk of receiving care from unsuitable staff.” from the report
Management oversight was not effective
seriousThe home's audits and quality checks did not identify the safety and recruitment problems. One incident that should have been reported to the CQC was reported only after inspectors raised it.
“The registered manager did not have effective quality assurance systems in place to help them identify shortfalls and complete timely actions.” from the report
- 01Have all expired medicines been removed, and how are medicine expiry dates and opened eye drops now checked?
- 02What written guidance is now available for people's as-required medicines and for creams they need help to apply?
- 03Have fire doors, escape routes, water temperatures, legionella risks and electrical safety all been checked and any required work completed?
- 04Have recruitment files been reviewed to confirm employment histories, identity, previous care work and other required checks?
- 05What new quality checks are in place to identify problems promptly, and how are incidents reported to the CQC when required?
This was a full inspection covering all five key questions, the premises and the care provided; all five ratings were assessed at this visit. This explanation was written from the published report of 17 December 2019 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 159 Wensley Road
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 2011.
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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