CQC report explained · a residential care home
What the CQC found at 280-282 Wells 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, March 2021
280-282 Wells Road: inspected but not rated; inspectors found strong infection-control arrangements but gaps in staff testing and infection-control auditing.
This was an announced, targeted inspection on 04 December 2020. It looked at infection prevention and control during the coronavirus pandemic, rather than giving a full service rating.
Inspectors found that visiting, isolation, social distancing, PPE, handwashing, cleaning and COVID-19 monitoring arrangements were generally in place. The home appeared clean, and staff had training in using PPE and washing their hands.
There were two shortfalls. A staff member returned to work and completed five shifts before being tested. Inspectors also found no evidence of a specific infection-control audit to check cleanliness and staff practice.
The service was inspected but not rated. This means this visit did not produce a Good, Requires Improvement or Inadequate rating.
PPE and handwashing
Staff had access to PPE and hand sanitiser. They were trained and observed before being assessed as competent.
“Staff had been trained and observed in practice before being signed of as competent in the correct use of PPE and handwashing.” from the report
Clean surroundings
The home appeared clean, with cleaning scheduled throughout the day and extra attention to frequently touched surfaces.
“The premises looked clean, cleaning was scheduled for morning, afternoon and night.” from the report
Support during restrictions
People were supported to isolate in their bedrooms and to keep in touch with relatives using alternative methods when visits were restricted.
“People living at the home were supported to use alternative methods to remain in contact with relatives.” from the report
COVID-19 monitoring
People were tested regularly and had their temperatures checked twice daily to help identify infection and deterioration.
“Temperatures were taken twice daily to help identify new cases and monitor people with the virus for signs of deterioration.” from the report
Staff testing
seriousOne staff member returned to work without being tested and worked five shifts before a test was carried out. The manager later updated the policy to cover testing after sickness or annual leave.
“We were not assured that the provider had always accessed testing for staff when necessary.” from the report
Infection-control audit
needs fixingThere was no evidence of a specific audit checking the home's cleanliness and staff practice. The manager said an audit was being developed.
“At the time of the inspection, there was no evidence to show that a specific infection control audit was carried out, to check and monitor the cleanliness of the home and staff practice.” from the report
- 01How do you now check staff have been tested before returning after sickness or annual leave?
- 02Has the infection-control audit now been introduced, and how often is it completed?
- 03What happens if someone living here needs to isolate in their bedroom?
- 04How do people keep in touch with relatives when visits are restricted?
- 05How are cleaning of touch points and staff infection-control practice checked?
This was a targeted inspection of infection prevention and control practices during the coronavirus pandemic; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 9 March 2021 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, October 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but concerns about staffing, records, training and medicines.
This was an unannounced inspection on 23 September 2019. One inspector spoke with people, relatives and staff, and reviewed care records, medicines, recruitment, training and incident management.
The home provided accommodation and personal care for six people with learning disabilities and/or autism. People were described as receiving kind care, having choices, and being supported with activities, healthcare, communication and community life.
There were important shortfalls. Weekend staffing did not always meet people's assessed needs, and inspectors were not sure that some one-to-one hours were being provided. Records about incidents and medicines were not always complete or accurate. Staff had still not received learning disability and autism awareness training promised at the previous inspection.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement, while Caring and Responsive were rated Good. The home had one breach of Regulation 17 on good governance, and the previous overall rating of Good had deteriorated.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw respectful relationships and support for people's dignity and independence.
“People received kind, caring and compassionate care from staff who knew them well and had developed positive relationships with.” from the report
Choice and independence
People were involved in everyday decisions and were encouraged to do things for themselves, such as preparing food, cleaning bedrooms and making drinks.
“People were involved in day to day decisions and we saw examples of how people had been involved in the review of their care.” from the report
Clean environment
The home was visibly clean, hygienic and well maintained. The food hygiene rating was five.
“We found the service to be visibly clean and free of malodour.” from the report
Staffing and one-to-one support
seriousStaffing levels did not consistently meet people's assessed needs, particularly at weekends. Inspectors were not sufficiently assured that two people received all their additional one-to-one care hours.
“From speaking with staff and reviewing people's care records we were not sufficiently assured these people were receiving their additional care hours.” from the report
Medicines records
needs fixingTwo bottled medicines were being used without opening dates. The medicines audit had incorrectly said the dates were recorded.
“People's medicines were not consistently managed in accordance with national best practice guidance.” from the report
Incident recording
seriousAn incident involving injuries to a person's arm had not been recorded in daily notes, an incident form or recent handover notes. This limited the home's ability to review what happened and reduce further harm.
“Behavioural incidents were not consistently recorded. For example, we noted a person had some injuries to their arm which looked red and inflamed.” from the report
Staff training
needs fixingLearning disability and autism awareness training had not been provided, despite this being identified at the previous inspection and promised by the registered manager.
“At this inspection, we found learning disability and autism awareness training had not been provided.” from the report
Weak governance
seriousQuality checks did not reliably identify problems with staffing, records, training and medicines. This resulted in a breach of Regulation 17.
“The registered provider had not ensured the systems and processes to assess, monitor and improve quality and safety were effective.” from the report
- 01What has changed about weekend staffing, and how do you make sure each person's assessed support is available?
- 02How do you record and check the additional one-to-one hours for people who need them?
- 03Have all staff now completed learning disability and autism awareness training?
- 04How are medicine opening dates and medicine audits checked now?
- 05How are incidents, injuries and handovers recorded and reviewed to prevent further harm?
This was an unannounced inspection of the care home covering all five CQC key questions, with accommodation and personal care both included. This explanation was written from the published report of 16 October 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 280-282 Wells Road
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 1 April 2015.
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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