CQC report explained · a residential care home
What the CQC found at 37 Wolseley 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
- Fire risks had not been regularly assessed, three fire doors were held open by wedges, and fire drills were not regular or properly followed up. Other individual risk assessments, staffing arrangements, medicines and infection control were found to be good.
- Effective?
- Good
- People's health, dietary and social needs were assessed and supported. Staff received relevant training, worked with health professionals and followed the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in choices about their care and daily routines, although the home did not actively promote independence enough.
- Responsive?
- Good
- Care was personalised and records reflected people's preferences and needs. People were supported with communication and community activities, although relatives gave mixed views about whether there were enough meaningful activities.
- Well-led?
- Requires improvement
- The manager was approachable and staff felt supported, but some quality checks were ineffective. They did not identify the missing fire assessment or problems with door-release mechanisms.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found kind, effective care but serious weaknesses in fire safety checks and oversight.
The inspection visit took place on 10 March 2020 and was unannounced. One inspector spoke with people, relatives, staff, managers and care professionals. They also observed care and reviewed care, medicines, training, incident and quality records.
People were generally safe, well cared for and supported by staff who knew them well. Medicines, staffing, food, health support, communication and personalised care were mostly handled well. People and relatives said they felt safe, and staff were described as kind.
The main safety concern was fire protection. Fire risks had not been assessed since September 2017, and wedges were holding three fire doors open. Fire drills were not regular and learning from them was not recorded or acted on. Quality checks had failed to identify these problems.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led fell from Good at the previous inspection to Requires Improvement.
Kind relationships
Inspectors saw positive relationships and respectful care. People and relatives described staff as kind and friendly.
“The staff are kind and look after me nice.” from the report
Safe medicines support
Staff were trained and checked as competent to give medicines. Medicines were ordered, stored and administered through effective systems.
“The service had effective systems and staff managed medicines consistently and safely.” from the report
Personalised care
Staff knew people's needs, preferences and communication methods. Care plans were detailed and updated when people's needs changed.
“People received personalised care from staff who knew them well.” from the report
Fire safety risks
seriousFire safety had not been assessed for several years. Three fire doors were wedged open, which could stop them working properly in a fire.
“These doors close when a fire alarm is activated, but the wedges prevented this from happening.” from the report
Weak fire drill arrangements
seriousFire drills were not regular and the home did not record or act on learning from them. There was also no clear plan for an evacuation if a manager was not on duty.
“There was no procedure in place for actions to be taken if a manager was not on duty at the time of a fire, such as overnight.” from the report
Ineffective quality checks
needs fixingThe home's checks did not identify the missing fire assessment or door problems. This contributed to the fall in the Well-led rating.
“However, we found some of the audits undertaken were ineffective, for example the audits relating to premises had not identified that a fire risk assessment had not taken place for some years.” from the report
More independence and stimulation needed
needs fixingPeople were supported with some independence, but there was no system to actively develop independent living skills. Two relatives also felt their family members were bored and lacked stimulation.
“We found that people were supported to maintain some areas of independence but there was no system in place to actively promote it.” from the report
- 01When was the current fire safety risk assessment completed, and can we see the actions that came from it?
- 02How have you stopped fire doors being wedged open, and how do you check that they close correctly?
- 03What is the evacuation plan if a fire happens when a manager is not on duty, including overnight?
- 04How are fire drills now scheduled, recorded and used to improve practice?
- 05What specific activities and plans are now in place to build each person's independence and reduce boredom?
This was a planned, unannounced inspection covering all five CQC questions; Safe and Well-led deteriorated from Good, while Effective, Caring and Responsive remained Good. This explanation was written from the published report of 16 April 2020 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 2017
Care Services (UK) Limited - 37 Wolseley Road was rated Good; inspectors found safe, caring and well-managed support, with improvements since the last inspection.
The inspection was unannounced and took place on 6 September 2017. The home supported five people with learning disabilities and could accommodate up to five people. Inspectors spoke with people, staff, the registered manager and a relative. They also observed care and checked care plans, training, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable staff training and support with food and health appointments.
People were treated with patience and respect. They were involved in decisions, supported to be independent and helped to take part in activities and maintain important relationships. The home had systems for listening to feedback and checking the quality of care.
The home was still rated Good, as it had been at the inspection in February 2016. Inspectors found that the previous shortfall in recording why some decisions were in people's best interests had been corrected.
Kind and respectful care
Staff knew people well and supported them patiently. They respected privacy and encouraged people to make choices and do things for themselves.
“We observed staff spending time with people and talking about subjects that interested them.” from the report
Personalised support
Care records included people's routines, preferences and important relationships. People were supported to join activities at home and in the community.
“People's care records were personal to them.” from the report
Improvements were made
The home acted on the previous inspection's advice about recording decisions made for people who could not make those decisions themselves.
“At this inspection, we found that the required improvements had been made.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently record why a decision is in a person's best interests when they cannot make it themselves?
- 02How do you make sure staffing levels change when residents have different routines or community activities?
- 03What activities are available now, and how are residents involved in choosing them?
- 04How are medicines, including as-required medicines, checked and recorded when a resident spends time away from the home?
- 05How are relatives involved in regular care reviews and in giving feedback about the service?
This was an unannounced inspection covering all five CQC questions; inspectors checked two care plans, one staff file, training records and management quality checks. This explanation was written from the published report of 19 October 2017 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 37 Wolseley Road
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- April 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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