CQC report explained · a residential care home
What the CQC found at 19 Wheelwright 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
- Inspectors found gaps in choking and epilepsy risk assessments, fire safety actions that had not been completed, and an incorrectly given as-required medicine. Staff numbers were sufficient, and regular staff and agency staff knew people's needs.
- Effective?
- Good
- Care plans generally reflected people's needs and communication support. People received healthcare support and had health action plans, although some food was not provided in line with specialist guidance.
- Caring?
- Good
- Staff were kind, patient and respectful. They understood people's communication styles, protected privacy and dignity, and supported independence, although people were not always fully involved in care planning and reviews.
- Responsive?
- Requires improvement
- People were not consistently supported to take part in activities they enjoyed or to develop meaningful personal goals. They were also not consistently involved in planning or reviewing their care.
- Well-led?
- Requires improvement
- Management systems did not reliably identify or resolve risks involving fire safety, food, epilepsy, medicines, visits, activities and care plan reviews. New improvement processes had been introduced, but the provider remained in breach of the good governance regulation.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found kind and effective care, but serious gaps in safety, personalised support and management remained.
The home provides personal care for six people. Inspectors visited without notice on 31 January and 23 February 2022, with inspection work ending on 3 March 2022. They spoke with people, a relative and staff, observed care, and checked care, medicine, staff and management records.
Inspectors found that people were treated kindly and with dignity. Staff understood people's communication needs, supported access to healthcare, and usually provided medicines correctly. The home was clean and people could personalise their rooms.
However, some people were at risk because choking and epilepsy guidance was incomplete or not followed. One person was nearly given food that was unsafe for them. An as-required medicine was given incorrectly. People were not always supported with activities, goals or care plan reviews, and management checks had not found these problems.
The overall rating is Requires Improvement. Safe, Responsive and Well-led were rated Requires Improvement. Effective and Caring were rated Good. The provider remained in breach of Regulations 9 and 17 and was also found in breach of Regulation 12.
Kind and respectful care
Staff showed warmth and patience. They knew people well and respected their privacy, dignity and need for personal space.
“Staff members showed warmth and respect when interacting with people.” from the report
Good communication support
People had individual communication plans. Staff understood different ways people communicated and knew how to respond.
“Staff had good awareness, skills and understanding of individual communication needs, they knew how to facilitate communication and when people were trying to tell them something.” from the report
Healthcare support
People had health action plans and were referred to healthcare professionals. Inspectors found examples of positive health outcomes.
“These examples demonstrated the provider had worked with a number of healthcare professionals, over a period of time, to ensure people had received the healthcare they needed which had resulted in positive outcomes for people.” from the report
Clean and personalised home
The home was clean, well equipped and well furnished. People could personalise their rooms and had been involved in choices about decoration.
“People's care and support was provided in a clean, well equipped and well-furnished environment.” from the report
Unsafe food and incomplete risk guidance
seriousChoking risks were not always properly assessed or managed. Inspectors had to intervene when a person was about to be given food that was unsafe and incorrectly prepared.
“The inspector had to intervene to ensure food that was unsafe and prepared incorrectly was not given to the person.” from the report
Epilepsy support was not reliable
seriousSome care plans did not give staff enough guidance about seizures. One staff member could not explain when emergency help should be called.
“This meant there could have been delays in seeking medical attention or staff not recognising seizure activity.” from the report
Medicine error
seriousAn as-required medicine was given incorrectly. The home's medicine audits had not found the error.
“We identified a medicine error whereby an 'as required' medication had been given incorrectly.” from the report
Activities and goals were not personalised
needs fixingPeople were not consistently supported to take part in activities that matched their interests. Their goals were not always meaningful or developed with them.
“People had not been supported to be involved in the planning and reviewing of their care.” from the report
Management checks missed important problems
seriousQuality checks did not identify several safety and care concerns, including fire safety, unsafe food, epilepsy guidance, medicines and activities.
“Systems were not robust enough to demonstrate effective monitoring of the quality and safety of the service.” from the report
- 01What has changed to make sure food is prepared exactly as required for people at risk of choking?
- 02What written guidance is now available for each person's epilepsy, including when staff must call emergency services?
- 03How do you check that as-required medicines are given correctly and that any errors are acted on quickly?
- 04How does each person choose activities and set meaningful goals, and how is their progress recorded?
- 05How are people and their families involved in care plan reviews and decisions about support?
This was an unannounced inspection covering all five key questions and infection prevention and control, using observations, discussions and a sample of care, medicine, staff and management records. This explanation was written from the published report of 28 March 2024 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 2020
Rated Requires Improvement; inspectors found improvements in safety and culture, but governance checks were still not reliable.
Inspectors visited on 24 August 2020 and reviewed records, care plans, medicines, incidents, staffing and infection control. They spoke with people living at the home, staff, relatives and managers. A further inspector reviewed documents and made telephone calls on 25 August.
The home had improved its safeguarding arrangements and support plans for behaviour that may challenge. Medicines were generally given safely, staffing levels were sufficient, and staff described a more positive culture. However, some risks and records were not managed consistently.
The home remained rated Requires Improvement overall. Safe was Requires Improvement and Well-led was Requires Improvement. The home had improved from Inadequate for Well-led at the previous inspection, but it was still in breach of Regulation 17 because its quality checks did not reliably identify or resolve problems.
Improved safeguarding
Safeguarding concerns were being reported to the right authorities in a timely way. Staff said they understood how to recognise and report abuse.
“Following our last inspection safeguarding incidents had been reported to relevant authorities in a timely manner.” from the report
Better behaviour support
The home had reviewed behaviour support plans and given staff additional training. Staff said they were clearer about how to support people and incidents had reduced.
“Following our last inspection, work had been carried out in-conjunction with the provider's behaviour support team to review and improve the plans to support people with behaviours that may challenge.” from the report
Enough staff
Most people had a staff member allocated to support them for most of the day. Inspectors saw this level of support during their visit.
“Most of the people living at the home had a staff member allocated to support just them for the majority of the day.” from the report
More positive culture
Staff reported that the culture had become more open and inclusive. They also said people were happier and staff felt more supported.
“At this inspection staff reported a change in the culture to a more positive and inclusive one” from the report
Medicines generally safe
Only trained staff administered medicines, and the records checked showed that daily medicines had been given safely.
“A review of medicines records demonstrated that people's daily medicines were given safely.” from the report
Governance breach
seriousThe provider's checks did not reliably find missing or incorrect records, conflicting care guidance, or unresolved safety issues. The provider remained in breach of Regulation 17.
“The provider had not made sustained improvements in the governance systems at the service.” from the report
Delayed medical advice
seriousInspectors found one incident where there was an overnight delay before medical advice was sought. They said the new systems needed to become embedded so action was prompt every time.
“However, we found one incident had a delay of overnight before medical advice was sought.” from the report
Conflicting care guidance
needs fixingSome care plans did not match the positive behaviour support plans. This could lead to staff taking different approaches when supporting someone.
“We saw some discrepancies between the care plans and PBS which may of caused an inconsistency in approach when supporting a person.” from the report
Infection control checks
needs fixingSome staff had refused Covid-19 testing without a risk assessment in place at first. Covid-19-specific checks had also not been added to infection control audits.
“There had been no risk assessment put in place around this, although this was completed by the end of the inspection.” from the report
Incomplete medicines protocols
needs fixingTwo protocols for medicines given when needed were missing, and another contained incorrect dosage information. These were corrected by the end of the inspection.
“We noted that two protocols for 'as required' medicines were not in place and one protocol stated incorrect dosage information.” from the report
- 01How do you now check that care plans and positive behaviour support plans say the same thing?
- 02What has changed to make sure medical advice is sought promptly after an incident?
- 03How do you check that medicines protocols are complete and contain the correct dosage information?
- 04How are water checks, fire safety actions and other follow-up actions recorded, given that previous actions did not always have deadlines or sign-off?
- 05What risk assessment and infection control arrangements are now used for Covid-19 testing and for situations where masks need to be removed?
This was a focused inspection of Safe and Well-led, including infection control; the other three question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 23 October 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.
Every inspection of 19 Wheelwright Road
6 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- March 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 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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