CQC report explained · a nursing home
What the CQC found at Cullum Welch Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, infection control, risk management and staffing were found to be safe during the inspection.
- Effective?
- Requires improvement
- Staff had relevant training, but most of the staff records reviewed showed no one-to-one supervision in 2022. Inspectors said staff were not adequately supported to be effective in their roles.
- Caring?
- Good
- People were treated with kindness, dignity and respect, and were involved in everyday choices. One person reported that some night staff complained when support with toileting was requested.
- Responsive?
- Requires improvement
- People received care that met their needs, and activities were available. However, care plans did not explain enough ways to remind people with memory problems about activities and events in advance.
- Well-led?
- Requires improvement
- Management and leadership had been inconsistent, with high staff and manager turnover. New systems and improvements were being introduced, but staff were not using one care-recording system effectively.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found safe and kind care, but concerns about staff support, care planning and inconsistent management.
This was an unannounced comprehensive inspection in July and August 2022. Inspectors spoke with people, relatives, staff and managers. They reviewed care files, medicines records, staff supervision and training records, complaints, incidents and quality checks.
The home was rated Good for Safe and Caring. Inspectors found people were protected from abuse, medicines were managed safely, staffing levels had improved and people were treated with kindness and respect. People had access to food, drink, healthcare and activities.
The home was rated Requires Improvement overall, Effective, Responsive and Well-led. Staff were not receiving enough supervision, care plans did not always explain the best ways to support people with memory problems, and management changes and staff turnover had affected the service. The provider was required to send an action plan, and progress will be monitored.
Medicines managed safely
Inspectors found that medicines were administered by qualified nurses, records were clear and controlled medicines were securely managed.
“People's medicines were administered and managed safely.” from the report
People protected from abuse
Staff had safeguarding training and understood how to recognise and report abuse. Management had investigated safeguarding allegations and involved other agencies when needed.
“People were protected from the risk of abuse.” from the report
Kind and respectful care
Inspectors saw warm relationships between people and staff. Staff promoted privacy, independence and involvement in daily decisions.
“Staff showed people kindness and consideration in the way they treated them and cared for them.” from the report
Food, drink and activities
People were offered choices at mealtimes, support to eat and drink, and a range of activities including exercise, games, puzzles and music.
“People were engaged in activities to occupy them.” from the report
Improving communication
The new management team had started regular meetings and updates for relatives and staff. Relatives said communication had improved.
“We have regular zoom meeting with the manager now and emails updates regularly which are helpful.” from the report
Limited staff supervision
seriousSeven of the nine staff records reviewed showed no one-to-one supervision in 2022. Inspectors said staff were not getting the support needed to improve their motivation and effectiveness.
“Staff were not supported to be effective in their roles.” from the report
Unstable management
needs fixingThere had been frequent changes in managers and high staff turnover. There was no registered manager in post when inspectors visited.
“There was high turnover of staff and managers which had affected the quality of the service and staff performance.” from the report
Care plans did not cover memory support fully
needs fixingCare plans did not always explain how to remind people with memory problems about daily activities and events in advance. Inspectors recommended that the home look at best practice in this area.
“Care plans had not explored ways to remind people who have memory problems of daily activities in the home.” from the report
Many complaints in the previous year
needs fixingThere had been a high level of complaints about staffing, care standards and management changes. Complaints had been investigated, but some were still ongoing.
“There had been a high level of complaints about the service in the last year.” from the report
Care-recording system not used properly
needs fixingA system intended to prompt and record care was in place, but staff were not using it effectively. Management had identified this and was providing further training.
“However, when we reviewed the system it showed staff were not using it effectively as they should.” from the report
- 01How often does each member of staff now receive one-to-one supervision, and how is this recorded?
- 02Is there now a registered manager in post, and how are management changes being prevented from affecting care?
- 03How will you remind people with memory problems about activities and events early enough for them to prepare?
- 04How are staff being checked to make sure the care-recording and fluid-monitoring systems are used correctly?
- 05What action has been taken in response to the previous complaints about staffing, care standards and management changes?
This was an unannounced comprehensive inspection covering all five key questions, including both the premises and nursing and personal care; infection prevention and control was also checked. This explanation was written from the published report of 6 October 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, June 2018
Cullum Welch Court Care Home was rated Good overall; inspectors found safe, kind and personalised care with effective management.
This was an unannounced inspection on 24 April 2018. Inspectors spoke with people living at the home, relatives, staff and healthcare professionals. They also reviewed medicines, care and staff records, and observed care and mealtimes.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably trained staff, safe medicines arrangements, detailed care planning and good access to healthcare.
People and relatives described staff as kind and respectful. Inspectors found that care was personalised, activities reflected people's interests, complaints were dealt with, and managers used checks and feedback to improve the service.
The home had breached regulations at the March 2017 inspection about medicines and quality assurance. A focused inspection in August 2017 found these legal requirements had been met. At this inspection, the home continued to meet the regulations.
Safe medicines
Inspectors reviewed medicine records for 20 people and found that medicines were administered, stored and recorded safely.
“People received their medicines as prescribed. Only trained and competent staff administered medicines to people.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people with kindness, maintaining privacy and responding to emotional needs.
“People, and their relatives told us that staff were kind, compassionate and caring.” from the report
Personalised support
Care plans included people's needs, backgrounds, preferences and routines. Staff were able to describe how people wanted to be supported.
“People received care personalised to their needs.” from the report
Activities and relationships
The home offered varied activities, including group and one-to-one options. People were supported to keep in touch with relatives and maintain cultural and religious practices.
“People were actively encouraged to participate in meaningful activities of their interest.” from the report
Quality monitoring
The home used audits, meetings, feedback and action plans to monitor care and make improvements.
“Regular checks and audits of the quality of care were carried out to improve on service delivery.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure staffing levels remain sufficient when staff are absent?
- 02How are medicine audits completed now, following the medicine management breach found in March 2017?
- 03How will you use the Red Bag scheme when someone moves to hospital or another service?
- 04How quickly do staff usually respond to call bells, and how do managers check this?
- 05How are relatives involved in care plan reviews and decisions about care?
This was an unannounced inspection covering all five key questions and both the accommodation and care provided; 45 people were living at the home during the visit. This explanation was written from the published report of 27 June 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 Cullum Welch Court Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Cullum Welch Court Care Home →
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Cullum Welch Court Care Home →
- September 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 13 May 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Greenwich
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 87 can care for a couple. 11 years' experience on average.
“She cared for my mum with Alzheimer's with endless patience and kindness, always arriving with a smile and a positive attitude”
“Usha rapidly became 'one of the family' and is sorely missed.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.