What the CQC found at The Well House

Staff knew people well, communicated in ways they understood and treated them with warmth and respect.

“Staff supported people in a person-centred way. Staff knew people well and understood how to communicate effectively with each person.” from the report

People were supported to make everyday choices, take part in activities and develop their independence.

“We saw that people were encouraged to do things independently and received praise from staff.” from the report

Relatives were positive about people's experiences, and staff supported people to have visitors and maintain relationships.

“People were supported by staff to have regular visitors and staff supported people's relationships with their friends and family.” from the report

The home made referrals when needed and worked with health professionals, including around diabetes and medicines.

“The registered manager made referrals to health professionals when needed, for example the speech and language therapist (SALT) and worked in partnership with health professionals.” from the report

Inspectors found there were enough staff to keep people safe, although staffing shortages had been covered by extra shifts and agency staff.

“There were enough staff to keep people safe. Although there had been staffing shortages, recruitment was ongoing, and shifts were covered by staff doing extra shifts or agency staff.” from the report

Some risk assessments were missing or had not been reviewed. Guidance was unclear for people with epilepsy and for one person at high risk of choking.

“People's risks were not always effectively assessed and managed. People's risk assessments had not been regularly reviewed or updated and some risk assessments were missing.” from the report

On the first inspection day, staff were not wearing face masks in line with government guidance, including during a COVID-19 outbreak. The home changed this after inspectors raised the issue.

“Staff were not wearing face masks unless supporting people with personal care. This included whilst the home had an outbreak of COVID-19.” from the report

Some medicines instructions were out of date or unclear. This included guidance for medicines taken when needed and one person's blood test results on their medicines record.

“PRN protocols to guide staff on when the person should receive this medication were inconsistent and did not clearly detail how staff would know whether the person needed that medicine.” from the report

Audits did not identify problems with care plans, medicines, fire evacuation plans or recruitment. Some audits had not been completed since December 2021.

“Issues that we found during our inspection were not identified by the provider's auditing processes.” from the report

There were gaps in employment records and evidence that some gaps had not been explored. Risk assessments were completed after the inspection.

“Recruitment processes did not ensure staff were recruited safely. There were gaps in staff's employment records and no evidence that these gaps had been explored through the interview process.” from the report

Some people had restrictions without clearly recorded mental capacity assessments and best-interest decisions to support them.

“Deprivation of liberty safeguards (DoLS) had been applied for people who had restrictions, but not everyone had mental capacity assessments and best interest decisions to support this.” from the report