CQC report explained · a residential care home
What the CQC found at Walberton Place Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Inadequate and placed in special measures; inspectors found serious safety, safeguarding and leadership failures.
This was an unannounced, focused inspection on 11 October 2023. Four inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicines records, staff records, rotas, training and management records.
The home was rated Inadequate for Safe and Well-led. Inspectors found that risks were not consistently assessed or managed. Medicines records were unclear, infection control was not properly reviewed, and people were not always protected from improper treatment or neglect.
Staff did not always have the skills needed for people's needs. Management checks had failed to find or fix problems, and improvements had not been sustained. People and relatives did describe care staff as kind and caring, and recruitment checks were in place.
The previous rating was Requires Improvement, published in June 2023. The home had been rated Requires Improvement at the previous four inspections and was still in breach of regulations. It is now in special measures while CQC monitors whether significant improvements are made.
Kind and caring staff
People and relatives said care staff were kind and caring, although there were concerns about communication.
“People and their relatives told us the care staff were kind and caring but there were concerns about communication at the home.” from the report
Recruitment checks
The home had checks in place before staff were employed, including references and DBS checks.
“The provider had safe systems in place for recruiting staff.” from the report
Mental capacity processes
Mental capacity assessments and best-interest decisions were recorded, and deprivation of liberty authorisations were monitored.
“The provider was working in line with the Mental Capacity Act.” from the report
Visitors allowed
People could receive visitors without restrictions, in line with the guidance referred to in the report.
“People were able to receive visitors without restrictions in line with best practice guidance.” from the report
Risks not managed
seriousRisk assessments and care plans did not always give staff the information needed to keep people safe. Inspectors observed unsafe support for a person at high risk of choking.
“The provider did not always assess risks to ensure people were safe.” from the report
Medicines errors
seriousPRN instructions were not always followed, records were unclear, and medicine stock records contained errors. One person's pain relief was not recorded in their care plan or administration records.
“Some PRN protocols were not being consistently followed by staff and medicine administration record (MAR) charts were not clear.” from the report
Safeguarding failures
seriousInspectors raised safeguarding alerts for two people. Some incidents had not been identified or reported as possible safeguarding concerns, and staff could not always explain how they would recognise abuse.
“People were not always protected from abuse and improper treatment.” from the report
Infection control
seriousDuring a COVID-19 outbreak, not all staff wore masks and some were unsure about personal protective equipment. The manager had not reviewed the infection control risk assessment or current guidance.
“People were not always protected from the risk of infection as staff were not consistently following safe infection prevention and control practices” from the report
Staff skills
seriousStaff did not always have the skills or confidence to manage people's needs, including allergies, falls, catheter care and additional support needs.
“The provider had not ensured all staff had the skills and competence to provide care safely.” from the report
Weak oversight
seriousAudits did not identify inaccurate records, missing care information or medicine discrepancies. Repeated action plans had not reduced problems such as falls or embedded learning.
“There had been a continued failure to make, and sustain, improvements over time.” from the report
- 01What immediate changes have been made to risk assessments and care plans for choking, hydration, epilepsy, falls, dementia and end of life care?
- 02How are PRN medicines, pain relief, medicine stocks and MAR charts now checked for accuracy?
- 03What safeguarding concerns were identified, reported and investigated, and how will you prevent similar incidents?
- 04What training and competency checks have staff completed for the needs of people currently living in the home?
- 05What evidence can you show that audits and the improvement plan are now identifying problems and making changes that last?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection and used to calculate the overall rating. This explanation was written from the published report of 9 February 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, June 2023
Rated Requires Improvement; inspectors found kind care and good staff support, but risks and management checks were not consistently effective.
This was an unannounced focused inspection on 4 April 2023. Inspectors spoke with people, relatives, staff and a visiting social care professional. They observed care and checked care plans, staff records, rotas, training plans and management records.
The home was rated Requires Improvement overall. Safe and well-led were rated Requires Improvement because some risks were not managed consistently, some incident records were incomplete, and quality checks had not found these problems. Effective was rated Good, with improvements in staff training, food and drink support, healthcare and decision-making.
The home had enough staff, safe medicine systems and good infection control arrangements. People described staff as kind and said they felt safe. The home had also acted on earlier recommendations about staff training and staff wellbeing. However, it had been rated Requires Improvement at the previous inspection too, and the CQC asked for an action plan and will monitor progress.
Kind and familiar staff
People were supported by staff who knew them well and treated them kindly. People and relatives said they were happy with the care.
“People were supported by kind and caring staff who knew them well.” from the report
Enough staff
Inspectors found enough suitable staff, and observed staff responding to people's needs and call bells quickly.
“There were enough suitable staff to provide safe care to people.” from the report
Medicines handled safely
Medicines were ordered, stored, administered and recorded through safe systems. Staff explained medicines and protected people's privacy.
“People were supported to receive their medicines safely and as prescribed.” from the report
Improved training
The home had improved staff training and support since the previous inspection. Staff had a plan for regular training updates.
“Staff were receiving the training and support they needed to be effective in their roles.” from the report
Food and healthcare
People received support with food and drinks, including modified diets where needed. Staff worked with other services to meet people's health needs.
“People received the support they needed with food and drinks.” from the report
Risk guidance was unclear
seriousSome care plans contained contradictory information. This meant staff were not always confident about how to provide personal care, increasing risks to dignity and wound safety.
“The failure to ensure that risks were effectively managed was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Dementia distress was not recorded well
needs fixingStaff did not complete some ABC records effectively. This meant missed opportunities to understand triggers and reduce anxiety or distress.
“Staff were not completing these effectively and this meant there were missed opportunities to make changes that might reduce people's anxiety and distress.” from the report
Incidents were not always reported
seriousSome incidents, including a choking incident, were recorded in daily notes but not reported through the home's internal system. The manager took immediate steps after inspectors raised this.
“Some incidents were not reported through the provider's internal reporting system.” from the report
Management checks missed problems
seriousThe quality system had not identified the problems found with risks, incident analysis and care records. The CQC said governance systems were not working effectively.
“Systems for governance were not operating effectively to improve the quality and safety of the service.” from the report
Care records were not always accurate
needs fixingThe electronic system recorded when some entries were made rather than when care was provided. This meant records did not always give a true picture of people's care.
“Records were not consistently accurate.” from the report
- 01What changes have you made to risk assessments and care plans so staff receive clear, consistent guidance?
- 02How do you now record and review anxiety or distress for people living with dementia?
- 03How are choking incidents, falls and other accidents reported, analysed and followed up?
- 04How do you check that electronic care records show when care was actually provided?
- 05What evidence can you show that the action plan has been completed and that improvements have lasted?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the overall rating used the other ratings from the previous inspection. This explanation was written from the published report of 10 June 2023 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 Walberton Place Care Home
4 rated inspections over 3 years: the service has slipped, from Requires improvement to Inadequate.
- February 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- June 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- July 2021Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2019
Registered with the Care Quality Commission on 1 October 2019.
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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28 live-in carers within about an hour of West Sussex
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 £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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.