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CQC report explained · a residential care home

What the CQC found at Wallace Mews

Goodpublished 15 February 2024, 2 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found detailed risk plans, safeguarding systems, enough staff and safe recruitment. They also found unlocked doors to areas containing cleaning materials, but the manager acted immediately to make this safe.
Effective?
Good
This area was not assessed during this focused inspection. Its previous rating was carried forward.
Caring?
Good
This area was not assessed during this focused inspection. Its previous rating was carried forward.
Responsive?
Good
This area was not assessed during this focused inspection. Its previous rating was carried forward.
Well-led?
Good
Inspectors found positive leadership, regular checks and an open culture. People, relatives, staff and professionals were involved and said managers were approachable.
The latest report, explained

What inspectors found, February 2024

Wallace Mews is rated Good; inspectors found safe, person-centred care, with some minor safety, medicines and training issues.

This was a focused inspection on 23 January 2024. One inspector spoke with three people, six staff, two relatives and two professionals. They also reviewed care records, medicines information and other documents.

The home was rated Good for Safe and Well-led. Inspectors found detailed risk plans, enough staff, safe recruitment and systems for safeguarding. People appeared happy and relaxed, and relatives and professionals said they felt people were safe.

There were some issues. Unlocked doors led to areas containing cleaning materials, although this was fixed during the inspection. There had also been minor medicines errors, some gaps in cleaning records and some statutory training below 80% completion.

This was not a full inspection of every area of care. The ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection in 2018. The overall rating remained Good.

What inspectors praised
  • Respectful, individual care

    Care records included people's preferences and choices. Inspectors found that staff respected people as individuals and supported their independence.

    “People were supported in a way that respected them as individuals and their personal and cultural choices.” from the report
  • Staffing and safeguarding

    Inspectors found enough suitable staff and safe recruitment checks. Staff understood safeguarding and relatives and professionals said people were safe.

    “The provider ensured there were sufficient numbers of suitable staff.” from the report
  • Positive atmosphere

    People appeared happy and relaxed with staff. Inspectors found a friendly, homely atmosphere and good relationships.

    “There was a friendly and homely atmosphere at the service and people and staff enjoyed each other's company.” from the report
  • Strong management

    The home had a clear management structure, regular checks and an open culture. Families and professionals were involved in people's care and activities.

    “There was a positive and open culture at the service.” from the report
What inspectors were concerned about
  • Unlocked cleaning areas

    needs fixing

    Some doors to areas containing cleaning materials were unlocked, creating a potential hazard. The manager acted during the inspection to make the situation safe.

    “We found a number of doors into areas where there were cleaning materials stored were unlocked.” from the report
  • Previous medicines errors

    needs fixing

    There had been several minor medicines errors before the inspection. The home had provided refresher training and had recently introduced an electronic medicines records system.

    “There had been a number of minor medicine errors at the home in the months prior to the inspection.” from the report
  • Training completion

    needs fixing

    Most required training was completed, but some areas were below 80%. Ask the home which training areas were affected and how completion is being improved.

    “The homes training record showed that most statutory training was well completed, although some areas were below 80% completion.” from the report
  • Cleaning records

    minor

    Inspectors found minor gaps in cleaning records. The manager was told about these gaps.

    “There were some minor gaps in cleaning records which we brought the attention of the registered manager.” from the report
Questions to ask them, based on this report
  1. 01What medicines errors happened before the inspection, and what has changed since the electronic medicines records system was introduced?
  2. 02How do you now make sure doors to areas containing cleaning materials stay locked?
  3. 03Which statutory training areas were below 80%, and when will all staff have completed them?
  4. 04How are cleaning records checked after the gaps identified by inspectors?
  5. 05How will you show that the care still meets people's individual choices and cultural needs?

This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection in 2018. This explanation was written from the published report of 15 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.

An earlier report, explained

What inspectors found, July 2018

Wallace Mews was rated Good overall; inspectors found safe, kind and personalised care, with no serious risks or concerns.

Inspectors carried out a comprehensive inspection over two days in February 2018. The first day was unannounced. They spoke with people living there, relatives and staff, reviewed care and recruitment records, observed care, and checked the building and records.

The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safely managed medicines, suitable training, personalised care plans and respectful relationships.

People were supported to make choices, take part in activities and build independence. The home also supported people with health needs, including end of life care, and had systems to deal with complaints and monitor quality.

The rating stayed Good from the previous inspection in December 2015. The report says there was no evidence of serious risks or concerns.

What inspectors praised
  • Safe staffing and medicines

    Inspectors found enough staff for people's assessed needs. Medicines records were correctly completed and staff were trained and checked as competent.

    “During the inspection we reviewed the medicines administration records (MARs) and these were all correctly completed.” from the report
  • Kind and respectful care

    People were treated with dignity and staff understood their individual preferences. Inspectors observed positive and caring interactions.

    “People's privacy and dignity was respected by staff.” from the report
  • Personalised support

    Care plans covered people's physical, social, emotional, cultural and religious needs. People and relatives were involved in shaping their care.

    “Each care plan we viewed was person centred and they contained detailed instructions for carrying out people's care.” from the report
  • Promoting independence

    The home used a transition programme to help people develop skills and work towards living in their own home.

    “This program encouraged independence to allow the person to be confident and capable to live at their own home.” from the report
  • Strong quality monitoring

    The registered manager and provider carried out regular audits. Actions and improvements were recorded.

    “There was a robust quality assurance framework in place.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How would you support my relative's specific health, mobility or communication needs?
  2. 02How do you help people build independence, and what goals would you set with my relative?
  3. 03What activities and community opportunities would be available for my relative?
  4. 04How do you keep families informed about changes in medicines, care needs or health?
  5. 05Have staffing levels, the registered manager and the quality monitoring arrangements remained the same since the February 2018 inspection?

This was a comprehensive inspection covering all five CQC questions, and the first day was unannounced. This explanation was written from the published report of 28 July 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.

The story over the years

Every inspection of Wallace Mews

3 rated inspections over 8 years: the service has held its Good rating throughout.

  1. February 2024Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Wallace Mews →

  2. July 2018Goodstayed Good
    Safe: GoodWell-led: Good

    Read what inspectors found at Wallace Mews →

  3. February 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. September 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. December 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. December 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. April 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. November 2010

    Registered with the Care Quality Commission on 26 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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