CQC report explained · a residential care home
What the CQC found at Walsham Grange
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 a discrepancy in one person's repositioning requirements and some unclear medicine instructions. They also received mixed feedback about staffing, although staff were observed responding promptly to call bells and requests.
- Effective?
- Requires improvement
- This key question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Well-led?
- Requires improvement
- The provider had improved its quality assurance processes and was no longer in breach of Regulation 17. However, audits had missed some important record errors, and there was no registered manager in post.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found kind care and some safety systems, but risks, medicines records and management checks were not always reliable.
This was an unannounced focused inspection. Inspectors visited on 22 June 2023 and reviewed information through 6 July 2023. They looked only at Safe and Well-led because concerns had been raised about falls and management oversight.
The home had trained staff, infection control procedures and systems for medicines, risk checks and safeguarding. People appeared comfortable and were treated with kindness. However, inspectors found a discrepancy in one person's repositioning requirements and unclear instructions in some medicine records. Relatives also gave mixed views about staffing and communication.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. The previous breach about governance had been resolved, but the newer quality checks had not yet become reliable enough. There was no registered manager in post during the inspection.
Kind treatment
People appeared comfortable with staff, who were observed treating them with dignity, respect and kindness.
“People appeared to be relaxed and comfortable with staff. Staff were observed treating people with dignity, respect and kindness.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicine training
Medicines were given by trained staff, with regular checks of their skills and knowledge.
“People received their medicine from trained and competent staff.” from the report
Safeguarding and choice
Staff understood how to report concerns, and inspectors found that people were supported to make choices under the Mental Capacity Act.
“The provider had effective processes in place to protect people from harm.” from the report
Learning from falls
The home had introduced more detailed analysis of falls and was trialling a different alert system for someone at increased risk.
“A more in-depth analysis of falls in the service had been implemented.” from the report
Risk assessment error
seriousInspectors found a discrepancy in one person's repositioning requirements. The regional manager corrected it immediately, and inspectors said there had been no impact, but this showed the records were not fully reliable.
“On the day of our inspection visit discrepancies were identified within repositioning requirements for one person.” from the report
Unclear medicine instructions
seriousSome medicine records did not clearly state details such as the length of an antibiotic course or which eye needed drops. This led to a person receiving a few extra doses.
“there were some occasions where the information on the system was not clear enough, such as the course length of an antibiotic” from the report
Management checks
needs fixingThe new audits had not picked up the risk-record error or missing information in a staff recruitment file. Inspectors said the systems needed more time to become robust.
“these audits had not identified missing information within a staff recruitment file or the discrepancy in a person's risk assessment.” from the report
Staffing concerns
needs fixingRelatives gave mixed feedback about staffing and whether staff came quickly enough. Inspectors observed adequate staffing during their visit, but recruitment was still ongoing.
“We received mixed feedback from relatives regarding the staffing levels in the home.” from the report
Communication
needs fixingSome relatives said communication was inconsistent, although others said staff returned calls and kept them informed.
“Some relatives told us they had not experienced good communication with the service” from the report
- 01Who is currently managing the home, and when will a registered manager be in post?
- 02How are you checking that repositioning instructions and other risk assessments are accurate and up to date?
- 03What changes have been made to prevent unclear medicine instructions and extra doses?
- 04How many staff are usually on duty for each shift, and how are current staffing gaps being covered?
- 05How will relatives receive regular and reliable updates about their family member?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 21 July 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.
What inspectors found, June 2022
Rated Requires Improvement; care was kind and personalised, but medicines and management systems still needed work, and the home had only recently left special measures.
Inspectors made an unannounced visit on 6 April 2022. They spoke with people, relatives and staff, and checked medicines records, care plans, accident records, staff files and management records.
The home had improved since its previous inspection, when it was rated Inadequate and placed in special measures. Inspectors found kind, respectful care, person-centred planning, good support with food and drinks, and good involvement of people and relatives.
Some medicines were not recorded or stored safely, and the review of accidents did not clearly show what action had followed. Management checks were not strong enough to identify and fix problems. The overall rating was Requires Improvement. The home was no longer rated Inadequate or in special measures.
Kind and respectful care
Inspectors saw staff speaking kindly to people, checking on them and respecting their privacy. People and relatives also gave positive feedback about how people were treated.
“Our observations showed staff spoke with people in a kind way, and we saw staff stopping by people's rooms to ask if they were okay when they were walking about the service.” from the report
Personalised support
Care plans described individual needs and preferences. People and relatives were involved in planning and reviewing care.
“A review of people's care records showed their care was planned for in a person-centred way which detailed their individual care needs and preferences.” from the report
Food and drink choices
People could choose when and where to eat, had access to drinks, and received meals prepared in the right texture where needed.
“People had a choice of when they ate, and drinks were readily available.” from the report
Progress since the last inspection
The home improved from an Inadequate rating and left special measures. Several previous breaches, including those about staffing, nutrition, dignity, person-centred care and consent, were no longer in place.
“There had been improvements at the service since our last inspection, however further improvements were still required.” from the report
Medicines records and storage
seriousThe electronic medicines system had led to errors and discrepancies. Topical medicines were not always stored securely, patch records were incomplete, and blood glucose checks were missing from some records.
“We also noted there were discrepancies arising due to inadequacies of the electronic recording system.” from the report
Weak management checks
seriousAudits did not always identify problems or set clear deadlines for fixing them. Several actions in the improvement plan were still outstanding.
“The quality monitoring systems in place required further refinement in order to effectively monitor, assess and drive improvement.” from the report
Learning from incidents
needs fixingThe home analysed accidents and incidents, but it was not clear what action had followed. Inspectors also found that falls had not initially all been reported to the local authority, although this was corrected.
“There was an action plan in place for improvement required at the service, however, many of the actions remained outstanding.” from the report
Mixed induction feedback
needs fixingStaff understood people's care needs overall, but one member of staff said their induction did not give enough information about people's needs and they did not have time to read care records thoroughly.
“One member of staff told us their induction lacked information about people's needs.” from the report
- 01What changes have been made to the electronic medicines system, and how do you now check that medicines are given and recorded correctly?
- 02How are topical medicines and medicated skin patches stored and checked for safety?
- 03How do you make sure every accident, fall or incident is reported, reviewed and followed by clear action?
- 04Which actions from the improvement plan were still outstanding, and have they now been completed?
- 05How do new staff learn about each person's needs before working independently?
This inspection considered all five key questions and included infection prevention and control under Safe; it followed the previous comprehensive inspection published on 28 October 2019. This explanation was written from the published report of 28 June 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.
Every inspection of Walsham Grange
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- October 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementstayed Requires improvementWell-led: Inadequate
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 13 May 2013.
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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