CQC report explained · a nursing home
What the CQC found at Warberries Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Warberries Nursing Home is rated Requires Improvement and remains in special measures; inspectors found caring staff but serious gaps in safety checks and management oversight.
Inspectors visited on 21 and 23 November 2023, including an unannounced visit. They spoke with people, relatives, staff and health professionals. They observed care and reviewed care plans, risk assessments, medicines records, training, recruitment, rotas and quality checks.
Some risks were not managed safely. Records did not always show that staff followed health advice, checked blood glucose, gave supplements or used the correct choking guidance. There were also medicine stock discrepancies and delays in responding to constipation. The home made immediate referrals and changes when inspectors raised concerns.
People were treated with kindness and respect. There were enough staff, people could have visitors, and staff understood people's needs. However, systems for checking the quality and safety of care were still not reliable enough.
The overall rating is Requires Improvement. Safe and Well-led were rated Requires Improvement, while Caring was rated Good. The home is no longer rated Inadequate, but it remains in special measures because of persistent breaches.
Kind and respectful care
Inspectors saw warm interactions. People said staff were caring and respectful, and their privacy, dignity and independence were promoted.
“People were well supported, and their privacy, dignity and independence was promoted.” from the report
Enough staff
Rotas showed that the home's assessed staffing levels were met. Inspectors saw high numbers of staff, and most people and families said help was available.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Improved involvement and activities
People and families were asked for their views, and the home added an activity coordinator after people asked for more activities.
“Changes were made as a result of issues raised at residents meetings.” from the report
Some progress since the last inspection
The home was no longer in breach of regulations covering dignity, safeguarding, staff training, confidentiality, incident monitoring and notifications to CQC.
“At this inspection, we found that although some improvements had been made, and they were no longer in breach of regulation 10 or 18” from the report
Open working with other professionals
The home sought advice from health and social care professionals and inspectors found a positive and open culture.
“The provider worked in partnership with others.” from the report
Health risks were not consistently managed
seriousCare records did not always show that staff followed professional advice or completed important monitoring. This included risks linked to tube feeding, diabetes, choking, nutrition and catheters.
“Risks to people were not always monitored and managed in a safe way, particularly risks associated with people's specific health needs.” from the report
Medicines stock checks were unreliable
seriousInspectors found discrepancies in medicine stock levels, including for an antipsychotic medicine. The home could not always show that medicines were being managed safely.
“We found discrepancies in medicine stock levels, including for an anti-psychotic medication, which put people at risk of harm.” from the report
Care plans were incomplete or contradictory
seriousSome care plans lacked enough detail for staff to respond consistently. Records also sometimes gave conflicting instructions about modified food and drink, increasing the risk of choking.
“Risk assessments were in place for people at risk of choking. However, records were sometimes contradictory about the level of modified diet required.” from the report
Quality checks did not find problems
seriousThe home's governance systems did not reliably identify problems in care records, medicines, care plans or the updating of professional advice.
“Although there had been improvements since our last inspection, the provider's systems did not always effectively monitor the quality of care provided to drive improvements.” from the report
Some families were not involved in care planning
minorMost relatives said they were involved and kept informed, but two relatives said they had not been asked about their family member's care plan.
“However, 2 relatives told us they had not been asked about their family member's care plan.” from the report
- 01What have you changed to make sure staff follow professional advice in care plans, including advice about tube feeding and other complex health needs?
- 02How do you now check medicine stock levels and investigate discrepancies?
- 03How do you make sure choking risk assessments and modified food and drink instructions are accurate and consistent?
- 04How do you check that staff record blood glucose checks, nutritional supplements and action taken when people become constipated?
- 05What action has been taken after the warning notice, and what evidence can you show of progress before the next CQC inspection?
This inspection examined concerns about an alleged abuse incident and reviewed Safe, Caring and Well-led; Effective and Responsive were not separately rated in the report. This explanation was written from the published report of 14 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, September 2022
Rated Requires Improvement and still in special measures; inspectors found serious weaknesses in leadership, safety systems and care planning.
This was an unannounced follow-up inspection on 14 and 20 June 2022. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, medicines records, training information and quality checks.
The home had improved since its previous rating of Inadequate. Staffing levels, infection control, activities, communication support and some care planning had improved. People and relatives generally described staff as kind and supportive.
However, inspectors found continuing risks. Medicines were not always managed safely. Incidents and safeguarding concerns were not always properly recorded, reported or analysed. Care plans did not always explain how to support people whose behaviour might challenge others, and staff said their training in this area was ineffective.
The overall rating is Requires Improvement, but the well-led rating remains Inadequate. The home therefore remains in special measures, meaning CQC will keep it under review and expects significant improvement.
Staffing and prompt support
Inspectors observed enough staff to meet people’s needs. Staff responded promptly when people needed help.
“Throughout the inspection the staff responded promptly to people who needed support.” from the report
Kind and respectful care
People and relatives described staff as caring. Inspectors saw staff treating people with warmth, kindness and respect.
“We observed staff were kind and compassionate and showed they had formed a strong relationship with people and knew them well.” from the report
Activities and relationships
People were supported to take part in flexible activities and maintain important relationships, helping them avoid social isolation.
“There was a wide range of activities offered, and throughout the day we observed people engaged with staff and enjoying what they wanted to do, alongside planned activities.” from the report
Infection control
Inspectors were assured about the home’s infection prevention arrangements, including PPE, testing, hygiene and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Consent and choice
Staff understood the Mental Capacity Act and supported people to make decisions where possible. Decisions made on behalf of people were recorded as being in their best interests.
“People's rights to make their own decisions were respected and people were in control of their support.” from the report
Medicines and diabetes safety
seriousInsulin opening dates were not recorded and checks on blood glucose meters could not show they were done regularly. Inspectors said this placed people at risk of harm.
“On the first day of our inspection we noted that the insulin open dates had not been recorded.” from the report
Incidents were not properly analysed
seriousViolent incidents and assaults involving people and staff were not always recorded under the home’s policy. The provider did not analyse patterns to reduce the risk of recurrence.
“The provider had failed to carry out an analysis of these incidents in order to identify themes and trends” from the report
Safeguarding referrals
seriousFour safeguarding incidents were recorded but were not recognised as abuse or reported to the local authority. The manager made the referrals after inspectors asked the home to do so.
“All these incidents had been recorded on the providers incident reporting system, however, they had not recognised them as abuse” from the report
Inadequate oversight
seriousQuality checks did not identify important problems with medicines, incidents, safeguarding, care planning or confidential information. The provider had been warned about repeated themes but had not made enough improvement.
“The providers systems and processes to assess, monitor and improve the quality and safety of the service were not operating effectively.” from the report
Staff training for challenging behaviour
needs fixingStaff said their training did not give them the right skills to support people whose behaviour may challenge others. Care plans also lacked clear guidance for staff.
“However, staff told us this training was ineffective and did not provide staff with the right skills and competence.” from the report
Confidential information
seriousPersonal information about people’s health needs was found outside the home after being given to a charity shop. The provider did not know it was missing.
“confidential personal information had in fact left the service and the provider was unaware that it was missing until they were informed.” from the report
- 01How are you recording insulin opening dates and checking that glucometers are accurate?
- 02What has changed so that safeguarding incidents, violence and assaults are reported and reviewed properly?
- 03What training do staff now receive for supporting people whose behaviour may challenge others?
- 04How do you check that care plans give staff clear, personalised guidance for managing these behaviours?
- 05What action has been taken to prevent confidential personal information from leaving the home?
This was an unannounced follow-up inspection covering the five CQC key questions, including infection prevention and control under Safe; the report also compares findings with the previous inspection in August 2021. This explanation was written from the published report of 24 September 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 Warberries Nursing Home
7 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2022Requires improvementup from InadequateSafe: Requires improvementCaring: Requires improvementWell-led: Inadequate
- April 2022Inadequatedown from Requires improvementSafe: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 15 November 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.
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21 live-in carers within about an hour of Torbay
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 £1,400 a week. 17 can care for a couple. 12 years' experience on average.
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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.