CQC report explained · a nursing home
What the CQC found at Welbourn Hall Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people missed prescribed medicines, including medicines for dementia and a laxative. Records about medicine patches, as-required medicines and medicine fridge temperatures were not consistently complete.
- Effective?
- Requires improvement
- Mental capacity assessments, dietary guidance and staff training records were not consistently complete or up to date. People were supported with their health needs and had access to food, drinks and health professionals.
- Caring?
- Good
- People said staff treated them with dignity and respect. Inspectors observed kind, patient and reassuring interactions.
- Responsive?
- Requires improvement
- Care plans did not always accurately reflect people's needs and could contain contradictory information. People had access to activities, communication support and a complaints process.
- Well-led?
- Requires improvement
- New audits, checks and communication systems had been introduced, but they were not yet fully established. The manager had an action plan and showed awareness of the improvements needed.
What inspectors found, June 2023
Welbourn Hall Nursing Home is rated Requires Improvement; inspectors found kind care, but medicines were not always given safely and records and systems needed work.
This was an unannounced inspection on 22 May 2023. Inspectors, a pharmacy specialist and an Expert by Experience spoke with people, relatives and staff. They observed care and reviewed care records, medicine records, staff files and management checks.
The main safety concern was medicines. Some people did not receive prescribed medicines when they should have. Records and guidance about medicines were also incomplete. This led to a breach of Regulation 12, Safe care and treatment.
Inspectors found that staff were kind and respectful. People were supported with food, drinks, health needs, activities and contact with relatives. However, care plans, staff training, consent records and quality checks were not consistently complete or up to date.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was rated Good. New systems and an improvement plan had been introduced, but inspectors said more time was needed for them to become established.
Kind and respectful care
People were treated with dignity and staff showed compassion. Inspectors saw staff offering reassurance when people were distressed.
“Staff showed great care and compassion. We saw how staff provided reassurance to people at times of emotional distress.” from the report
Infection control
Inspectors were assured about infection prevention, use of protective equipment, cleanliness and the home's ability to manage outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Health support
Staff monitored known health conditions and worked with external health professionals. A weekly GP visit took place.
“The service was supported by local GP surgeries and a weekly GP visit occurred.” from the report
Improvement work
The manager had introduced new systems, staff meetings, daily handovers and daily checks. An action plan was in place to drive improvements.
“The registered manager had made a positive impact at the service in implementing new and improved systems and processes.” from the report
Missed medicines
seriousPeople did not always receive prescribed medicines when required. One person missed dementia medicine for four consecutive days and a laxative for three days.
“People did not always receive their prescribed medicines.” from the report
Medicine records and guidance
seriousRecords did not consistently show patch application sites, the reason for as-required medicines or medicine fridge temperatures. Guidance about side effects and risks was not detailed enough.
“Staff did not consistently record the reason or outcome of when required (PRN) medicines were administered.” from the report
Care plans
needs fixingSome care plans were contradictory, incomplete or did not reflect current needs. This could make it harder for staff to follow the right guidance.
“Care plans did not always accurately reflect people's needs.” from the report
Staff skills and records
needs fixingThere were gaps in training, and nursing staff needed further training and competency checks. Mental capacity assessments were also not consistently completed.
“The training matrix showed some gaps in training and in discussion with a nurse and the registered manager, it was clear nursing staff required further training and competency assessments to upskill them.” from the report
- 01How do you now make sure every prescribed medicine is available and given at the correct time?
- 02What checks confirm that medicine records, patch sites, as-required medicines and fridge temperatures are complete?
- 03Which care plans have been reviewed since the inspection, and how do you make sure they reflect current needs?
- 04What training and competency checks have nursing and care staff completed since the inspection?
- 05How are you tracking progress against the action plan and sharing the results with residents and relatives?
This was an unannounced first inspection of the newly registered service and covered all five key questions, including infection prevention and control; the previous provider's last rating was published in November 2022. This explanation was written from the published report of 13 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 Welbourn Hall Nursing Home
4 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- September 2021Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2023
Registered with the Care Quality Commission on 11 April 2023.
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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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.