CQC report explained · a residential care home
What the CQC found at Welbourn Manor Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found improvements in falls management, medicines, fire safety and safeguarding, although infection screening records were not always robust.
- Effective?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- The provider had strengthened management and quality checks. Care plans were more person-centred, and people, relatives and staff described the manager as open and supportive.
What inspectors found, March 2022
Rated Good; inspectors found improved safety, person-centred care and stronger management, but infection screening records were not always robust.
This was an unannounced focused inspection. Inspectors visited on 13 January 2022, spoke with people, staff and relatives, and checked care, medicines, staffing, recruitment and management records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found that risks, falls, medicines, safeguarding and fire safety were being managed better. There were enough staff on the day, although some people and relatives had concerns about staffing levels.
The home had improved since the previous inspection, which was rated Requires Improvement and found multiple breaches. At this inspection, the provider was no longer in breach of the regulations checked.
Some infection screening checks were not properly recorded. Inspectors also said communication with relatives about earlier events could have been better.
Safer risk management
The home had improved how it assessed and managed risks, including falls. Staff followed updated care plans and the number of falls had reduced.
“The manager had processes in place to analyse incidents, such as falls, to learn from these events and work to reduce the risks to people.” from the report
Medicines managed better
People were receiving medicines as prescribed. Staff had suitable training and medicines were stored safely, with regular audits.
“At this inspection we found the manager had worked with staff to improve the management of medicines.” from the report
Person-centred support
Care plans gave staff clearer guidance about people's needs, preferences and anxieties. Inspectors saw staff supporting people in the way they wanted.
“There was a very person-centred approach to the guidance in people's care plans and we observed staff working with people in a person-centred way.” from the report
Stronger leadership
Inspectors found better quality monitoring and a management team that was visible and supportive. People, relatives and staff had more confidence in the new team.
“People, relatives and staff told us the manager was open and honest and had worked to keep them informed of changes at the service since their appointment.” from the report
Infection screening records
needs fixingInspectors were not always assured that visitor vaccination checks were being carried out and recorded properly. The same issue applied to checks for visiting health professionals.
“Some aspects of infection control screening processes were not robust.” from the report
Staffing concerns
needs fixingPeople and relatives gave mixed views about whether there were enough staff. There were enough staff on the inspection day, but the provider was still recruiting to vacant posts.
“People and relatives gave mixed responses about whether there were enough staff to support people.” from the report
Communication with relatives
minorSome relatives felt communication about earlier events at the home could have been better. The provider said it would use this feedback to improve its communication.
“Some relatives felt the provider's communication around the previous events at the service could have been improved.” from the report
- 01How are you now recording vaccination checks for visitors and visiting health professionals?
- 02How many staff are currently in post, and how are vacant posts affecting staffing on different shifts?
- 03What changes have been made to prevent falls and how are individual risks reviewed?
- 04How are medicines audits completed and how are any errors followed up?
- 05How will relatives be kept informed if serious concerns or incidents arise?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 3 March 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.
What inspectors found, November 2021
Requires Improvement overall, with Safe rated Inadequate because inspectors found risks involving abuse, falls, medicines and fire safety.
This was an unannounced focused inspection on 6 October 2021. Inspectors reviewed Safe and Well-led because safeguarding concerns had been raised. They spoke with people, a relative and staff, and checked care records, medicines, recruitment files and management records.
The Safe rating fell from Good to Inadequate. Inspectors found unsafe medicines arrangements, poor management of falls, out-of-date fire evacuation information, unlocked areas containing chemicals and weaknesses in staff recruitment. They also found people were not always protected from abuse or improper treatment.
The Well-led rating fell from Good to Requires Improvement. Management oversight and quality checks had not identified or fixed important problems. The provider had suspended staff and taken action after whistleblowing concerns, but the inspection found that further improvement was needed.
The overall rating changed from Good to Requires Improvement. The other three questions were not inspected, so their previous ratings were used in the overall rating. The provider was asked for an action plan and CQC said it would monitor progress and return to inspect.
Action after safeguarding concerns
The provider suspended staff while investigations took place and worked with safeguarding teams and CQC. This was intended to protect people while concerns were investigated.
“Following the whistle blowing concerns being raised the provider had acted swiftly prior to our inspection to ensure the safety of people at the service” from the report
Infection control
Inspectors were assured that infection prevention arrangements covered visitors, protective equipment, testing, admissions, hygiene and visits.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Staffing support
Although several staff had been suspended, the provider maintained adequate staffing and brought in an experienced interim manager to support improvements.
“Although the provider had suspended several staff, they ensured people were supported by adequate numbers of staff.” from the report
Some immediate safety fixes
During or after the inspection, the interim manager updated the paper medicines records and fire information and arranged locks for areas containing hazardous chemicals.
“The interim manager immediately addressed our concerns around the information in both the paper based MAR system and the fire safety folder” from the report
People were not always protected from abuse
seriousSafeguarding concerns included alleged neglect, verbal abuse and physical abuse. Inspectors also found evidence of a poor staff culture and incomplete safeguarding update training.
“People living at the service were not always safe from abuse.” from the report
Medicines were not managed safely
seriousSome people did not receive medicines as prescribed. Inspectors found unsafe storage of controlled drugs, insufficient stocks, out-of-date medicines and incomplete information for safe administration.
“Management of people's medicines was unsafe and there was a lack of clear consistent information to support safe administration of medicines.” from the report
Falls and fire risks
seriousCare plans did not show measures to reduce repeated falls. Fire evacuation information was out of date, and some people did not have evacuation plans.
“The risks to people's safety were not always managed safely and actions were not taken to mitigate risks to people.” from the report
Weak management oversight
needs fixingQuality checks had not identified or followed up important problems. There was also poor communication between the provider's quality monitoring team and the home.
“Quality assurance tools had either not highlighted when people's care had fallen below the standard of care expected from the service, or actions highlighted had not been followed up.” from the report
Care plans and staff support were incomplete
needs fixingSome care plans lacked useful, person-centred information. Staff did not consistently receive meaningful supervision or required update training.
“People's care plans were not always person centred and lacked details.” from the report
Hazardous chemicals were not locked away
seriousTwo sluices and a cupboard containing hazardous chemicals were unlocked. Inspectors said this created a risk of harm to people who lacked capacity.
“This presented a risk people who lacked capacity could ingest the chemicals causing harm or injury.” from the report
- 01What changes have been made to ensure medicines are given as prescribed, stored safely and kept in sufficient supply?
- 02How are repeated falls now assessed, recorded and reduced for people at risk?
- 03How are safeguarding concerns and staff behaviour monitored, and what safeguarding update training has staff completed?
- 04How do you check that fire evacuation plans and personal emergency evacuation profiles are current for every person?
- 05What quality checks are now in place to make sure problems are identified, acted on and followed up?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 9 November 2021 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 Manor Care Centre
6 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 December 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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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.