CQC report explained · a residential care home
What the CQC found at Welby Croft Residential 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
- Risk assessments were often generic and did not always reflect people's health conditions or changing needs. There were also gaps in guidance and recording for some medicines.
- Effective?
- Good
- This question was not inspected at this visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected at this visit. The report says people and relatives described staff as kind and caring.
- Responsive?
- Good
- This question was not inspected at this visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Audits and meetings did not clearly show who was responsible for actions or whether improvements had been completed. The home's quality systems had not identified and acted on the concerns found.
What inspectors found, March 2021
Welby Croft Residential Home was rated Requires Improvement; inspectors found kind care but gaps in risk assessments, medicines records and management checks.
This was an unannounced inspection on 17 February 2021 by one inspector. The inspection looked mainly at safety, infection control and how the home was managed. The inspector reviewed care, medicines, staff and management records, spoke with staff and a health professional, and contacted relatives afterwards.
The home had enough staff and people were supported by kind and familiar carers. People enjoyed meals, had choices about food and were helped to keep in touch with family. Infection control arrangements were mostly assured, including the visiting pod, testing and use of protective equipment.
However, some risk assessments and care plans were too general or out of date. There were gaps in guidance and recording for medicines, and some staff still needed training about specific health conditions. Management audits had not reliably found or followed up problems. The overall rating fell from Good at the previous inspection to Requires Improvement.
Kind, familiar staff
Relatives described staff as kind and caring. The home did not use agency staff during the pandemic, so people were supported by staff they knew.
“Relatives we spoke with reflected on the kind and caring nature of the staff.” from the report
Food and mealtimes
People enjoyed the relaxed lunchtime experience. Staff offered help when needed and there were choices to support people's dietary needs.
“There was a relaxed atmosphere in the home and people enjoyed the lunchtime experience.” from the report
Family contact
People were supported to maintain relationships with family. Relatives received videos and messages, and visiting arrangements were available.
“People were encouraged and given the opportunity to maintain relationships with family.” from the report
Safeguarding awareness
Staff understood how to recognise and report concerns about abuse. The manager worked with the local authority when safeguarding concerns were raised.
“All the staff we spoke with had received training in safeguarding and knew how to raise any concerns.” from the report
Risk assessments and care plans
seriousSome assessments were generic and did not cover health conditions or changing needs in enough detail. Care plans were not always reviewed, and there were no end-of-life plans.
“Risks to people's health and safety had not always been assessed and mitigated.” from the report
Medicines records
seriousInstructions were not always available for medicines given only when needed. The application and removal of some pain-relief patches were not always recorded.
“Where people required 'as needed' medicines, protocols were not always in place to inform staff when they should administer these medicines.” from the report
Management checks
seriousAudits did not consistently identify problems or show that actions had been completed. Meetings did not clearly record who would do each action or when it would be finished.
“The governance and quality assurance systems at the home were ineffective and had failed to identify and act on the concerns raised during this inspection.” from the report
Condition-specific training
needs fixingStaff needed more training to support people with specific long-term health conditions, including diabetes. COVID-19 training that had been outstanding was later completed.
“Staff had received training, however there were some areas where training was required to support people's long-term health conditions, for example diabetes.” from the report
- 01Have all risk assessments and care plans been updated to cover each person's health conditions, changing needs and end-of-life wishes?
- 02How are medicines given only when needed managed, and how are pain-relief patch application and removal recorded?
- 03What actions came from the audits and meetings, who is responsible for them, and how do you check they are completed?
- 04How do you record best-interest decisions and make sure people are supported in the least restrictive way?
- 05What training have staff completed for conditions such as diabetes, and how is their understanding checked?
This was a focused inspection of Safe, infection control and Well-led; the other key questions were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 19 March 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.
What inspectors found, January 2019
Rated Good in all five areas; inspectors found safe, kind and personalised care.
The home was inspected without notice on 6 December 2018. One inspector and one expert-by-experience spoke with people living there, relatives, staff and the provider. They observed care and reviewed care plans, medicines records, complaints, accidents and quality checks.
The inspectors found enough staff, safe medicines systems and suitable checks on risks. Staff were trained and supported, and people were helped with food, health care and making their own choices. The home was clean and the environment had been adapted to help people feel at home.
People were treated with kindness, dignity and respect. Staff knew people well, supported activities and followed personal care plans. The overall rating was Good, as were the ratings for Safe, Effective, Caring, Responsive and Well-led. The previous inspection was also rated Good.
Safe staffing
Inspectors found enough staff to meet people's needs safely and saw staff respond promptly when help was requested.
“There were enough staff to ensure that people's needs were met safely.” from the report
Kind relationships
People and relatives described staff as kind and supportive. Inspectors also saw caring interactions during the visit.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Personalised care
Staff knew people well and care plans recorded their preferences, needs and wishes. Plans were reviewed regularly.
“There were care plans in place which were detailed and regularly reviewed.” from the report
Choice and dignity
People were supported to choose where they spent their time and how they were cared for. Staff adapted their communication and respected privacy.
“People were enabled to make choices about the care they received.” from the report
Activities and interests
The home arranged regular activities and outings, including individual activities based on what people wanted to do.
“There were activities planned throughout the week and included at least one outing.” from the report
Quality checks
The home used audits, meetings and reviews to monitor care and identify improvements.
“There were quality audits in place to measure the success of the service and to continue to develop it.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and update my relative's care plan if their health, mobility or communication needs change?
- 02How do you decide staffing levels for each shift, and how quickly can staff respond when someone uses their call bell?
- 03How do you record and review falls or other incidents, and what actions would you take to reduce the risk of them happening again?
- 04How are people's wishes for activities, food and end-of-life care kept up to date and shared with the staff team?
- 05What actions have resulted from your recent medicines, infection control and other quality audits?
This was an unannounced scheduled inspection of the whole care home and all five CQC questions, including the premises and care provided; the previous overall rating was Good. This explanation was written from the published report of 12 January 2019 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 Welby Croft Residential Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Welby Croft Residential Home →
- January 2019Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Welby Croft Residential Home →
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 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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