CQC report explained · a residential care home
What the CQC found at Welford Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some as-required medicines records were not completed properly, and two environmental risks were found. The environmental concerns were addressed during the inspection, while medicines recording remained a concern.
- Effective?
- Good
- People's needs were assessed and care plans gave staff clear guidance. Staff were trained and supported people with nutrition, healthcare, consent and independence.
- Caring?
- Good
- This key question was not inspected during this visit, so no new rating was given.
- Responsive?
- Good
- This key question was not inspected during this visit, so no new rating was given.
- Well-led?
- Good
- The management team had oversight of the home and had improved its quality assurance processes. People, relatives and staff gave positive feedback about the service and its leadership.
What inspectors found, April 2023
Rated Good overall; inspectors found kind, effective care, but safety systems still needed improvement.
This was an unannounced inspection on 7 and 8 March 2023. One inspector visited the home, while an Expert by Experience spoke to relatives by telephone. Inspectors also spoke with people, relatives and staff, and checked care records, medicines, recruitment files, audits, the building and equipment.
The home was rated Good overall. Effective and well-led were rated Good. Staff were described as trained, caring and supportive. People were supported with food, healthcare, consent and personal choices. Relatives and staff gave very positive feedback.
Safe was rated Requires Improvement. Inspectors found that some as-required medicines records were incomplete, and identified an upstairs window without the correct restrictor and a propped-open fire door. The manager dealt with the environmental concerns during the inspection, but the medicines recording issue remained a concern.
The previous overall rating was Requires Improvement, published in April 2020. The overall rating improved to Good because quality checks and other parts of the service had improved. The Safe rating remained Requires Improvement.
Trained staff
Staff had training, supervision and competency checks. Inspectors found they had the skills needed to support people.
“People were cared for by staff who were well trained and skilled to deliver the support they needed.” from the report
Positive relationships
People, relatives and staff spoke positively about the home. Inspectors found a warm, person-centred culture.
“Feedback about the service, staff and management was very positive.” from the report
Improved oversight
The home had introduced regular checks covering areas such as care records, infection control and medicines.
“Systems were in place to provide oversight of the quality of the home.” from the report
As-required medicines records
seriousRecords for some as-required medicines were not always completed in line with best practice. This could make it harder for health professionals to review whether the medicines were working effectively.
“Where people were supported with PRN (as required) medicines the records of administration were not always completed in line with best practice guidelines.” from the report
Environmental safety
seriousAn upstairs window did not have the correct restrictor and a fire door was propped open. The manager corrected these issues immediately during the inspection.
“We identified an upstairs window was without the appropriate window restrictor and a fire safety door was propped open.” from the report
- 01How do you now make sure records for as-required medicines are completed every time?
- 02How do you check that the upstairs window restrictor remains in place and that fire doors are kept closed?
- 03What action has been taken to prevent similar environmental safety risks happening again?
- 04How often are medicines, care records and environmental safety checks audited, and who reviews the results?
- 05What evidence can you provide that the improvements made since the previous inspection have been maintained?
This was a focused inspection looking mainly at Safe, including infection prevention and control, and Well-led; Effective was also rated, while Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 6 April 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, April 2020
Rated Requires Improvement; inspectors found kind care, but identified risks, weak checks and gaps in decision-making records.
Inspectors made an unannounced visit on 4 March 2020 after information from the local authority. They spoke with people using the home, a visitor and staff. They observed care and checked care, medicine, recruitment and management records.
The home was rated Good for Caring and Responsive. People were treated kindly, their privacy and independence were respected, and staff knew their needs. Care plans covered people's preferences, although activities were limited for some people.
The home was rated Requires Improvement for Safe, Effective and Well-led. Inspectors found unsecured products in bedrooms, some medicine guidance that was out of date, delays in health referrals, missing mental capacity and best-interest records, and quality checks that did not find problems quickly enough.
The overall rating fell from Good at the previous inspection. The home had an action plan with the local authority, and some improvements were made during or after the inspection. CQC said it would continue monitoring the home and could inspect sooner if it received concerning information.
Kind and respectful care
People were treated with kindness and respect. Staff knew people well and promoted their privacy, dignity and independence.
“People received care from kind and caring staff who knew them well.” from the report
Personalised support
Care plans described people's needs, preferences, routines, interests and communication requirements. Staff had positive relationships with people and understood their wishes.
“Care plans also included information on people's personal history, interests and choices including those related to the protected characteristics under the Equality Act.” from the report
Trained staff
Staff had up-to-date mandatory training and specialist training for complex health needs. Formal supervision had recently been introduced.
“The training matrix showed annual mandatory refresher training took place and was up to date.” from the report
Food choices and dietary support
People were offered choices at mealtimes. Kitchen staff knew about people's dietary needs, likes and dislikes.
“People spoke positively about the food in the service.” from the report
Unsecured products
seriousDenture cleaning tablets and prescription cream were left in two bedrooms rather than stored in cupboards. Inspectors said these could be used or swallowed accidentally.
“This meant they were visible and could be consumed or used accidentally if someone wandered into those rooms.” from the report
Missing decision-making records
seriousMental capacity assessments and best-interest decisions were not recorded for people who could not make particular decisions themselves.
“MCA assessments were not completed when people did not have capacity to make specific decisions, and there were no best interest decisions noted on people's care files.” from the report
Delayed health referrals
needs fixingSome referrals for specialist health support were not made promptly. One person who had lost weight over time was not referred to a dietician until inspectors raised the issue.
“Referrals were not always made promptly for specialist health input when needed.” from the report
Weak quality checks
needs fixingAudits did not reliably identify problems with fluid records, medicines, care plans or follow-up after incidents. The provider was asked to improve its quality assurance processes.
“Quality assurance and audit processes did not cover all aspects of the service.” from the report
Limited activities for some people
minorFeedback was mixed about daily activities. Some people wanted more activities and outings, while activities were provided on some days.
“We received mixed feedback about how much there was for people to do on a daily basis, some people felt there was not enough.” from the report
- 01What has been done to make sure medicines, denture tablets and creams are stored safely?
- 02Have mental capacity assessments and best-interest decisions now been completed and recorded for everyone who needs them?
- 03How do you check that care plan reviews contain new information and that health referrals are made promptly?
- 04What activities and outings are currently available, and how do you tailor them to each person's interests?
- 05What changes have been made to the audit system since the inspection, and how are you checking that they work?
This was an unannounced inspection prompted by local authority information and covering all five key questions, including the care and the premises. This explanation was written from the published report of 10 April 2020 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 Welford Court
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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