CQC report explained · a nursing home
What the CQC found at Wellesley Road Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found safe medicines systems, reviewed risk assessments, infection controls and enough staff, but identified gaps in some medicines audit records and saw unsafe hoisting practice that was addressed immediately.
- Effective?
- Good
- This question was not assessed in this focused inspection.
- Caring?
- Good
- This question was not assessed in this focused inspection.
- Responsive?
- Good
- This question was not assessed in this focused inspection.
- Well-led?
- Good
- The home had monitoring systems, regular meetings and links with other professionals. Some staff reported weaknesses in teamwork and feedback, and managers were working to improve communication.
What inspectors found, August 2021
Wellesley Road Care Home was rated Good; inspectors found people were safe, but medicines records and staff communication needed improvement.
This was an unannounced focused inspection on 20 May 2021. Two inspectors spoke with people, staff, relatives and professionals. They reviewed care records, medicines records, staff recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found medicines were stored and given safely, risks were reviewed, infection controls were in place, staffing was usually sufficient and people felt safe.
There were some shortfalls. One person was seen being hoisted by one staff member, and some weekly medicines audits were not recorded. Some staff also said teamwork and information sharing were not always good. The provider took immediate action on the issues raised.
Safe medicines administration
Medicines were stored securely and given by trained nurses whose competence had been checked. Medicines administration records were accurately completed.
“Medicines administration records (MARs) were accurately completed.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including the safe use of protective equipment and visitor arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing and recruitment
Staff were recruited with reference and criminal record checks. Inspectors saw enough staff on shift and said call bells were answered promptly.
“We saw there were enough staff on shift to support people's needs.” from the report
Risk management
People had personalised risk assessments covering areas such as falls, mobility, skin integrity and nutrition. These were reviewed when needs changed.
“These had been reviewed regularly and updated when there were any changes to people's needs.” from the report
Working with other professionals
The manager worked with health and social care professionals to respond to changing needs and improve practice.
“The staff are proactive in getting in touch when they have concerns about someone.” from the report
Hoisting practice
seriousInspectors saw a staff member trying to hoist a person alone. The provider investigated immediately and arranged refresher training and competency checks.
“During the inspection we observed a staff member attempting to hoist a person single-handedly.” from the report
Medicines audit records
needs fixingSome weekly medicines monitoring records had not been completed, although daily checks meant errors were identified and acted on.
“However, we found some weekly audits had not been recorded.” from the report
Team communication
needs fixingSome staff said teamwork was not always good and that they did not always receive information or feedback after raising concerns. Managers were increasing meetings and working on communication.
“However, some staff told us team working was not always good.” from the report
- 01How do you now make sure weekly medicines audits are completed and recorded every time?
- 02What refresher training and competency checks were completed after the unsafe hoisting incident?
- 03How do staff receive feedback when they raise concerns?
- 04What changes have been made to improve teamwork and information sharing?
- 05How are staffing levels reviewed when people's needs change or there is an unexpected staff absence?
This was a focused inspection of Safe and Well-led only; the other three key questions were not assessed. This explanation was written from the published report of 3 August 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 2018
Rated Good; inspectors found kind, effective and person-centred care, but staffing still relied on agency workers.
This was an unannounced comprehensive inspection on 19 and 29 September 2017. Inspectors spoke with people, a relative, staff and health professionals. They observed care and mealtimes, looked around the home, checked care records and reviewed recruitment, safety and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People received their medicines safely, had suitable food and drinks, and were supported with their health needs. Inspectors saw respectful care, personalised care plans and activities.
The home had improved since May 2016, when it was rated Requires Improvement. There was now a registered manager, more permanent staff, regular staff supervision and better quality checks. However, agency staff turnover remained high, some posts were vacant, and some pressure mattresses were initially set incorrectly.
Safe medicines
Inspectors found medicines were stored, administered and recorded safely. Staff had relevant training and competency checks.
“We checked medicine administrations records (MAR) and found no unexplained gaps.” from the report
Respectful care
Staff protected people's privacy and dignity, offered choices and adapted their communication and support to individual needs.
“We observed courteous interactions between staff and people throughout the inspection.” from the report
Personalised support
Care plans included people's medical conditions, preferences and risks. Inspectors found staff followed these plans and updated them when needed.
“We saw evidence that support plans were followed by staff and that care plans were updated accordingly.” from the report
Improved management
The home had appointed a registered manager and introduced stronger checks of care, medicines, the environment and infection control.
“We found that action had been taken to improve quality monitoring systems.” from the report
Agency staffing and vacancies
needs fixingAlthough the home had recruited permanent staff, agency staff turnover was still high. Some vacant posts were being covered by long-term agency workers, and staff were busy for long periods.
“Although we found that action had been taken to improve staffing, there was still a high turnover of agency staff.” from the report
Pressure mattress settings
needs fixingInspectors found that some pressure mattresses were not set correctly. The registered manager acted immediately during the inspection to resolve this.
“We found that some pressure mattresses were not set at correct settings.” from the report
Communication with healthcare professionals
minorOne healthcare professional said communication with the home could improve. The home was aware of this and said it was working on improvements.
“A healthcare professional told that communication with the home could improve.” from the report
- 01How many permanent care and night staff are now in post, and have the vacancies mentioned in the inspection report been filled?
- 02How do you check that pressure mattresses are set correctly for each person, and how often are those checks recorded?
- 03What has changed to reduce agency staff turnover and make sure staff are not too busy to provide care?
- 04What improvements have been made to communication with GPs and other healthcare professionals?
- 05How will you make sure my relative's care plan reflects their preferences, risks, diet and activities?
This was an unannounced comprehensive inspection covering all five key questions, following improvements identified since the May 2016 inspection. This explanation was written from the published report of 27 January 2018 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 Wellesley Road Care Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementstayed Requires improvementSafe: Good
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015
Registered with the Care Quality Commission on 24 June 2015.
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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