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CQC report explained · a residential care home

What the CQC found at Wellhead Lane

Goodpublished 12 April 2024, 2 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The latest report, explained

What inspectors found, March 2022

Wellhead Lane was inspected but not rated; inspectors found good infection control and support for family visits.

This was an announced, targeted inspection on 24 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected the home.

The home had regularly reviewed risk assessments, COVID-19 testing and suitable protective equipment. Inspectors were assured that the home was managing infection risks, keeping the building clean and following its infection control policy.

People were supported to keep in touch with their families. Indoor and outdoor visits were supported, and people could visit family homes or go on family holidays where suitable risk arrangements were in place.

The home was inspected but not rated. This means the report does not give an overall quality rating or a rated judgement for the areas not covered by this targeted inspection.

What inspectors praised
  • Infection control

    The home used testing, temperature checks, PPE and visitor controls to reduce infection risks. Staff had training on COVID-19 testing.

    “We were assured that the provider was using PPE effectively and safely.” from the report
  • Clean premises

    The home was cleaned throughout the day, with cleaning records monitored by the registered manager. High-contact surfaces were cleaned frequently.

    “The home was clean and being cleaned throughout the day by staff.” from the report
  • Family contact

    People were supported to maintain contact with relatives through indoor and outdoor visits, visits to family homes and some family holidays.

    “People had been supported to keep in touch with families and visiting was being supported.” from the report
  • Risk planning

    Risk assessments covered individual needs and the risks linked to COVID-19. These were reviewed regularly and supported people to take part in chosen activities safely.

    “Risk assessments were in place and were reviewed regularly.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01What infection prevention and control arrangements are in place now, and when were they last reviewed?
  2. 02What are the current rules for family visits, including visits to relatives' homes and family holidays?
  3. 03Are there currently any staffing pressures, and how could these affect the people living in the home?
  4. 04How are people supported to take part in their chosen activities while managing any relevant risks?
  5. 05What recent inspection or assessment covers care, medicines, staffing and leadership, since these were not covered here?

This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 9 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.

An earlier report, explained

What inspectors found, March 2018

Wellhead Lane was rated Good overall, but inspectors found the Mental Capacity Act records and some care information needed improvement.

Inspectors visited on 9 January 2018 with 24 hours' notice. They spoke with people living in the home, relatives, staff and visiting professionals. They also reviewed care plans, staff files, training records, policies and quality checks.

The home was rated Good for Safe, Caring, Responsive and Well-led. People told inspectors they felt safe and had the care they needed. Staff were described as kind, knowledgeable and supportive, and people were helped to make choices and build independence.

Effective was rated Requires Improvement. Staff understood how to support decision-making, but Mental Capacity Act assessments and best-interest decisions were not always recorded correctly. Some detailed information had also not been fully added to current care plans.

Inspectors found smaller issues with recording bath temperatures and adding an as-required medicines protocol to the medicines record. The overall Good rating means the home was meeting the required standard in most areas, but improvements were needed in how care and decision-making were documented.

What inspectors praised
  • Clean and safe environment

    The home was clean and tidy, with infection control arrangements and safety checks in place.

    “The home was clean and tidy, with infection control procedures in place.” from the report
  • Kind staff

    Inspectors saw warm interactions and found that staff understood people's personalities, preferences and needs.

    “Staff interacted with people in a kind and compassionate manner.” from the report
  • Choice and independence

    People were supported to choose activities, meals and routines, and to develop everyday life skills.

    “People were encouraged and enabled to develop independence in day to day routines.” from the report
  • Strong management oversight

    The manager was visible in the home and systems were used to monitor care, incidents, the environment and staff practice.

    “There are systems in place to monitor and assess the quality of care for people living in the home.” from the report
What inspectors were concerned about
  • Decision-making records

    needs fixing

    Staff understood the Mental Capacity Act, but some capacity assessments and best-interest decisions were missing, incomplete or out of date.

    “However, staff understanding of how to apply the Mental Capacity Act (2005) was not always recorded in people's care plans accurately, or in accordance with the legal process.” from the report
  • Care plans not fully updated

    needs fixing

    Detailed information about behaviour, communication and understanding was available, but it had not all been added to the current care plan.

    “Information held within the folder regarding each person's behaviour, communication and understanding was detailed but had not yet been fully incorporated into a current care plan document.” from the report
  • Bath temperature checks

    needs fixing

    Staff were testing bath water by touch rather than using a thermometer, and temperatures were not being recorded. The manager said this was addressed immediately.

    “At this inspection, however, we observed that there wasn't a bath thermometer in use and temperatures were not currently being tested or recorded.” from the report
  • As-required medicines record

    needs fixing

    Medicines were otherwise managed safely, but the as-required medicines protocol still needed to be added to the medicines record.

    “A PRN (as required) protocol was in place but needed to be added to the medicines record.” from the report
Questions to ask them, based on this report
  1. 01Have all Mental Capacity Act assessments and best-interest decisions now been completed, recorded correctly and kept up to date?
  2. 02Has the detailed information about each person's behaviour, communication and understanding been added to their current care plan?
  3. 03How are bath temperatures tested and recorded now?
  4. 04Has the as-required medicines protocol been added to the medicines record?
  5. 05Has the waking-night staff vacancy been filled, and what staffing levels are in place at weekends?

This was an announced inspection of the overall service, including the premises and care, and it rated all five key questions. This explanation was written from the published report of 23 March 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.

The story over the years

Every inspection of Wellhead Lane

2 rated inspections over 2 years: the service has held its Good rating throughout.

  1. March 2022Inspected but not ratedcurrent rating
    Safe: Inspected but not rated

    Read what inspectors found at Wellhead Lane →

  2. March 2018Goodstayed Good
    Safe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Wellhead Lane →

  3. March 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  4. September 2015

    Registered with the Care Quality Commission on 9 September 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.

Next steps

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