CQC report explained · a residential care home
What the CQC found at Welshwood Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Good; inspectors found safe, well-managed care and improvements since the previous inspection.
This was an unannounced targeted inspection. Inspectors visited on 19 and 24 April 2023, reviewed records, observed care and spoke with staff and the registered manager. They checked Safe and Well-led, including infection control and whether earlier legal requirements had been met.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines practice, suitable risk assessments, safeguarding arrangements and infection control measures. They also found that incidents were reviewed and used to improve care.
The management team was visible and knew people well. Audits and other checks were being used to monitor care, and people, relatives and staff were asked for their views.
The previous rating was Requires Improvement, with breaches relating to medicines, risk management and governance. Inspectors found enough improvement had been made, so the home was no longer in breach of regulations. The overall rating changed to Good.
Medicines were safer
Medicines were given as prescribed and records were accurate. Staff training and checks of staff competence were in place.
“At this inspection, improvements had been made and people received their medicines in a safe way, as prescribed for them.” from the report
Enough staff
Inspectors saw people receive help when needed and call bells answered promptly. Recruitment checks were also carried out before staff started work.
“There were enough staff to meet people's needs. We observed people were assisted when needed and call bells were answered in a timely manner.” from the report
Risks were managed
People had individual risk assessments covering areas such as mobility, skin care and catheter care. Fire safety checks and emergency evacuation plans were also in place.
“Assessments of risk had been undertaken for each person's individual health, social and personal care needs” from the report
Strong oversight
The management team used regular audits to identify problems and create action plans. Inspectors found the home was no longer in breach of the governance regulation.
“Quality management systems were effective and with registered manager oversight of the service were used to identify shortfalls and reduce risk to people.” from the report
People were involved
People and relatives were asked for their views through meetings, surveys and everyday conversations. Staff said they felt supported and valued.
“People using the service and their relatives were regularly asked for their views, so the service could continually improve.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you checking that medicines records remain accurate and that any medicines errors are acted on?
- 02How do you review changes in my relative's risks, including mobility, skin care or catheter care?
- 03How do you use audits and action plans to make sure improvements are sustained?
- 04How will you tell relatives about accidents, incidents or changes in their relative's care?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was a targeted inspection of Safe and Well-led, including infection control and the earlier warning notice; the other key-question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 2 June 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, February 2023
Rated Requires Improvement; inspectors found unsafe medicines and fire-risk records, despite kind care and positive feedback.
This was an unannounced focused inspection on 23 November 2022. Inspectors checked whether the home had improved its systems for safety and leadership after the previous inspection. They spoke with people, relatives, staff and a professional, observed care, and checked care records, staff files, medicines, fire safety and quality audits.
The home was not always safe. Medicines were not consistently given or recorded as prescribed. Personal emergency evacuation plans did not match the people living in the home, and fire drills had not included night staff. Infection control was generally in place, but face masks were not always worn correctly and visitor illness checks were not completed.
The home was not well-led because its audits and reporting systems had not found or fixed important problems. The home received Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. The rating had not improved since the previous inspection and had remained Requires Improvement for two consecutive inspections.
Kind staff
Inspectors saw staff interacting with people in a friendly and caring way. People and relatives gave positive feedback about the care and atmosphere.
“We observed how staff interacted with people in a friendly and caring way.” from the report
Enough staff
Inspectors observed enough staff in communal areas and found that call bells were answered promptly.
“Call bells are answered promptly, there are enough staff. They walk past and check on (relative) often.” from the report
People involved
Residents' meetings allowed people to comment on the service, and the home acted on feedback about food portions.
“People were encouraged to be actively involved with changes to the service.” from the report
Medicines
seriousMedicines were not always recorded or given as prescribed. Inspectors found missing signatures, lower doses and medicines left without staff observing people take them.
“The provider could not be assured medicines had been administered as prescribed.” from the report
Fire evacuation information
seriousPersonal emergency evacuation plans did not match the list of people living in the home. This could put people at risk during a fire, and fire drills had not included night staff.
“This put people at significant risk of harm and their safety compromised in the event of a fire emergency.” from the report
Weak quality checks
seriousAudits were incomplete or did not analyse information properly. They failed to identify medicines and fire safety problems, and there was no recorded evidence of learning from accidents and incidents.
“This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Infection control details
needs fixingInspectors were only somewhat assured that personal protective equipment was used safely and that visitors were checked for signs of illness.
“On arrival to the service, staff did not undertake relevant checks for signs of illness such as temperature check.” from the report
- 01What changes have been made to ensure every medicine dose is given as prescribed and recorded correctly?
- 02How do you check that personal emergency evacuation plans match the people currently living in the home?
- 03Have fire drills now included night staff, and what did those drills show?
- 04How are accidents, incidents and medicine errors recorded, reviewed and used to prevent them happening again?
- 05What action has been taken in response to the Regulation 17 warning notice and the CQC action plan?
This was a focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 2 February 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.
Every inspection of Welshwood Manor
6 rated inspections over 6 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 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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