CQC report explained · a residential care home
What the CQC found at Wentworth House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found concerns about medicines storage, an unlocked sluice room, fire doors and a missing best-interests decision for bed rails. They also found enough staff, safe recruitment procedures and appropriate safeguarding systems.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Outstanding
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- Care records were incomplete or not reviewed often enough, and quality checks had not found all the problems. The home did have audits, staff supervision, meetings and systems for gathering feedback.
What inspectors found, July 2023
Requires Improvement; inspectors found gaps in care records and some safety checks, although people and relatives spoke positively about the care.
This was an unannounced inspection on 18 May 2023. One inspector and an expert by experience visited the home. They spoke with six people, four relatives and seven staff, and reviewed care plans, recruitment records, training records and quality checks.
The home was not always safe. Some creams were accessible in bedrooms, a sluice room was unlocked and fire doors were held open inappropriately. These issues were raised with the care manager and addressed during or after the inspection. One person had bed rails without a completed decision about whether this was in their best interests.
Inspectors found important gaps in care records. Some people did not have complete care plans, and some records about personal care, oral hygiene and repositioning were not accurate or complete. The home had audits and feedback systems, but these had not identified or corrected all the problems.
The overall rating changed from Good at the previous inspection in March 2020 to Requires Improvement. This inspection only assessed Safe and Well-led. The Effective, Caring and Responsive ratings were carried over from the previous inspection.
Enough staff
Inspectors found enough staff to care for people safely. People and relatives also said staffing was adequate, although one relative said there could always be more staff.
“There were enough staff employed to care for people safely.” from the report
Positive feedback
People and relatives spoke positively about the care. They said people were well looked after, happy and treated patiently.
“People achieved good outcomes whilst living at Wentworth House and the feedback about the care at the home was positive.” from the report
Safeguarding awareness
Staff understood safeguarding and how to report concerns. A safeguarding policy and procedure was in place.
“Staff understood about safeguarding and said they had received training.” from the report
Infection control
Inspectors were assured that infection risks, protective equipment, visiting and outbreak arrangements were being managed appropriately.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Incomplete care records
seriousSome people were missing care plans or had plans without important details. Records about personal care, oral hygiene and repositioning were also not always complete.
“Some people's care plans lacked important details about the care they required.” from the report
Quality checks missed problems
seriousAudits and daily checks were in place, but they had not identified all the gaps in records or some safety issues in the building.
“Audits were carried out to monitor the quality of service, however these needed to improve to ensure gaps in record keeping were identified and addressed.” from the report
Unsafe storage and doors
seriousSome creams were accessible in bedrooms, and an unlocked sluice room could have allowed people to place themselves at risk. Fire doors were also held open by inappropriate means.
“Some medicines were not stored securely, mainly creams and sluice room doors were not always locked to prevent people being placed at risk.” from the report
Missing best-interests decision
seriousOne person had bed rails in place without a decision-specific mental capacity assessment to confirm this was in their best interests. This was put in place after the inspection.
“A decision specific mental capacity assessment had not been completed to ensure this was in the person's best interests.” from the report
- 01What action have you taken to make sure every person has a complete and up-to-date care plan?
- 02How do you now check records for oral hygiene, personal care and repositioning?
- 03How are creams, sluice rooms and other areas kept secure now?
- 04What checks are in place to make sure fire doors are never held open inappropriately?
- 05What is the current process for recording best-interests decisions when bed rails or other restrictions are used?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 13 July 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 2021
Inspected but not rated; targeted checks found strong infection prevention and control arrangements during the COVID-19 pandemic.
Inspectors visited on 22 January 2021. This was an announced, targeted inspection looking only at infection prevention and control in the care home.
They found that visitors were tested, had their temperature checked and wore personal protective equipment. The home had plans for isolation, zoning and managing outbreaks, and worked with the local authority to prepare for possible outbreaks.
The home was clean and had increased cleaning of frequently touched areas. It kept daily activities running and maintained family contact through window visits, telephone and video calls where possible.
The service was inspected but not rated. This means the visit did not provide an overall quality rating or ratings for most of the five areas CQC usually assesses.
Clean premises
The home had increased cleaning of frequently touched areas. Night staff also carried out deeper cleaning in communal areas.
“Premises were clean throughout. The cleaning schedule had been amended to include additional cleaning of frequent touch points.” from the report
Maintaining family contact
Although normal visiting was paused, the home supported contact through window visits, telephone and video calls. It also continued a daily activities programme.
“However, contact with families had been maintained as much as possible via window visits, phone and video calls.” from the report
Pandemic planning
The home had plans covering isolation, zoning and cohorting. Inspectors also noted that it was working with the local authority to prepare for outbreaks.
“The home had been proactive in working closely with the local authority, to ensure they were ready to deal with any outbreaks.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and how have they changed since the inspection on 22 January 2021?
- 02What are the current visiting arrangements, including visits for people receiving end-of-life care?
- 03How often are frequently touched areas and communal rooms cleaned, and who checks that this is done?
- 04What happens if a new resident cannot complete the home's usual isolation period?
- 05What are the home's current plans for managing a COVID-19 or other infection outbreak?
This was a targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 10 February 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.
Every inspection of Wentworth House
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- March 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 15 April 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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