CQC report explained · a residential care home
What the CQC found at Wetley Manor Care Home
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 were assured that the home was following safe infection prevention and control procedures. They found arrangements covering visitors, social distancing, admissions, protective equipment, testing, cleaning and outbreak management.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, August 2020
Inspected but not rated; inspectors found good infection control and visiting arrangements during the coronavirus pandemic.
This was an announced, targeted inspection on 05 August 2020. Inspectors looked only at infection prevention and control as part of a coronavirus pandemic review.
Inspectors were assured that the home was managing visitors, social distancing, shielding, admissions, protective equipment, testing, cleaning and infection outbreaks safely. They also found that the infection control policy was up to date.
The home had created a visiting area so relatives could see and speak to people without entering the building. The overall service and the safe question were inspected but not rated, so this report does not give an overall quality rating.
Safer visiting arrangements
The home created a visiting area that allowed relatives to see and speak to people without entering the home. Inspectors said this helped people with dementia recognise their relatives and see facial expressions.
“Visitors were able to speak and see their relatives from the sunroom into a bedroom via an intercom without wearing face masks because the risk of cross contamination had been mitigated.” from the report
Protective equipment
Inspectors found that protective equipment was being used in line with guidance. The home also sourced masks designed to reduce problems for staff who wore glasses.
“Personal Protective Equipment (PPE) was worn in line with current guidance and the provider had sourced masks with an anti-fog strip” from the report
Cleaning and disinfection
The home had considered which products would work best for cleaning frequently touched areas and had sourced different products to sanitise the home.
“The domestic staff member had researched disinfectant and alcohol based products to ensure touch point cleaning was effective.” from the report
Support for staff wellbeing
Staff were given opportunities to discuss anxieties and were directed to counselling and other wellbeing services if needed.
“Discussions were held with staff to reduce any anxieties they felt and the provider had signposted them to wellbeing services such as counselling if needed.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the visiting arrangements described in the report changed since August 2020?
- 02How do you currently test people living here and staff for infections?
- 03How do you make sure PPE is used safely and remains available?
- 04How often are frequently touched areas cleaned, and which products are used?
- 05What arrangements are in place to prevent and manage an infection outbreak?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; the overall service and safe question were inspected but not rated, and the other quality areas were not assessed. This explanation was written from the published report of 14 August 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.
What inspectors found, November 2019
Wetley Manor Care Home is rated Requires Improvement; inspectors found kind, effective and responsive care, but medicines management and oversight still needed work.
This was an unannounced follow-up inspection after the previous Requires Improvement rating. Inspectors spoke with people, relatives and staff, observed care and reviewed care, medicines and management records.
People were generally treated kindly and received care that met their needs and preferences. Staff were trained, knew people well, supported healthcare needs and offered choice. The home was clean, and its environment had been improved for people living with dementia.
Medicines records were not always accurate. In two cases, records showed medicines had been given when they had not. Checks did not identify all the problems inspectors found. The overall rating remained Requires Improvement, with Safe and Well-led also rated Requires Improvement.
Kind and respectful care
Inspectors saw positive relationships between staff and people. People said staff were pleasant, attentive and caring.
“There were positive interactions between staff and people seen during our inspection that evidenced good relationships were in place.” from the report
Improved staff training
The home had introduced a training matrix covering areas such as medicines, diabetes and catheter care. Staff said their induction, training and supervision supported them.
“At this inspection the provider had improved staff training.” from the report
Better dementia-friendly environment
The home had been redecorated with simpler walls and furnishings to reduce the risk of disorientation for people living with dementia.
“There was evidence of extensive redecoration with plainer walls and furnishings that would not cause people living with dementia to become disorientated.” from the report
Choice and personalised support
People could choose aspects of their daily routines, meals and activities. Staff were knowledgeable about people's individual needs and preferences.
“People told us they were able to make choices that reflected their personal likes and preferences.” from the report
Positive healthcare support
Staff worked with health and social care professionals when people needed support with their health.
“Staff worked with other health and social care professionals to ensure positive outcomes for people.” from the report
Medicine records were not always accurate
seriousTwo medicine administration records were signed even though the medicines had not been given. Inspectors also found problems with timing instructions and recording where skin patches were applied.
“However, there were two examples of where the MARS were signed to confirm administration had taken place, but medicines had not been administered.” from the report
Medicine audits missed problems
needs fixingThe home carried out regular medicine audits, but these checks did not identify all the issues inspectors found in the records.
“However, audits were not always effective despite comparing the quantity of medicines found against the administration records.” from the report
Communication plans needed development
minorInspectors found scope to improve plans for people who had difficulty communicating, including people with hearing difficulties.
“There was scope to develop communication plans for people who may have difficulty communicating however, for example when they had difficulty hearing.” from the report
- 01What changes have been made to ensure medicine administration records are signed only after medicines have been given?
- 02How are you now checking that medicines are given at the correct time and that skin patches are rotated and recorded safely?
- 03How do your current medicine audits identify errors that earlier audits missed?
- 04How are people with hearing or other communication difficulties supported and is this recorded in their care plans?
- 05What new or different activities have been introduced in response to people's requests?
This was an unannounced follow-up inspection covering all five key questions, after the previous Requires Improvement rating and regulatory breach. This explanation was written from the published report of 1 November 2019 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 Wetley Manor Care Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- August 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- November 2012
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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