CQC report explained · a residential care home
What the CQC found at WhiteHorse Care - Brownhills
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks were recorded, medicines were managed safely and staffing levels were maintained, although some fire safety work and improvements to a mould-affected shower room were still in progress.
- Effective?
- Good
- Staff had received training specific to people's needs and were observed to be competent. People received suitable food, healthcare support and care in line with the Mental Capacity Act.
- Caring?
- Good
- Staff were kind, respectful and knew people well. People were involved in decisions about their care and were encouraged to make choices and remain independent.
- Responsive?
- Requires improvement
- Activities at home had increased, but people needed more opportunities to go out into the local community, especially at weekends and in the evenings. Care plans did not always record support for personal goals and everyday skills.
- Well-led?
- Requires improvement
- Leadership, audits and improvement plans had strengthened, and the manager was visible and approachable. Further work was needed to make improvements fully consistent, including completing building work and improving care records.
What inspectors found, April 2023
WhiteHorse Care - Brownhills was previously in special measures and is now rated Requires Improvement, with major progress but further work needed on activities, care records and management.
This was an unannounced inspection on 14 February 2023. One inspector met all six people living there, spoke with relatives, staff and health and social care professionals, and reviewed care, staff and management records.
Inspectors found clear improvements since the previous inspection. People were safer, medicines were managed properly, staffing was more stable, and staff had better training. People were treated kindly and with dignity.
The home still needed to improve how it supported people to take part in activities outside the home. Care records did not always explain how people would reach their goals or build everyday skills. Management systems had improved but were not yet fully established.
The overall rating was Requires Improvement. Safe, Effective and Caring were rated Good. Responsive and Well-led were rated Requires Improvement. The service was no longer in breach of regulations or in special measures.
Safer care
Staff had been trained to understand distress and prevent incidents from escalating. Incidents had reduced and systems were in place to learn from them.
“There had been a significant reduction in incidents because staff knew people's needs better.” from the report
Safe medicines
Medicines were kept in a locked room, given safely and recorded properly. Staff competency checks had been completed.
“People received their medicines on time and in a safe way.” from the report
Stable, trained staff
The home had a more consistent staff team. Staff had training in areas including learning disability, autism, epilepsy and dysphagia.
“A stable and consistent staff team was in place.” from the report
Kind and respectful care
Inspectors saw staff spending time with people and communicating in a respectful way. People were supported to make choices and maintain independence.
“We observed staff throughout our inspection frequently sit and chat with people relaxing in the communal areas.” from the report
Improved atmosphere
The home was described as calmer and more settled than at the previous inspection. Relatives and staff reported positive changes.
“There was a relaxed, friendly welcoming atmosphere.” from the report
Limited community activities
needs fixingPeople had more activities at home, but inspectors found they still needed more chances to take part in activities in the local community, particularly during evenings and weekends.
“People needed more opportunities to go out in the local community.” from the report
Care records missed some personal goals
needs fixingCare plans did not always explain how staff would support people to achieve their goals, aspirations and everyday skills, even though staff could describe some of this support.
“Care plans did not capture how people were supported to achieve their personal goals and aspirations.” from the report
Building work still outstanding
needs fixingA shower room had a build-up of mould linked to poor ventilation. Some fire safety work, including replacing doors, was still being completed.
“A shower room had a build up of mould.” from the report
Improvements not fully embedded
needs fixingManagement checks had improved, but the report said more work was needed before leadership and quality systems were consistently effective.
“Further work was required, so improvements were fully embedded into practice.” from the report
- 01How often will each person take part in activities outside the home, including at weekends and in the evenings?
- 02How are each person's goals, aspirations and everyday skills recorded and reviewed in their care plan?
- 03When will the mould in the shower room be removed and the ventilation work completed?
- 04When will the remaining fire safety work, including replacement doors, be finished?
- 05How will you check that recent improvements remain consistent between inspections?
This was an unannounced inspection to monitor progress after the previous breaches, rather than the last comprehensive inspection; CQC also reviewed infection prevention and control under Safe. This explanation was written from the published report of 4 April 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, August 2022
Rated Inadequate and placed in special measures; inspectors found serious concerns about safety, staffing and leadership.
This was the first inspection of the newly registered service. It was unannounced and took place on 05 April 2022. Two inspectors spoke with people, relatives and staff, observed care and checked care, medicine, staffing and management records.
The home was supporting eight people, including seven people with a learning disability or autism. Inspectors found ongoing incidents between people, unclear risk assessments, unsafe moving and handling, gaps in staff training and problems with medicine storage and records.
Staff and managers had changed frequently. There were not enough meaningful activities, and the shared area was often noisy for people who disliked noise. Inspectors also found that the provider had not properly checked whether improvements were working.
The overall rating was Inadequate. Safe and Well-led were rated Inadequate. Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures, which means CQC said it would closely monitor the home and normally reinspect within six months.
Healthcare support
People were supported to use healthcare services in the community, with advice sought from health professionals.
“People were supported to access healthcare in the community and advice was sought from health professionals in order to provide people with the support they needed.” from the report
Communication
People had communication passports describing how they preferred to communicate. Inspectors also saw a staff member use sign language with one person.
“This contained information on their preferred method of communication.” from the report
Independence
The home supported people to take part in preparing their own food and drinks where they could.
“People were supported to maintain their independence.” from the report
Consent arrangements
Inspectors found mental capacity assessments and best-interest decisions in care plans, and the required authorisations were in place or being sought where needed.
“There were mental capacity assessments in peoples' care plans and evidence of best interest decisions” from the report
Ongoing incidents and unsafe care
seriousThere were continuing incidents between people, with no clear evidence that the provider had found the cause or taken effective action. Inspectors also saw one person left alone while eating despite a choking risk, and another person transferred unsafely.
“There was no evidence of learning or analysis from these incidents to try to reduce the reoccurrence of them in the future.” from the report
Staffing and training
seriousThere had been a high turnover of staff and managers. Some staff had not received relevant training, supervision or formal competency checks.
“Staff who were supporting people during the inspection had not received any training from the provider in how to support people who were experiencing distressed behaviours.” from the report
Risk information
seriousRisk assessments were out of date and did not give staff enough detail about how to support people's needs safely, including catheter care and moving and handling.
“Risk assessments at the service were not updated and lacked sufficient information to guide staff on how to support peoples' needs safely.” from the report
Medicine management
seriousSome medicines were stored at unsuitable temperatures, the medicine trolley was not secured, some records were not up to date and one as-required medicine had no protocol.
“The provider had not ensured themselves whether this medicine was still needed or being used.” from the report
Activities and environment
needs fixingPeople did not have enough meaningful activities or outings. The only communal area was often noisy and busy, and the building and garden needed updating.
“They [people] need to get out more. It doesn't happen now. It hasn't happened for a long time.” from the report
Weak oversight
seriousThe provider's checks had not identified or resolved several important problems. There was also no registered manager in place at the time of the inspection.
“There had not been enough learning and improvement made to improve the quality of care people received.” from the report
- 01What has changed to prevent incidents between people, and how do you now analyse incidents and act on what you learn?
- 02How do you make sure permanent and agency staff have the training, supervision and competency checks needed for each person's needs?
- 03How have you updated risk assessments, especially for choking, catheter care and moving and handling?
- 04How are medicines now stored at the correct temperatures, secured and recorded on current medication records?
- 05What activities and outings are now available, and how do you reduce noise for people who find it difficult?
This was an unannounced inspection of all five CQC key questions, including infection prevention and control; it was the first inspection of this newly registered service. This explanation was written from the published report of 24 August 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.
Every inspection of WhiteHorse Care - Brownhills
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at WhiteHorse Care - Brownhills →
- August 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at WhiteHorse Care - Brownhills →
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2021
Registered with the Care Quality Commission on 23 September 2021.
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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