CQC report explained · a residential care home
What the CQC found at Wimbledon House Residential 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
- People were protected from abuse and received their medicines as prescribed. However, some risk assessments and medicine guidance were not detailed enough, and accident and incident information was not effectively analysed.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Management did not operate quality checks and monitoring systems effectively. Records were disorganised, and requested actions were not always completed or followed up.
What inspectors found, February 2023
Wimbledon House Residential Care Home is rated Requires Improvement; inspectors found caring support but weaknesses in risk records and management oversight.
The inspection was unannounced and took place on 3 January 2023. One inspector spoke with people living in the home, relatives and staff. They also reviewed care plans, risk assessments, medicine records, staff files and management records.
People told inspectors they felt safe and happy. Staff protected people from abuse, supported their mental health and helped them see health professionals. Medicines were stored safely and people received them as prescribed. However, some risk assessments did not explain clearly what staff should do if someone choked, and guidance for some constipation medicines was not detailed enough.
The main problem was weak management oversight. The home did not effectively record and analyse accidents, incidents and audits. This was a breach of Regulation 17 on good governance. The overall rating changed from Good at the previous inspection, published in March 2020, to Requires Improvement.
People felt safe
People and relatives told inspectors that people felt safe and received support when they needed it.
“People told us they felt safe and happy living at the service.” from the report
Mental health support
Staff knew people well, watched for changes in mental health and worked with community mental health professionals.
“We work closely with the mental health team.” from the report
Safe staffing and recruitment
The home used a consistent staff team where possible. Recruitment checks included employment histories, references and criminal record checks.
“People were supported by staff who had been recruited safely.” from the report
People's views were heard
Residents could suggest changes to daily life, and the home acted on suggestions such as providing more meal choices.
“When people had made suggestions to make changes to the service, these had been listened to and acted on.” from the report
Incomplete risk guidance
seriousSome risk assessments did not tell staff what to do if a person began to choke. This created a risk for unfamiliar or agency staff. The manager updated the assessments after the inspection.
“This meant there was a risk staff who were unfamiliar would not know what action to take.” from the report
Insufficient medicine instructions
needs fixingGuidance for some medicines used when people were constipated did not say when the medicine should be given or when professional advice should be sought. The protocols were updated during the inspection.
“There was a PRN protocol in place, however this did not contain enough information.” from the report
Poor incident monitoring
seriousAccidents and incidents were recorded, but there was no effective log to identify patterns or trends. A new recording and analysis system was introduced during the inspection.
“The registered manager did not keep a log of incidents and accidents, to enable them to identify any patterns or trends.” from the report
Weak management oversight
seriousThe registered manager did not keep effective records of quality checks or review senior staff audits properly. This made it difficult to know whether identified problems had been fixed.
“There was a lack of oversight and scrutiny on the day to day running of the service by the registered manager.” from the report
- 01What action has been completed since the inspection to improve management oversight and quality audits?
- 02How are choking risk assessments checked and shared with new and agency staff?
- 03How are constipation medicine protocols reviewed, including when medicines should be given and when professional advice is needed?
- 04How are accidents and incidents now recorded, analysed and acted on when patterns appear?
- 05How will the home make sure actions identified in audits are completed and followed up?
This inspection focused on Safe and Well-led, including infection prevention and control; ratings for the other key questions were carried forward from the previous inspection. This explanation was written from the published report of 4 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.
What inspectors found, March 2022
Targeted inspection found good infection-control arrangements overall, but infection-control audit records were inconsistent; the service was inspected but not rated.
Inspectors made an unannounced, targeted visit on 25 February 2022. They looked mainly at infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures affected people.
The inspectors were assured about testing, personal protective equipment, visiting arrangements, admissions, shielding and social distancing. People could receive visitors without restrictions and could go out with family, friends and staff.
The inspectors were only somewhat assured about the recording of infection-control checks and audits because records were inconsistent. The service was inspected but not rated, so this report does not give an overall quality rating.
Visiting arrangements
Visitors received clear guidance and could visit without restrictions in line with current guidance.
“Visitors to the service were provided with clear guidance on the process they needed to follow during visits to Wimbledon House Residential Care Home.” from the report
Testing
People and staff followed the current COVID-19 testing programme to help identify infections quickly.
“People and staff followed the current Covid-19 testing programme to quickly identify any infections.” from the report
Safe outings
People were supported to go out safely with family, friends and staff.
“People were supported to safely go out and about with their family, friends and staff.” from the report
Protective equipment
Inspectors were assured that personal protective equipment was being used safely and effectively.
“We were assured that the provider was using PPE effectively and safely.” from the report
Infection-control records
needs fixingRecords of infection-control checks and audits were not consistent. This made it harder to show that checks were being completed reliably.
“The recording of infection control checks and audits was inconsistent.” from the report
- 01How have you improved the recording of infection-control checks and audits since this inspection?
- 02Who checks the infection-control records, and how often are they reviewed?
- 03What arrangements are currently in place for visitors and COVID-19 testing?
- 04How would you manage COVID-19-related staffing pressures if they happened again?
- 05Which areas of care will be assessed in the next full inspection?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other key questions. This explanation was written from the published report of 15 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.
Every inspection of Wimbledon House Residential Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Wimbledon House Residential Care Home →
- March 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Wimbledon House Residential Care Home →
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 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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