CQC report explained · a residential care home
What the CQC found at Wisteria House Residential Home - Somerset
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Rated Good; inspectors found safer care and stronger management after earlier breaches were fixed.
This was an unannounced focused inspection on 12 August 2022. One inspector spoke with people, relatives, staff and professionals, observed care and checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found improvements in infection control, fire safety, medicines, staffing, recruitment and management checks. People and relatives said people felt safe.
The previous rating was Requires Improvement. The provider had been in breach of regulations at the earlier inspection, but inspectors found enough improvement for those breaches to end. The overall rating changed to Good.
Improved safety
Fire safety, infection control and medicines management had improved since the previous inspection. Inspectors found the home visibly clean and medicines records correctly completed.
“Since our last inspection fire safety had improved and was well managed.” from the report
Staffing and recruitment
Recruitment checks were robust and staffing levels had increased from two staff to a minimum of three staff on shift.
“Since the last inspection the number of staff on shift had been increased from two staff to a minimum of three staff.” from the report
Stronger management checks
The manager had increased oversight, introduced monthly reports and delivered improvements through a service improvement plan.
“Since the last inspection the registered manager had improved oversight of the home.” from the report
Positive atmosphere
Staff described the home as supportive and homely. Staff said they felt valued and had opportunities to develop their skills.
“The home had a supportive and homely feel.” from the report
Some rooms may not suit people with mobility difficulties
minorThe building has some rooms that may be less suitable for people with mobility difficulties. The management team said they considered this when assessing new residents.
“The house is an older style building set over two floors with some rooms less suitable for people with mobility difficulties.” from the report
Personal detail in as-needed medicine guidance
minorInspectors initially found that guidance for as-needed medicines needed more personal detail. This was corrected immediately during the inspection.
“We identified more detail was required on these to make them more personal and this was rectified immediately.” from the report
- 01Which rooms would be suitable for my relative if they have mobility difficulties?
- 02How do you decide how many staff are needed on each shift for residents' needs?
- 03How are as-needed medicines recorded and how is the guidance personalised for each resident?
- 04What checks are now carried out each month on fire safety, medicines, care plans and infection control?
- 05What were the ratings for Caring, Effective and Responsive at the last comprehensive inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried over from the last comprehensive inspection. This explanation was written from the published report of 14 September 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.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found risks with infection control, fire safety, recruitment and management oversight.
This was an unannounced inspection on 12 May 2021. One inspector and an Expert by Experience spoke with people, relatives, staff and visiting health professionals. They observed care and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that staff were not using masks as required at the time, fire safety problems had not been dealt with, recruitment checks were incomplete and medicine records were not always properly completed.
People and relatives generally said they felt safe and received kind care. However, inspectors also found limited activities, an environment needing refurbishment and too little evidence that accidents, incidents and other problems were being analysed properly.
The last rating was Good, published in July 2019. This inspection only examined Safe and Well-led because it was prompted by concerns. The previous ratings for the other questions were used in the overall rating.
Kind and reassuring care
People and relatives described staff as caring and said communication with families was good. Inspectors also saw positive interactions.
“We are looked after very well – almost as if we were family” from the report
People felt safe
People and relatives said they felt safe and could get help when needed. Staff knew people well and were observed supporting them safely when moving around the home.
“I have called for help and they have reassured me when I am struggling” from the report
Food and weight monitoring
People said they liked the food. People at risk of weight loss received supplements and had their weight checked regularly, with health concerns discussed with health professionals.
“A health professional confirmed that any concerns about weight loss were discussed with the local GP team and action taken to address the risk.” from the report
Some health professional support
The home worked with several health professionals. A GP representative said concerns were shared promptly and recommendations were followed.
“They confirmed any concerns were shared in a timely way and recommendations made by the GP and practice nurses were followed.” from the report
Improved access
A new passenger lift had been installed since the previous inspection. This made access to some areas easier.
“Since the last inspection the provider has installed a passenger lift, which makes access to some areas easier.” from the report
Infection control
seriousStaff were not wearing masks as required by government guidance, and the policy did not reflect the guidance. Cleaning records also had gaps. This created a risk of infection spreading.
“The provider had failed to ensure risks relating to infection prevention and control (IPC) including those relating to COVID-19 were being managed safely at Wisteria House.” from the report
Fire safety
seriousSeveral fire doors did not close properly and one bedroom door was propped open. The evacuation list was out of date and room identification was confusing, which could make an emergency evacuation more difficult.
“This meant the doors would not have prevented the spread of fire or smoke in the event of an emergency.” from the report
Recruitment checks
seriousThere were no references for one staff member and no record of a satisfactory DBS check for another. The provider had not completed robust checks to confirm staff were suitable.
“The provider had not followed safe recruitment practices to ensure prospective staff were suitable to work at the service.” from the report
Management oversight
seriousAudits did not identify the problems found during the inspection. Accident and incident analysis was too limited, and the improvement plan had no end dates.
“The provider and registered manager had failed to operate effective systems to assess, monitor and improve the quality of the service people received.” from the report
Limited activities
needs fixingThere was no planned activities programme. People were often unoccupied or sleeping in communal areas, with television sometimes used mainly to relieve boredom.
“There was no activities programme for people to enjoy.” from the report
Building and staffing pressures
needs fixingSome areas needed refurbishment, only one bathroom was in use for 11 people, and at times only two staff were available for 11 people. Inspectors recommended reviewing staffing levels and deployment.
“This meant at times, only two staff were available to provide care and support for 11 people.” from the report
- 01What has been changed to make sure staff always use PPE in line with current guidance, and how is this checked?
- 02Have all fire doors, room labels and evacuation records been corrected, and when were they last checked?
- 03Have all staff recruitment files been completed with references and satisfactory DBS evidence?
- 04What has changed in the medicines system, including PRN instructions and records for creams?
- 05What regular activities are now available, especially for people living with dementia?
This was a focused inspection of Safe and Well-led prompted by concerns; the other key questions were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 17 June 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 Wisteria House Residential Home - Somerset
4 rated inspections over 6 years: the service has held its Good rating throughout.
- September 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Wisteria House Residential Home - Somerset →
- June 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Wisteria House Residential Home - Somerset →
- July 2019Goodstayed GoodSafe: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 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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76 live-in carers within about two hours of Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
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