CQC report explained · a nursing home
What the CQC found at Withens Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found up-to-date care plans and risk assessments, safe medicines systems, suitable staffing, safeguarding arrangements and infection control measures. They found the home had improved and was no longer in breach of Regulation 12 or Regulation 18.
- Effective?
- Good
- Inspectors looked at support with eating and drinking because of specific concerns. People received food and fluids in line with professional advice, including modified diets where needed.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found daily handovers, audits, risk meetings and a home development plan. They found the provider had improved its quality monitoring and was no longer in breach of Regulation 17.
What inspectors found, October 2021
Withens Nursing Home rated Good; inspectors found safer care and stronger management, but some staff said weekends could be better staffed.
Inspectors visited on 31 August and 6 September 2021. They spoke with people living in the home, relatives and staff. They also checked care plans, medicines records, staff files, safety checks, audits and meeting records.
The home was rated Good overall. Safe and well-led were rated Good. Inspectors found that care plans, risk assessments, medicines systems, safeguarding and infection control had improved. People and relatives said they felt safe.
Effective was inspected but not rated, focusing on concerns about food, drink and nutrition. Inspectors found people received suitable food and fluids, including modified diets where needed. Caring and Responsive were not inspected, so their previous ratings carried forward.
The previous inspection had rated the home Requires Improvement and found three breaches of regulation. Inspectors found enough improvement had been made and that the home was no longer in breach.
Care records and risk checks
Care plans and risk assessments were detailed, organised and up to date. Staff were observed following them, including instructions about falls, choking and skin damage.
“Care plans and risk assessments were comprehensive, organised and up to date, and contained enough information for staff to provide safe care.” from the report
Medicines
Medicines were stored, administered and recorded safely. Audits were completed, and medicines errors were investigated with learning shared with staff.
“Medicines were managed safely in line with national guidance.” from the report
Food and drink
People received food and drinks of the right consistency. Staff understood modified diets and there were enough staff to help people eat and drink.
“People were supported to eat and drink safely in line with recommendations received from Speech and Language Therapists (SALT) and dieticians.” from the report
Learning from incidents
Accidents and incidents were recorded and investigated. The home used action plans, meetings and trend analysis to reduce the risk of problems happening again.
“Lessons learned were thorough and included a page, called "Our Learning" which staff needed to sign to confirm they had been read and understood.” from the report
Management and oversight
The home had daily checks, regular audits and clinical risk meetings. Staff described managers as supportive and approachable, and the provider had interim arrangements after the registered manager left.
“The provider had a quality monitoring system in place.” from the report
Weekend staffing
minorMost staff felt there could be more people on duty at weekends, when support roles were not working. The home was recruiting more permanent staff at the time.
“Most staff thought there could be more people on duty particularly at weekends when support roles were not working.” from the report
Staff morale
minorStaff described the culture as open and honest, but most said morale was not consistently strong.
“Staff told us there was an open and honest culture, but most said morale was 'up and down'.” from the report
- 01How many permanent staff are now working at weekends, and how often are agency staff needed?
- 02What interim management arrangements are currently in place following the manager's departure?
- 03How do you check that care plans and risk assessments stay up to date when people's needs change?
- 04How are medicines errors recorded, investigated and used to improve practice?
- 05How do you monitor staff morale and respond when staff raise concerns?
This was a focused inspection of Safe and Well-led and a targeted inspection of eating and drinking under Effective; Caring and Responsive were not inspected and previous ratings carried forward. This explanation was written from the published report of 21 October 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.
What inspectors found, October 2020
Rated Requires Improvement; inspectors found risks with staffing, medicines, safety checks and management systems.
Inspectors visited on 27 August 2020. They spoke with people, relatives and staff, and checked care, medicine and management records. This was a focused inspection of Safe and Well-led only.
People said they felt safe and received their medicines as prescribed. The home was clean, infection control measures were in place, and staff worked with health professionals. Staff also said support and morale had improved under the new manager.
However, risks were not always assessed or managed properly. There were not consistently enough staff, some medicines were stored unsafely, safeguarding concerns were not always reported quickly, and checks did not find important problems. The overall rating fell from Good at the previous inspection to Requires Improvement.
Clean and prepared for infection control
The home was clean and staff used personal protective equipment as required. Infection control measures for COVID-19 were in place.
“The service was clean and odour free. There was enough domestic staff to ensure the cleanliness of the service was maintained.” from the report
Medicines usually given correctly
People received their medicines as prescribed and records were adequate. Nurses administered medicines and their competence was checked each year.
“People received their medicines as prescribed and records were completed adequately.” from the report
Staff support had improved
Staff said morale and support had improved since the new manager started. Regular staff meetings gave them a chance to raise concerns.
“Improvements had been made and staff we spoke to were positive about the morale levels and support from the new manager.” from the report
Links with health professionals
Staff worked with speech and language therapists, dieticians, hospitals, GPs and other health professionals to support people's health needs.
“The staff and manager worked with a range of health care professionals to provide joined up care for people.” from the report
Risks were not managed consistently
seriousOne person left the home unsupported twice after their risks had not been identified properly. Falls, hot water, fire evacuation and thickening powder also presented safety concerns.
“Lessons had not been learnt from the first incident and placed this person at continued risk of harm as it happened again.” from the report
Not enough staff at times
seriousPeople sometimes waited for personal care and call bells were not always answered promptly. The staffing assessment did not account for the building's layout.
“The registered persons had failed to consistently deploy sufficient numbers of suitably competent, skilled staff to meet people's needs.” from the report
Unsafe medicine storage
seriousThe medicine fridge had reached 18 degrees, outside the required range, and creams were kept in rooms without temperature checks. The home took action during the inspection.
“People's medicines were not always stored safely which placed them at risk of harm.” from the report
Checks did not find problems
needs fixingThe home's quality checks failed to identify issues with medicine storage, hot water, fire safety and accident patterns. The provider was asked to improve its monitoring.
“The registered persons quality assurance processes had failed to identify issues relating to the quality and safety of the service.” from the report
Safeguarding notifications were delayed
seriousThe manager did not always refer safeguarding concerns quickly and had not notified CQC about one incident as required. This could delay action to protect people.
“The provider had failed to notify CQC of a safeguarding incident that occurred.” from the report
- 01How many staff are on duty on weekdays and weekends, and how do you monitor call bell response times?
- 02What has changed to make sure falls, the risk of leaving the building, hot water and fire evacuation are managed safely?
- 03How are refrigerated medicines and creams stored and temperature-checked now?
- 04What action has been taken in response to the breaches of Regulations 12, 17 and 18?
- 05How do you make sure safeguarding concerns and incidents are reported to the right authorities without delay?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection in 2017. This explanation was written from the published report of 22 October 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.
Every inspection of Withens Nursing Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2017Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2014
Report published without a new overall rating.
- November 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 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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