CQC report explained · a residential care home
What the CQC found at Withins (Breightmet) Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Withins (Breightmet) Limited was rated Requires Improvement; inspectors found kind, person-centred care but medicines were not always managed safely.
This was an unannounced focused inspection. Inspectors looked at whether the home was safe and well-led. They spoke with people, relatives, staff and health professionals, and checked care records, medicines records, staff files and quality checks.
The home had enough staff and recruited them safely. People were treated with dignity and kindness, and staff supported their choices, interests and independence. Inspectors also found good safeguarding, infection control, care planning and partnership working.
Medicines were not always given as prescribed. Some records were incomplete or inaccurate, and checks had not found these problems. The home remained in breach of the safe care and treatment regulation, so its overall rating stayed Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's assessed needs. Recruitment checks were also carried out before staff started work.
“There were enough staff on duty to meet people's assessed needs.” from the report
Kind and respectful care
Care was person-centred. Staff supported people's dignity, privacy, equality, choices and independence.
“Care was person-centred and promoted people's dignity, privacy, and human rights.” from the report
Good safeguarding
Staff understood how to recognise and report abuse. Risk assessments and capacity assessments had been completed.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Positive relationships
People, relatives and staff spoke positively about the home. Relatives said communication with staff was good.
“The registered manager and staff promoted a positive culture in the home.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines records
seriousMedicines were not always given as prescribed. Records were sometimes incomplete, making it difficult to check what medicines remained.
“The medicines administration records (MAR) showed people were not always given their medicines as prescribed” from the report
Medicine instructions
seriousInformation was missing where staff could give one or two tablets. This meant staff might not have had the information needed to give the correct amount at the right time.
“We found information to support the administration of medicines when there was an option to give 1 or 2 tablets was not available” from the report
Medicines checks
needs fixingThe home's medicines audits did not identify the problems found by inspectors. The provider was asked to make these audits more robust.
“The service completed audits of medicines; however, the audits had not identified the issues found during the inspection.” from the report
Creams in bedrooms
seriousSome creams were kept in people's bedrooms without an assessment of the risk of people accessing them. Inspectors were therefore not assured they were stored securely.
“The risk of people accessing the topical preparations had not been assessed therefore we were not assured the creams were kept securely” from the report
- 01What has changed in the medicines administration records since this inspection?
- 02How do you check that medicines are given exactly as prescribed, including when one or two tablets may be given?
- 03How are refusals or missed medicines recorded and checked against the remaining stock?
- 04What risk assessments are now in place for creams kept in people's bedrooms?
- 05How often are medicines audits completed, and how do you make sure they identify problems promptly?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 6 June 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, June 2022
Withins (Breightmet) Limited rated Requires Improvement; inspectors found unsafe medicines management and incomplete risk and care records.
This was an unannounced focused inspection on 17 and 23 May 2022. Inspectors reviewed information, spoke with people, staff and a relative, observed care, and checked care, medicines, recruitment and management records.
People were not always safe. Medicines were not always managed correctly, including controlled drugs, as-needed medicines and handwritten medicine records. Risk assessments and care records were sometimes incomplete or too general.
The home had enough staff, clean premises and systems to protect people from abuse and infection. People and relatives said staff were kind and supportive, and complaints were handled appropriately.
The overall rating changed from Good at the previous inspection to Requires Improvement. This inspection only assessed Safe and Well-led. The other ratings carried over from the previous inspection.
Enough staff
Inspectors found good staffing levels, and people said staff were kind and looked after them well.
“There were good numbers of staff on duty and people told us staff were kind and looked after them well.” from the report
Respectful care
People and relatives described supportive care. Inspectors observed kind and respectful relationships between staff and people using the service.
“We observed staff interactions, throughout both days of inspection, and witnessed kind, respectful exchanges.” from the report
Infection control
The home was clean and hygienic, with measures in place to prevent and control infection.
“The premises were clean and hygienic and measures were in place to help prevent and control the spread of infection.” from the report
Safeguarding systems
There were systems to help protect people from abuse, and staff had completed safeguarding training.
“The service had systems in place to help safeguard people from harm.” from the report
Improvement work started
The provider had started sepsis and Restore 2 training and planned further training on pain management and record keeping.
“Some improvements to the service had already been implemented.” from the report
Medicines were not always safe
seriousControlled drugs, as-needed medicines, pain patches, allergies, creams and medicine administration records were not always managed or recorded correctly. Inspectors said this put people at risk of harm.
“Medicines were not always managed safely, which put people at risk of harm.” from the report
Risk assessments lacked detail
seriousSome risk assessments were generic or missing. They did not always link properly with care plans or other records, including records about choking, diabetes and depressive episodes.
“Individual risk assessments were quite generic and did not include enough person-centred detail to make them effective.” from the report
Records were incomplete
seriousCare plans and risk records were not always complete or accurate. This could leave staff without clear guidance about people's needs.
“The lack of appropriate records and cross referencing with other documents, meant staff were not always aware of, or given guidance, to deal with certain concerns.” from the report
Learning from incidents needed stronger checks
needs fixingThe home recorded significant events and had learned from them, but inspectors said separating and auditing them by category would help identify patterns sooner.
“However, separating these events into different categories and auditing them monthly would help ensure patterns and trends were picked up and addressed in a timely manner.” from the report
- 01What has been changed to make controlled drugs, as-needed medicines and handwritten medicine records safe and accurate?
- 02How do you now check that risk assessments cover choking, diabetes, weight loss, pain and distress?
- 03What checks make sure care plans and risk assessments match and give staff clear guidance?
- 04How are medicine and care-record audits now carried out, and who reviews the results?
- 05What progress has been made on the action plan requested by CQC?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection published in 2018. This explanation was written from the published report of 24 June 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 Withins (Breightmet) Limited
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Withins (Breightmet) Limited →
- June 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Withins (Breightmet) Limited →
- April 2021Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- August 2011
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 30 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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