CQC report explained · a residential care home
What the CQC found at Wolsey House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found safe medicines management, suitable staffing, robust recruitment checks and effective infection control arrangements.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward for the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward for the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward for the overall rating.
- Well-led?
- Good
- The home had effective audits, complete medicines records and a positive, person-centred culture. People, relatives and staff were asked for their views.
What inspectors found, February 2022
Heathcotes Wolsey House rated Good; inspectors found people were safe and well supported, with improvements since the previous inspection.
This was an unannounced focused inspection carried out on 6, 18 and 24 January 2022. One inspector spoke with four people, one relative and seven staff. They reviewed care records, medicines records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse and avoidable harm. Medicines, staffing, recruitment and infection control were managed safely. Care plans included people's risks, choices and preferences.
The previous inspection found problems with record keeping and rated the service Requires Improvement. Inspectors found these issues had been addressed, and the home was no longer in breach of the regulations.
This was a focused inspection of Safe and Well-led only. The other three key-question ratings were carried forward from the previous inspection when the overall rating was calculated.
People felt safe
People said they trusted staff to keep them safe. Staff had safeguarding training and understood how to report concerns.
“People were protected from the risks of abuse and harm and people said they trusted staff to keep them safe.” from the report
Safe medicines support
Medicines were given on time and records were accurate. People were supported to manage their own medicines when appropriate.
“People's medicine needs were risk assessed and they were supported to manage their medicines independently where appropriate.” from the report
Person-centred care
People's choices and decisions were included in their care plans. Staff supported people to have control over their lives.
“People's choices were respected, and staff supported them to achieve good outcomes.” from the report
Improved management checks
The home had regular audits of care plans, medicines, staff files and the premises. This addressed the governance problem found at the previous inspection.
“Robust auditing systems were in place which comprised of manager and provider level audits.” from the report
Positive relationships
Inspectors found a friendly culture. People said they were happy living in the home and got on well with staff and other residents.
“There was a good culture within the service which had a positive impact on people.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure care plans and risk assessments stay up to date when a person's needs change?
- 02How are people supported to manage their own medicines, and how are the weekly reviews carried out?
- 03What audits are currently carried out on care plans, medicines records and the premises?
- 04How are people's views used when their care plans and support are reviewed?
- 05What were the findings from the most recent surveys of people, relatives and staff?
This was a focused inspection of Safe and Well-led, including infection control; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 10 February 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, January 2020
Rated Requires Improvement; inspectors found kind, person-centred care, but medicines records and oversight were not reliable enough.
This was the home’s first inspection since registration. One inspector visited unannounced over 31 October and 1 November 2019. They spoke with people, a relative and staff, observed care, and checked care, medicine, staff and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People said they felt safe and described staff as kind, respectful and supportive. Inspectors saw people making choices, building independence, enjoying activities and being involved in meals and care planning.
The overall rating was Requires Improvement because Well-led was rated Requires Improvement. Inspectors found gaps in medicine administration records, handwritten records that were not robust enough, and audits that had not found repeated recording problems.
The provider breached Regulation 17 on good governance. The manager took some action during the inspection, including checking staff competency and reviewing medicine recording materials. CQC asked for an action plan and said it would monitor progress and return for another inspection.
Kind and respectful staff
People said staff were kind, courteous and sensitive. Inspectors observed staff treating people with dignity and respect.
“People told us staff were kind, courteous and sensitive.” from the report
Choice and independence
People were involved in care planning, daily decisions, meals and activities. Staff supported them to learn skills and become more independent.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Suitable staffing and recruitment
Inspectors found appropriate staffing levels and robust recruitment checks. Staff said there was enough time to spend with people.
“During the inspection we observed appropriate levels of staffing to support the people who used the service.” from the report
Medicine records were incomplete
seriousInspectors found gaps in signing medication administration records. Handwritten records did not follow national guidance and were not reliable enough to show medicines had been given accurately.
“Although daily records showed people had received their medicines, we found gaps in the signing of medication administration records (MARs).” from the report
Some as-required medicine guidance was missing
needs fixingProtocols were not always available for as-required medicines. This meant staff had limited information about when particular medicines might be needed.
“We found PRN protocols for 'as required' medicines were not always in place.” from the report
Quality checks did not work well enough
seriousAn internal audit found one recording problem, but the wider issue was not corrected. Weekly medicine audits also failed to identify errors found by inspectors.
“These audits were not robust as they failed to pick up on the recording errors we found during our inspection.” from the report
No registered manager at the inspection
needs fixingThe home was being run by a registered manager from a sister home rather than having its own registered manager. The provider applied after the inspection to add that manager to this service’s registration.
“At the time of the inspection the service did not have a registered manager, however the service was being run by a registered manager from the provider's sister home.” from the report
- 01What has changed in the medicine administration records since the inspection, and how do you check that every dose is recorded correctly?
- 02Are written protocols now in place for every as-required medicine, and how are staff told when to use them?
- 03What did your action plan to CQC say, and what evidence can you show that the Regulation 17 breach has been addressed?
- 04Do weekly medicine audits now identify recording errors, and who independently checks the results?
- 05Has the home now got its own CQC-registered manager, or has the application to add the manager from the sister home been completed?
This was the first inspection of the newly registered care home and covered all five CQC questions, including accommodation and care provided. This explanation was written from the published report of 14 January 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 Wolsey House
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Requires improvementSafe: GoodWell-led: Requires improvement
- November 2018
Registered with the Care Quality Commission on 9 November 2018.
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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Most charge £980 to £1,260 a week. 90 can care for a couple. 10 years' experience on average.
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“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
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