CQC report explained · a nursing home
What the CQC found at Wordsworth House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and staff understood safeguarding procedures. Infection control, risk management, staffing, recruitment and medicines systems were found to be safe overall, although some as-required medicine protocols lacked detail.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- The home was managed through audits, action plans and feedback. Inspectors found a person-centred culture, teamwork and timely action to improve quality.
What inspectors found, May 2022
Wordsworth House is rated Good; inspectors found safe, kind care and improvements in infection control, with some records still needing more detail.
This was an unannounced focused inspection on 7 April 2022. One inspector spoke with people, relatives and staff, observed care, and checked care, medicines and management records.
The home was rated Good for Safe and Well-led. Inspectors found people felt safe, staff understood safeguarding, medicines were managed safely, and infection control had improved. Staff were described as kind, caring and supportive.
Some as-required medicines protocols did not explain in enough detail how staff should recognise when medicine was needed. The manager also knew some records needed more person-centred detail.
The previous rating was Requires Improvement, published in January 2021, with a breach linked to infection control. Inspectors found enough improvement had been made and the home was no longer in breach.
Improved infection control
Inspectors found that infection prevention and control had improved since the previous inspection. Staff understood how to use protective equipment correctly, and systems were in place to monitor practice.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
People felt safe
People and relatives said they felt safe and trusted staff to protect them. Staff knew how to recognise and report possible abuse.
“People said they felt, "very safe." Relatives also told us they trusted staff to keep their loved ones safe.” from the report
Safe medicines systems
Medicine records were completed in full and systems for managing medicines were safe overall.
“Medicine administration records were completed in full.” from the report
Good management oversight
The management team used audits to identify improvements and acted on them in a timely way. People, relatives and staff were involved in care planning and feedback.
“There were a range of audits completed which identified areas for improvement which were acted upon in a timely manner.” from the report
Kind and supportive staff
People said staff were kind and helped promote independence. Staff worked together to meet people's needs.
“People told us staff were kind and promoted independence.” from the report
Some medicine instructions lacked detail
needs fixingSome protocols for as-required medicines did not clearly explain how staff should recognise when a person needed the medicine. Staff could explain this in practice, but the written guidance needed improvement.
“Some protocols to support staff with the administration of as required medicine lacked detail on how staff would recognise if people needed their medicines.” from the report
- 01How have you added more person-centred detail to people's care and risk records?
- 02How do your written protocols explain when each as-required medicine should be given?
- 03How do you check that staff follow the correct infection prevention and control procedures?
- 04How do you monitor whether the improvements identified in audits remain effective?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were not inspected and were carried forward from the previous inspection. This explanation was written from the published report of 4 May 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 2021
Wordsworth House was rated Requires Improvement; inspectors found infection-control failures and issued a warning notice.
This was an inspection during the coronavirus pandemic. Inspectors visited on 11 and 16 November 2020. They observed care, spoke with relatives and staff, and checked care, recruitment and management records.
The home was not always safe. Staff did not always use or remove personal protective equipment correctly, and equipment was not always cleaned between uses. Cleaning records also had gaps. Inspectors found a breach of the safe care and treatment regulation.
The home had enough staff, medicines were managed safely, and systems were in place to respond to abuse and accidents. However, the checks used by managers had not found the infection-control problems. The overall rating and the ratings for Safe and Well-led were Requires Improvement, down from Good at the previous inspection.
Medicines
Medicines were managed safely, including medicines prescribed for use when needed.
“Protocols were in place for people who required medicines as required and records for medicine administrations were accurate.” from the report
Safeguarding and incidents
There were systems to protect people from abuse and to review accidents and incidents for lessons.
“Accidents and incidents were reviewed to identify if there were any trends or if lessons could be learned and improvement actions taken to minimise future risks.” from the report
Management support
Staff and relatives gave positive feedback about the management. The provider acted on the inspectors' concerns during the visit.
“The provider was responsive to our feedback and immediate action was taken to address our concerns.” from the report
Protective equipment
seriousStaff were observed supporting people without the appropriate protective equipment. The report says this increased the risk of harm.
“Staff did not always follow the correct procedure for wearing and removing Personal Protective Equipment (PPE).” from the report
Cleaning of equipment
seriousEquipment used to support people, including hoisting equipment, was not always sanitised between uses.
“Equipment used to support people was not always cleaned in between use.” from the report
Cleaning records and oversight
needs fixingSome cleaning schedules had gaps, and management audits had not found the infection-control problems.
“Quality monitoring systems had failed to identify the shortfalls in the infection control practices staff were using.” from the report
- 01What has changed since the inspection to make sure staff wear and remove protective equipment correctly every time?
- 02How do you check that hoists and other shared equipment are cleaned between uses?
- 03Can you show us recent cleaning schedules and explain how missing entries are followed up?
- 04What did the action plan require after the warning notice, and has each action been completed?
- 05How are managers now checking infection-control practice in real time rather than relying only on audits?
This started as a targeted coronavirus infection-control inspection and was widened to a focused inspection of Safe and Well-led; the other key questions were not rated. This explanation was written from the published report of 20 January 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 Wordsworth House
6 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2016GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 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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