CQC report explained · a nursing home
What the CQC found at Wray Common Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, effective safeguarding and safe medicines management. Most fire safety recommendations had been completed, with one remaining recommendation scheduled for action.
- Effective?
- Good
- Staff training and supervision had improved. People's health, nutrition and communication needs were assessed and reviewed, and the home followed the Mental Capacity Act.
- Caring?
- Good
- People and relatives described staff as kind, respectful and supportive. Staff offered choices, protected privacy and encouraged independence.
- Responsive?
- Good
- Care plans reflected people's needs, preferences, life histories and interests. Inspectors found activities were available, but people spending most of their time in bedrooms said they did not have enough one-to-one activities.
- Well-led?
- Good
- Management and quality monitoring had improved. Some paper records did not match their digital equivalents, and the manager said future care recording would use the digital system.
What inspectors found, October 2022
Rated Good; inspectors found kind, safe and well-organised care, with some improvements still needed in activities and record keeping.
Inspectors visited on 6 and 8 September 2022. The first visit was unannounced and the second was announced. They spoke with people living at the home, relatives and staff, observed care, and checked care records, medicines, recruitment files, training, complaints and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, good infection control, kind care and support that respected people's choices. People's health needs were monitored and care plans were personalised.
The home had improved since the previous inspection, when it was rated Requires Improvement and breached two regulations. Inspectors found it was no longer in breach. They did identify some people lacked enough one-to-one activities and some paper and digital records did not match.
Kind and respectful care
People and relatives consistently described staff as kind, caring and respectful. Staff supported people's choices, privacy and independence.
“Staff were kind and caring and treated people with respect.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and saw safe medicines practice. Recruitment and safeguarding arrangements were also in place.
“There were enough staff available to keep people safe and meet their care needs.” from the report
Health support
Staff monitored people's health and acted promptly when concerns arose. They worked with healthcare professionals and followed specialist guidance about food and fluids.
“Staff monitored people's health effectively and acted promptly if they identified concerns.” from the report
Improved leadership
The manager had improved care quality, staff support, communication with relatives and quality checks since the previous inspection.
“The registered manager had improved many aspects of the service since taking up their post” from the report
One-to-one activities
needs fixingPeople who spent most of their time in their rooms said they did not have enough opportunities for one-to-one activities. An additional member of staff was deployed to the activities team after inspectors raised this.
“However, people who spent most of their time in their rooms told us they did not have enough opportunities for one-to-one activities.” from the report
Records did not always match
minorSome paper records, including fluid charts, did not correspond with the digital records. The manager said future care would be recorded on the digital system to improve consistency.
“We found that some records in paper form, such as fluid charts, did not correspond with the digital equivalent.” from the report
Outstanding fire recommendation
needs fixingThe fire service had made several recommendations. All but one had been completed at the inspection, and the remaining work was scheduled for 27 September 2022.
“Following an assessment of fire safety at the home, Surrey Fire and Rescue Service made a number of recommendations, all but one of which had been implemented by the provider at the time of our inspection.” from the report
- 01What one-to-one activities are now available for people who spend most of their time in their rooms?
- 02Has the outstanding fire safety recommendation been completed, and what work was carried out?
- 03How do you make sure paper and digital care records, including fluid charts, are consistent?
- 04How will you keep families informed about changes in a person's health or care?
- 05What improvements have been made since the previous Requires Improvement rating?
This was a comprehensive inspection covering all five key questions and infection prevention and control, with visits on 6 and 8 September 2022. This explanation was written from the published report of 6 October 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, May 2019
Wray Common Nursing Home was rated Requires Improvement; care was safe and kind, but dementia support, activities and management checks were not consistent.
Inspectors visited on 28 February and 6 March 2019. The first visit was unannounced. They spoke with people living there, relatives and staff, observed care, and checked care plans, medicines records, risk assessments, policies and audits.
The home was rated Good for Safe and Caring. People said they felt safe and were treated with kindness and respect. Staffing, medicines, infection control and access to healthcare had improved since the previous inspection.
The home was rated Requires Improvement for Effective, Responsive and Well-led. Inspectors found that staff had not all received dementia training, the environment was not sufficiently dementia-friendly, some records lacked important information, and people spending time in their rooms did not always receive meaningful activities.
The overall rating means the home was not consistently meeting the standard expected. The provider breached Regulation 9 on person-centred care and Regulation 17 on good governance. CQC said it would continue to monitor the home and check whether improvements were made.
Safe staffing
Inspectors found enough staff to meet people's needs in a timely way. Call bells were answered promptly and recruitment checks were completed.
“There were sufficient staff deployed to meet people's needs in a timely manner.” from the report
Safe medicines
Medicines records were accurate, medicines were securely stored and instructions for medicines given when needed were clear.
“We looked at ten MARs and found they had been completed accurately with no unexplained gaps or omissions.” from the report
Kind and respectful care
People and relatives gave positive feedback. Staff offered choices, protected privacy and encouraged independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Healthcare support
The home communicated well about people's healthcare needs and followed advice from health professionals.
“There was good communication between care, staff nurses and management regarding people's healthcare needs.” from the report
Dementia training and environment
needs fixingMost people were living with dementia, but staff had not received dementia care training. The environment also lacked features to help people orientate themselves.
“Despite this, the staff we spoke with told us they had not completed training in dementia care and records confirmed this was the case.” from the report
Incomplete care information
needs fixingSome care records did not clearly explain people's health risks, communication needs, emotional support, personal history or preferences. This could make consistent personalised care harder.
“Some people's records did not include information regarding their needs in areas such as communication, emotional support, medical history and mental capacity.” from the report
Limited activities for people in rooms
needs fixingMore than half of the people spent time in their rooms during the inspection, but activities and social contact were not consistently offered there.
“There was a lack of activities for people who spent time in their rooms.” from the report
Weak management oversight
seriousQuality systems did not identify several problems, including gaps in risk planning, training, activities and DoLS applications. This was a continued breach of Regulation 17.
“The lack of management oversight of some areas of the service was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Person-centred care breach
seriousThe provider did not ensure care records were consistent, staff knew people's life histories, or people always had access to meaningful activities. This was a breach of Regulation 9.
“The provider had failed that care records were consistent, that staff were knowledgeable about people's life histories and that people always had access to meaningful activities.” from the report
- 01What dementia care training have all staff completed since this inspection?
- 02What changes have been made to the environment to help people living with dementia find their way and recognise their rooms?
- 03How do you provide activities and regular social contact for people who spend much of their time in their rooms?
- 04How do you make sure care records contain accurate risk information, life histories and personal preferences?
- 05How do your current audits identify problems with care records, staff training and legal authorisations?
This was a planned inspection covering all five key questions, including the premises and care provided; the previous overall rating was Requires Improvement. This explanation was written from the published report of 24 May 2019 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 Wray Common Nursing Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 31 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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