CQC report explained · a nursing home
What the CQC found at Wulfrun Rose Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People felt safe and risks were assessed, but guidance for medicines given when needed was not always correct. Staff were not always available promptly, and infection control procedures were not fully followed.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Well-led?
- Requires improvement
- Management checks did not always identify problems with medicines, records, staffing deployment or infection control. The report says these systems were not robust enough to show that safety was effectively managed.
What inspectors found, March 2021
Rated Requires Improvement; inspectors found kind care and some safety controls, but medicines, staffing, infection control and management checks needed improvement.
This was an unannounced, focused inspection on 16 February 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about care quality. They spoke with eight people, two relatives and nine staff, and reviewed care and management records.
People generally felt safe and spoke positively about the care and management. Risks were assessed, oral medicines were given as prescribed, and the home was clean. Staff supported people to keep in touch with relatives during the pandemic.
However, guidance for medicines given when needed was not always correct, medicine records had missing signatures, and people could sometimes wait for support. Infection control guidance was not always followed. Management checks had missed several of these issues, so both Safe and Well-led were rated Requires Improvement. The overall rating changed from Good at the previous inspection in January 2018.
People felt safe
People and relatives did not raise concerns about safety. Staff knew how to recognise and report possible abuse.
“I feel safe here. Staff are nice and joyful.” from the report
Kind interactions
Inspectors saw positive interactions between staff and people receiving support. People and relatives also spoke positively about the care.
“Throughout our inspection we saw positive interactions between staff and the people they were offering support to.” from the report
Contact with relatives
Staff helped people keep in contact with important people during the pandemic through video and telephone calls.
“People were supported to keep in contact with those who were important to them during the pandemic.” from the report
Risk assessment
The home considered, assessed and reviewed risks to people's health and wellbeing. Accidents and incidents were reviewed for learning.
“Risks to people's health and wellbeing were considered, assessed and reviewed.” from the report
Medicines storage
Although medicine guidance and recording needed improvement, medicines were stored safely and oral medicines were given as prescribed.
“Medicines were stored in a safe way.” from the report
Medicines guidance and records
needs fixingGuidance for medicines given when needed was not always available or matched to the prescription. Staff also missed signatures when recording prescribed creams.
“Staff were not consistently documenting where they had supported people with their prescribed creams.” from the report
Infection control
seriousA person was not supported to isolate in their room on arrival, and staff did not always wear the extra protective equipment required during isolation periods.
“Although staff were wearing face masks throughout the inspection on occasion staff were not always wearing further personal protective equipment when people were in isolation periods.” from the report
Weak management checks
seriousAudits had not identified several problems with medicines, temperature records, care plans, staffing deployment and infection control. This led to a breach of Regulation 17.
“The quality checks completed in the home were not always effective in identifying areas where improvements were required.” from the report
- 01What has changed in the guidance and records for medicines given when needed and prescribed creams?
- 02How do you now make sure there are enough staff at busy times and that call bells are answered promptly?
- 03What checks confirm that staff follow the correct protective equipment and isolation procedures?
- 04How often are medicine, care plan, staffing and infection control audits completed, and can we see the recent results?
- 05What action was included in the report sent to CQC after the Regulation 17 breach?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 19 March 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, January 2018
Rated Good; inspectors found safe, kind and personalised care, with some medicine records still needing attention.
This was an unannounced inspection on 27 November 2017. The inspectors spoke with people living in the home, visitors, staff and managers. They observed care and reviewed care records, staff files, medicine records, complaints, accidents and quality checks.
The inspectors found people were safe, treated kindly and supported by trained staff. Staffing levels, risk management, medicines, food, activities, privacy and access to health professionals had improved. The home was clean and people were involved in choices about their care.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found the service met the expected standards at the time of this inspection. The previous rating was Requires Improvement in August 2016, and the report says the required improvements had been made.
Improvement since the last inspection
The home had addressed the problems found in August 2016, including medicine recording, staff deployment, privacy, activities and quality checks.
“At this inspection we found the provider had made the required improvements.” from the report
Safe staffing
Inspectors saw enough staff to meet people's needs. Call bells were answered promptly during the visit.
“Call bells were answered promptly and people did not have to wait for their care and support.” from the report
Food and nutrition
People had meal choices and received support with eating and drinking when needed. Staff used dietary guidance and involved specialist professionals where necessary.
“People enjoyed their mealtimes and looked relaxed and comfortable whilst eating.” from the report
Personalised activities
Activities were based on people's interests. This included individual activities for people who were cared for in bed.
“People were engaged in activity and were smiling and chatting throughout.” from the report
Kind and respectful care
Staff knew people's preferences and life histories. People were supported to make choices and their dignity and privacy were maintained.
“People were treated with dignity and respect and their privacy was maintained.” from the report
Some cream records were incomplete
needs fixingSome topical medicine records had not been completed, although the people concerned said they had received their creams. The manager took immediate action after inspectors raised this.
“We found some of these records had not been completed.” from the report
Manager not yet registered
minorA manager was in post but had not yet registered with the CQC at the time of the inspection. The report says plans were in place to begin the application process.
“There was a manager in post at the time of the inspection; they had not yet registered with us.” from the report
- 01What checks are now in place to make sure topical medicine records are completed every time?
- 02Has the manager now completed the CQC registration application, and what is the current position?
- 03How many staff are usually on duty for the number and needs of people living here?
- 04How are people's individual interests recorded and used to plan activities?
- 05How are relatives told about changes in a person's care or any incidents?
This was an unannounced inspection of the overall service and covered all five CQC questions: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 12 January 2018 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 Wulfrun Rose Nursing Home
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- March 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016
Registered with the Care Quality Commission on 19 February 2016.
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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