CQC report explained · a residential care home
What the CQC found at Wycliffe
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by detailed risk assessments, safeguarding systems, safe recruitment and enough staff. Medicines and infection prevention arrangements were also found to be safe.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Managers promoted a positive, person-centred culture and involved people and families in care discussions. They were updating the governance system and reviewing incidents and improvements.
What inspectors found, July 2023
Rated Good; inspectors found safe, kind, person-centred care, while some records and governance systems were still being reviewed.
This was an unannounced inspection over five visits in June and July 2023. One inspector met two people, contacted two relatives, spoke with managers and staff, and reviewed care, medicine, staff and management records.
The home supported three people with learning disabilities. Inspectors found enough suitably trained staff, safe medicine arrangements, detailed risk assessments and appropriate safeguarding systems. People were supported to make choices, build independence and take part in meaningful activities.
The home was rated Good for Safe and Well-led. Managers were reviewing some capacity and best-interests records and updating the governance system. No legal breaches or enforcement action were reported.
This was a focused inspection of Safe and Well-led. The ratings for the other areas were carried forward from the previous inspection, which was rated Good and published in June 2018.
Choice and independence
Staff supported people to make decisions, use their strengths and work towards their goals. People were supported to have meaningful everyday lives.
“People were supported to have maximum possible choice, control and independence.” from the report
Kind and respectful care
Inspectors found that staff understood people's individual needs and protected their privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Safe staffing
There were enough staff during the day and night to meet people's needs and spend meaningful time with them.
“There were enough staff to safely care for people.” from the report
Safe medicines
Staff were trained and assessed as competent to give medicines. Regular checks were made to keep medicine records accurate.
“People's medicines were managed in a safe manner. Staff were trained in medicines management and were assessed as competent to administer people's medicines.” from the report
Capacity records being reviewed
needs fixingManagers were still reviewing capacity assessments and best-interests records so that each one was specific to the decision involved and accurate.
“The registered managers were in the process of reviewing people's care records to ensure all capacity assessments and 'best interests' documents were decision specific and accurate.” from the report
Governance system being updated
needs fixingManagers said the existing governance system needed updating and were creating a more robust system.
“They were currently in the process of creating a more robust governance system, as they felt the existing one needed updating.” from the report
- 01How far has the review of capacity assessments and best-interests records progressed?
- 02What changes have been made to the governance system since the inspection?
- 03How do you make sure there are enough staff at all times, including overnight?
- 04How are people supported to make choices and work towards their individual goals?
- 05How do you check that medicine records remain accurate and that staff remain competent to administer medicines?
This was a focused inspection of Safe and Well-led only; the other ratings used in the overall rating were carried forward from the Good rating at the 2018 inspection. This explanation was written from the published report of 19 July 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 2018
Wycliffe was rated Good; inspectors found safe, caring and personalised support, with some records and staff supervision details needing improvement.
This was a comprehensive, announced inspection carried out over three visits in April 2018. One inspector spoke with all three people living in the home, staff, a relative and health and social care professionals. Records, medicines, recruitment, training and the home itself were also checked.
Inspectors found enough staff, safe medicines support and suitable risk arrangements. People were supported to make choices, stay independent, eat well and use health services. Staff treated people with dignity and supported activities, work, relationships and community involvement.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. This was the same overall rating as the previous inspection in January and February 2016. Some care and risk records were difficult to follow, and not all supervision and appraisal discussions had been formally recorded, but managers had started work to improve this.
People felt safe
People and relatives said they felt safe, and inspectors found enough staff to respond promptly to requests and support activities.
“There were sufficient numbers of staff on duty to keep people safe and contingencies were in place to ensure that staff knew people's needs.” from the report
Safe medicines support
Medicines were stored and given safely. People who wanted to manage their own medicines had assessments and safety checks.
“We found appropriate arrangements were in place for the safe administration and storage of medicines.” from the report
Independence and choice
People were supported to make everyday choices, go out, shop, prepare food and develop skills for work and community life.
“People had choice and control of their lives and staff supported them in the least restrictive way; the policies and systems in the service supported this practice.” from the report
Kind and respectful care
Inspectors saw staff protecting people's privacy and dignity and responding compassionately when people needed emotional support.
“We observed staff and people who used the service interacting and saw that staff treated people with dignity and respect, for example knocking before entering a person's bedroom.” from the report
Meaningful activities
People chose activities, volunteering, work, relationships and community opportunities that mattered to them.
“People were able to take part in a range of activities of their choosing and which were meaningful to them.” from the report
Risk records were hard to follow
needs fixingRisk assessments were not in a standard format, were sometimes amended by hand and were not always stored in the same place. Managers had started a review of the care files.
“Risk assessments were not in a standard format, were sometimes amended several times by hand making them more difficult to read and were not kept in the same place in all files.” from the report
Supervision and appraisal records
needs fixingStaff received support, but some supervision discussions were informal and not recorded. Staff appraisals had been planned but had not yet taken place.
“Some of the discussions that took place were documented; however, both staff and the registered managers told us that meetings took place more frequently but where not always recorded.” from the report
Care plans were difficult to locate
needs fixingCare files contained useful information, but their styles varied and some had been updated by hand several times. The managers had begun reviewing them.
“The styles and content of files varied and some files were updated several times by hand, meaning information could be difficult to locate immediately.” from the report
Quality system needed updating
minorThe quality assurance system did not yet cover all feedback as robustly as needed. The provider updated it during the inspection.
“This required minor updates to ensure it covered all aspects of feedback from other agencies and was robust.” from the report
- 01Have all care plans and risk assessments now been rewritten in a clear, consistent format?
- 02How do you make sure staff supervision and appraisals are completed and recorded?
- 03How are medicines monitored when a person manages some or all of their own medicines?
- 04What work opportunities, volunteering, activities and community outings could the person take part in?
- 05How do people and relatives give feedback, and how is that feedback recorded and acted on?
This was a comprehensive inspection covering all five questions and the overall rating, which remained Good from the previous inspection in January and February 2016. This explanation was written from the published report of 6 June 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 Wycliffe
3 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 21 June 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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