CQC report explained · a nursing home
What the CQC found at Wykeham House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- DNAR information was not always clear or consistent across records, creating a risk in an emergency. Medicines, infection control, safeguarding and individual risk assessments were otherwise found to be managed safely.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Audits and governance systems did not reliably identify inconsistent records or wider trends in incidents and accidents. The management team responded during and after the inspection with plans to improve monitoring and record updates.
What inspectors found, June 2023
Wykeham House: Rated Requires Improvement; inspectors found risks from unclear emergency records and weak oversight, despite kind care and satisfactory staffing during the visit.
This was an unannounced focused inspection. Inspectors visited on 27 April 2023 and reviewed Safe and Well-led only. They spoke with people, relatives, staff and a health professional, and checked care, medicines, staffing and management records.
The main safety concern was that records about Do Not Attempt Resuscitation decisions were not always consistent. This meant staff might have had the wrong information in an emergency. Management also did not have strong enough systems to spot wider patterns in incidents or record-keeping problems.
People said they felt safe and relatives were generally confident in the care. Staff were kind and approachable. Staffing levels were satisfactory during the inspection, although some people and relatives were worried about staffing at weekends. The overall rating fell from Good at the previous inspection to Requires Improvement.
People felt safe
People said they felt safe, and relatives were confident in the care provided.
“People told us they felt safe, and relatives told us they were confident in the care provided to people.” from the report
Kind staff culture
Inspectors observed positive interactions. People, relatives and staff spoke positively about the staff team and management.
“It doesn't matter what staff member is in there, they are always nice and lovely to all the residents.” from the report
Medicines were managed safely
Inspectors found medicines were stored and recorded safely. Staff asked for consent and their medicines skills were checked regularly.
“We found medicines were stored safely and recorded accurately.” from the report
People were involved
People could give feedback through meetings and relatives were invited to take part in care and service discussions.
“There are resident's meetings, and if you say what needs to be changed, they really try to do it.” from the report
Unclear emergency records
seriousDNAR decisions were recorded in several places and did not always match. This could mean staff acted contrary to a person's wishes in an emergency.
“People were at risk of not being supported in line with their wishes regarding clinical care and treatment in a future emergency.” from the report
Weak management checks
seriousAudits did not identify inconsistent care records or wider patterns in incidents and accidents. This was linked to a breach of Regulation 17.
“Systems had not been established to mitigate risks to the health, safety and welfare of people using the service.” from the report
Weekend staffing concerns
needs fixingStaffing levels were satisfactory when inspectors visited, but some people and relatives said there did not always seem to be enough staff at weekends.
“People told us there was not always enough staff.” from the report
- 01How do you now make sure DNAR decisions match across every care record, handover document and colour-coded system?
- 02How quickly are changes from hospital admissions or medical recommendations added to all relevant records?
- 03What new checks are being used to identify trends in incidents, accidents and safeguarding concerns?
- 04How do you monitor staffing levels and management presence at weekends?
- 05What progress has been made on the action plan requested by CQC?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 22 June 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, November 2021
Wykeham House rated Good after improvement; inspectors found safe, kind and personalised care, with some weekend activity and documentation work still developing.
Inspectors visited without notice on 23 September 2021. They spoke with people living in the home, relatives and staff, observed care, and checked care plans, medicines, staff records and management records. They also checked infection prevention and control.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable training, safe medicines management, detailed care plans and kind interactions. People were supported to make choices, take part in activities and access healthcare.
The home had improved from Requires Improvement at the previous inspection in 2019. The report says the earlier breaches had been addressed and there were no breaches of regulations at this inspection. Inspectors did note that weekend activities and the quality of some daily documentation still needed attention.
Safe staffing
Staffing levels had been reviewed and inspectors saw staff had time to support people. The home had arrangements to cover gaps caused by sickness.
“We observed staff having time to spend with people and were able to carry out their roles.” from the report
Safe medicines
Medicines were managed by trained staff, given on time and checked through monthly audits.
“Medicines were managed safely by staff who had received suitable training and people received their medicines on time.” from the report
Kind and respectful care
People said staff were kind, and inspectors observed staff communicating positively and supporting privacy, dignity and independence.
“We observed staff interacting with people in a kind and caring manor.” from the report
Personalised care
Care plans included people's needs, preferences, life histories and wishes. Staff used this information to provide individual support.
“Care plans were highly personalised and contained information about peoples life histories, wishes and preferences.” from the report
Improved management
The home had a range of audits and recorded actions taken. Leaders shared information through meetings, reviews and staff communications.
“A variety of audits were in place to monitor quality, risk and regulatory requirements.” from the report
Weekend activities
minorOne person said weekend activities were not always happening and that this could feel lonely. The provider said it would review the person's care plan and the report records that this was fed back.
“They don't seem to get off the ground. It can be a bit lonely and people can be at a loose end.” from the report
Daily documentation
minorThe registered manager was still supporting staff to improve the quality of daily records. Families may want to ask how this work is checked.
“The registered manager told us that they were currently supporting the staff to improve on the quality of daily documentation.” from the report
- 01How do you make sure there are enough staff when sickness causes gaps in the rota?
- 02What weekend activities are currently provided, and how do you include people who stay in their rooms?
- 03How do you check that daily care records are complete and of good quality?
- 04How are care plans updated when a person's needs, choices or risks change?
- 05How will relatives receive regular updates about their family member's care?
This was a planned, unannounced inspection covering all five CQC questions and infection prevention and control, following an earlier Requires Improvement rating. This explanation was written from the published report of 6 November 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 Wykeham House
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2015Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
77 live-in carers within about an hour of Surrey
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 66 can care for a couple. 11 years' experience on average.
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
“Not only has she looked after him beautifully, she has also been great company for him with lively conversation, kindness and humour.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.