CQC report explained · a residential care home
What the CQC found at Wythall Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found kind care and some progress, but serious weaknesses remained in safeguarding, medicines and management checks.
This was an unannounced focused follow-up inspection on 14 June 2023 and 06 July 2023. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care plans, medicine records, staff recruitment files and management records.
The home remained Requires Improvement for Safe and Well-led. Inspectors found that people generally felt safe and spoke positively about staff, but safeguarding concerns had not always been reported properly. Medicines were not always given, stored or recorded safely. Food storage and infection control also needed improvement.
Some progress had been made since the previous inspection. The home had introduced an audit schedule, an action plan and a planned electronic system. However, the provider remained in breach of regulations and had not fully met the requirements of an earlier warning notice. CQC will request another action plan and monitor progress with the local authority.
People felt safe
People and relatives gave positive feedback about the staff and support. People said they felt safe living in the home.
“People told us they felt safe living at Wythall Residential Home.” from the report
Staffing during visits
Inspectors saw enough staff to provide safe care during their visits, and staff responded to people's needs promptly. Recruitment checks were also in place.
“During our inspection visits we saw there were enough staff to provide safe care and treatment.” from the report
Choice and least restriction
The home was working within the Mental Capacity Act principles. People were supported to make decisions and care was provided in the least restrictive way possible.
“People were supported to make decisions when they were able to.” from the report
Some management improvements
The provider had introduced an audit schedule with named responsibilities and was bringing in an electronic system to support records, audits and communication.
“The provider had introduced a schedule of audits to monitor the performance of the home which was accompanied by an action plan giving named staff responsibility for specific tasks.” from the report
Safeguarding was not always escalated
seriousTwo potential safeguarding concerns had not been referred to the appropriate external agencies or CQC when required. This meant inspectors could not be assured that people were fully protected.
“During the inspection we reviewed 2 potential incidents of safeguarding concern. However, the concerns were not escalated externally to appropriate agencies for further investigation, or to CQC as required.” from the report
Medicines were not always managed safely
seriousOne person did not receive a prescribed medicine for seven weeks without a recorded reason. Inspectors also found unlocked medicines and thickener, inaccurate stock records and incomplete records for medicines given as required.
“One person had not received 1 of their medicines as prescribed for 7 weeks. There was no documented evidence why this medicine had stopped.” from the report
Management checks missed problems
seriousAudits did not always identify the problems inspectors found or explain why repeated medicine errors had happened. Accidents and incidents were not consistently analysed for patterns.
“Systems and processes were not fully embedded to identify and monitor the quality of the service and drive improvements.” from the report
Food storage needed improvement
needs fixingInspectors found out-of-date food and food that was not clearly labelled or stored in airtight containers. The home's own checks had not found these issues.
“We observed food items that had exceeded their use by date and food items which had not been clearly labelled or stored in airtight containers.” from the report
No registered manager was in post
needs fixingThe home did not yet have a registered manager, although a manager had applied to register and was expected to move permanently to the home.
“The service remained without a registered manager; however, management support was being provided internally by experienced managers.” from the report
- 01What checks now make sure every medicine is given as prescribed, stored securely and recorded correctly, including medicines given as required?
- 02How are safeguarding concerns escalated to the local authority and CQC, including concerns that arise outside normal management hours?
- 03How do your audits identify the root causes of medicine errors and analyse accidents or incidents for repeated patterns?
- 04Has the manager's application to become registered with CQC been approved, and who is responsible for the home until then?
- 05How do you cover vacancies and sickness, especially at weekends when relatives reported that staffing could feel more chaotic?
This was a focused follow-up inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous inspection. This explanation was written from the published report of 26 September 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 2022
Rated Requires Improvement; inspectors found ongoing risks with safeguarding, medicines, care records and management, although no evidence of harm was found.
This was an unannounced, focused inspection over two days. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, staff files, medicines, incidents, safeguarding records and management checks.
The home was not always safe. Medicines were not always stored or given as prescribed. Risk assessments were not consistently updated, and potential safeguarding concerns had not been properly escalated or reported. Inspectors found no evidence of harm, but said people were at risk because safety systems were not reliable.
The home was also not always effective or well-led. Some health referrals were delayed, induction records were incomplete, and staff did not always know about authorised Deprivation of Liberty Safeguards. There was no registered manager, several managers had changed, and quality checks had not been effective. Safe, Effective and Well-led were rated Requires Improvement. The overall rating remained Requires Improvement, as at the previous inspection.
Enough staff
Inspectors saw that people did not have to wait long for help and there were enough staff to meet their needs.
“We saw people did not wait long for staff to support them and there were enough staff to meet people's safety and care needs.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Food and drink
People and relatives were positive about meals. Staff supported food preferences, including vegetarian choices and eating in a person's room.
“People were positive about their mealtime experiences and we saw people were encouraged to drink enough to remain well.” from the report
Listening to relatives
Relatives said they were consulted about safety and that their suggestions were listened to. Some described improvements since their family member moved in.
“People's relatives told us they were consulted about their family member's safety and felt their suggestions were listened to.” from the report
Safeguarding concerns
seriousThree unexplained bruising incidents and a cut had not been escalated or reported promptly to the safeguarding team or CQC. Inspectors said this placed people at risk of harm.
“This was a continued breach of regulation 13 (2), (3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Medicines management
seriousChecks on pain relief patches, storage temperatures and opening dates were not reliable. Audits had not identified all these problems.
“People did not always benefit from support to have their medicines administered safely.” from the report
Risk assessments
seriousSome assessments were not updated when people's needs changed. Inspectors also found weak oversight of bowel health, weight loss, choking risks and emergency evacuation plans.
“People's assessments were not consistently updated as their needs changed.” from the report
Delayed health referrals
needs fixingAdvice from GPs and health specialists was not always sought promptly when people lost weight or needed specialist support.
“We found where people experienced weight loss action was not always promptly taken to seek advice from people's GPs.” from the report
Weak management oversight
seriousThere was no registered manager, several managers had changed and no provider audits had been completed for a six-month period. The quality systems did not consistently identify or fix problems.
“The provider's quality and safety auditing systems were not effective, and checks were not regularly done.” from the report
Rights and notifications
needs fixingStaff did not know who had authorised Deprivation of Liberty Safeguards, and some notifications to the CQC were late or had not been made.
“The Care Quality Commission had not always been informed prior to our inspection where the supervisory body had authorised DoLS.” from the report
- 01What changes have you made to ensure pain relief patches, topical medicines and medicine storage temperatures are checked every time?
- 02How are unexplained injuries and other safeguarding concerns now identified, investigated and reported to the local authority and CQC?
- 03Are all residents' risk assessments and personal emergency evacuation plans now updated when their needs change?
- 04Who is currently managing the home, and has the manager applied to become registered with the CQC?
- 05How do you now check that weight loss and requests for GP, speech and language or other specialist advice are acted on promptly?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the overall rating used ratings from the previous inspection for questions not inspected. This explanation was written from the published report of 19 November 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.
Every inspection of Wythall Residential Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2017Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 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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