Background to this inspection
Updated
3 March 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.the inspection tool place on 13 January 2022
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The service was inspected by two inspectors. Following our visit, we used an Expert by Experience to make calls to relatives of people who used the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Welbourn Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager who had applied to become registered with the Care Quality Commission for this service. We will continue to monitor this application.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service about their experience of the care provided. We spoke with seven members of staff including the Clinical Director for the provider, the manager, the deputy manager, three care staff and the cook.
We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to interrogate records and seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke by telephone with nine relatives about their experience of the service.
Updated
3 March 2022
About the service
Welbourn Manor is a residential care home providing personal and nursing care for to up to 31 people. At the time of our inspection there were 16 people using the service. The care home accommodates people in one adapted building across two floors.
People’s experience of using this service and what we found
Some aspects of infection control screening processes were not robust. However, staff followed safe infection control practices when supporting people.
People were protected from the risk of abuse as there were clear processes in place to investigate any allegations made, and staff understood their responsibilities in safeguarding people in their care.
The risks to people’s safety were monitored and measures were in place to manage these risks. The manager had processes in place to learn from events, incidents and accidents at the service. People’s medicines were managed safely. People were cared for by staff who had the necessary skills and knowledge to safely support them. We were told there had been some concerns over staffing numbers. However, the provider had been responsive and was continuing to recruit to vacant posts. On the day of our inspection there were enough staff to support people.
The service was well led, the provider had worked to ensure there was clear management support following a period of unsettlement at the service. A new manager was in post. People, relatives and staff told us the manager was open, visible and supportive. There was a clear person-centred approach to the care people received, which was supported by staff, the manager and senior managers for the provider.
There were clear quality monitoring processes in place which had positively impacted on the care people received. The provider notified CQC of events in line with their registration responsibilities. The staff at the service worked with health professionals to effectively support people in their care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement and there were multiple breaches of regulations (published 9 November 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.
We carried out an unannounced focused inspection of the two key questions Safe and Well Led at this service on 6 October 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding service users from abuse and improper treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Welbourn Manor on our website at www.cqc.org.uk.