Welshwood Manor

Registration details

The location ID for Welshwood Manor is 1-109740645.

CQC register Welshwood Manor to carry out these legally regulated activities. Contact us if you think Welshwood Manor is operating services not listed here.

Type of service

• Residential homes

Service specialism

• Caring for adults over 65 yrs
• Caring for adults under 65 yrs
• Physical disabilities

Local authority

Essex

Monitored services

CQC register Welshwood Manor to carry out the following legally regulated services here:

Accommodation for persons who require nursing or personal care

Mr Christopher Reneham is responsible for these services.

Condition of this registration relating to carrying out this regulated activity

The Registered Provider must not admit any new service user to Welshwood Manor 37 Welshwood Park Road, Colchester, Essex, CO4 3HZ (Welshwood Manor) without the prior written agreement of the Commission. This includes respite care packages and emergency admissions.

By 27 October 2025, the Registered Provider must submit:
a) comprehensive environmental risk assessment specifically addressing risks associated with the use of and/or access to all staircases in Welshwood Manor
b) Written confirmation and evidence about how the following environmental risks have been addressed:
i) Installation of appropriate window restrictors;
ii) Completion of an up-to-date fire risk assessment;
iii) Completion of an up-to-date gas safety certificate.
c) Evidence that effective systems are in place to monitor, mitigate, and manage environmental safety risks on an ongoing basis, including clearly defined timescales for addressing any identified shortfalls and ensuring continued compliance.
d) Evidence that the risks associated with service users care including diabetes, skin integrity and nutritional risks have been assessed
e) Evidence that each care plan has been reviewed and updated accordingly, including all identified medical needs such as diabetes
f) All staff involved in delivering care have been informed of the updated care plans and understand the measures required to mitigate identified risks
g) A written report setting out the current organisational structure, including clearly defined roles and responsibilities. This must include details of the arrangements in place for the Registered Manager and how effective oversight and governance are being maintained. The report must demonstrate how the provider monitors the quality and safety of care delivered by staff.

The registered provider must produce an action plan to reflect the shortfalls found in the service and provide the Commission with a weekly update on how these are being rectified by 12 noon on each Monday of the week commencing 27 October 2025. This report must specify when the actions have been, or will be, completed and highlight who is responsible to ensure that the required improvements are made.

The Registered Provider must provide the Care Quality Commission with an action plan by 20 May 2026, setting out the actions taken or to be taken in relation to Service Users at risk of choking. The plan must also include the following:
a. details of the system(s) and processes that are implemented specifically to address risk associated with choking,
b. details of named individuals responsible for the actions including timeframes
c. details of relevant and suitable staff training for all staff particularly kitchen staff

The Registered Provider must develop and implement an effective system and/or process for the management of risk assessments in particular regards but not limited to risk of choking; this is to include:
a. urgent review of all current care plans
b. process for regular monitoring of risk assessments in particular when Service User needs change
c. details of how staff have the most current (up- to -date) plan for each Service User

The Registered Provider must develop and implement an effective system and/or process for the management of Service Users with potential risk of choking at mealtimes. The process should include but not limited to:
a. To ensure that information about the food and fluid consistency is correctly recorded to support Service User safety
b. Food is prepared in line with service user needs in line with International Dysphagia Diet Standardisation Initiative (IDDSI) levels.
c. Positioning and safe assistance to eat techniques are correctly recorded to support Service Users’ safety and
d. Any changes are promptly recorded and cascaded to all staff.

The Registered Provider must ensure all staff, including kitchen and agency staff, have the skills, knowledge and competence to support those Service Users safely in relation to safe consumption of food and drink in line with your action plan.

The Registered provider must ensure all care staff and kitchen staff, including the chef, have had suitable International Dysphagia Diet Standardisation Initiative (IDDSI) training to safely prepare, modify and serve food and drink to Service Users who have dysphagia or who are at risk of choking.

The Registered Provider must provide the Care Quality Commission with a report setting out the actions taken or to be taken in relation to the above conditions, by the first Monday of every week, or a Tuesday when this falls on a bank holiday. The report must also include the following:
a. details of the system(s) and processes that are implemented to comply with the conditions,
b. detail of action taken to incidents involving choking, with prompt review and learning.
c. details and confirmation of action taken to ensure the system(s) are being audited and monitored to improve the quality and safety of services.

Terms of this registration relating to carrying out this regulated activity

The Registered Provider must only accommodate a maximum of 34 service users at Welshwood Manor.

The Registered Provider must not provide nursing care under accommodation for persons who require nursing or personal care at all locations.