Welshwood Manor

Welshwood Manor is a residential care home providing accommodation and personal care for up

to 34 people, including people living with a physical disability. At the time of the inspection, 26 people were living at the service. Welshwood Manor is in a residential area of Colchester, in 1 adapted building set out over 2 floors.

People’s experience of using this service and what we found

People received safe care and treatment from staff who knew them well and understood their needs, including how to manage and reduce known risks. Staff had received training in safeguarding and health and safety. There were sufficient staff deployed across the service to meet people's needs and ensure their safety and safe recruitment practice was used when new staff were employed. Medicines were managed safely and people received their prescribed medicines when they needed. Infection prevention and control measures were used, to reduce the risk of cross contamination. Incidents were reviewed and analysed to consider what lessons could be learnt to reduce further risks and ensure improvements in service delivery were made.

The service was well-led and focused on providing person-centred care for people. The management team were visible and involved in providing care and clearly knew people well. Systems were in place to regularly monitor the service provided. Staff felt supported by the registered manager and their thoughts on the service were sought. People, their relatives and staff engaged in how the service was run through meetings, the use of surveys and day to day conversations with the registered manager and the staff team. There was a strong emphasis on continuous improvement and development of the service. The registered manager worked in partnership with others to make sure people received appropriate safe care and support.

The provider and registered manager operated effective governance systems to ensure the quality, safely and improvement of people’s care. Regular audits were undertaken of all aspects of the service to review the quality of care and identify where improvements were needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 (2 February 2023) and there were breaches of regulation. 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.

Please see the safe and well led sections of this full report.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

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 based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Welshwood Manor on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Welshwood Manor is a residential care home providing personal and nursing care to 27 people aged 65 and over at the time of the inspection. The service can support up to 34 people in one adapted building over two floors.

People’s experience of using this service and what we found

The provider had not ensured effective systems were in place to provide full oversight of the service. Audits had not fully identified or addressed quality and safety concerns. Medicines were not managed safely as staff did not always follow agreed processes. Fire safety risks to people were not always well managed.

The provider completed relevant recruitment checks for new staff; however, minor improvements were needed in the staff recruitment files to ensure they met with the requirements of the regulation. People were protected from the risk of abuse. Staff knew how to identify signs of abuse and felt comfortable raising concerns with the manager.

People told us they we happy and felt safe living at Welshwood Manor. Peoples relatives were complimentary about the care their loved one received. Staff spoke with confidence about the leadership of the home.

We observed staff interacting meaningfully with people. They appeared to know people well and anticipated their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 (24 November 2021), The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

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 the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 23 November 2022. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve systems in place to monitor the quality and safety of the service.

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. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We also 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Welshwood Manor on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to medicine management, management of risk and the providers governance and quality monitoring processes at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections has been included at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Welshwood Manor is a residential care home providing personal and nursing care to 28 people aged 65 and over at the time of the inspection. The service can support up to 34 people in one adapted building over two floors.

People’s experience of using this service and what we found

Quality assurance and governance of the service was not as effective as they should be in identifying shortfalls. As a consequence of our findings, the new manager was putting more robust systems in place. Risks to people’s safety and wellbeing were not always properly assessed and documented. These did not give staff clear guidance on how to safely care for people and meet their needs. However, staff demonstrated they knew people well, and a new care planning system had been purchased to allow for greater detail and oversight of people’s records and care plans.

We have made a recommendation about assessing and documenting risks to people.

Staff recruitment did not always follow best practice guidelines, the provider had not obtained complete employment histories for all staff. We received mixed feedback about staffing levels, whilst there were enough staff to meet peoples needs, people told us they sometimes have to wait a while for assistance. People were protected from abuse, staff were trained in how to keep people safe. People received their medicines as prescribed, and people were protected by the providers infection and prevention control measures. The provider had made changes to the building to accommodate safe and meaningful visitation from relatives and friends during the ongoing pandemic.

People and relatives spoke highly about their experiences with Welshwood Manor. Staff treated people with dignity and respect and were described as, “Lovely and very caring.”. One relative told us, “People are always given a choice and not treated like children.” People and their relatives were regularly invited to share their thoughts and opinions on the service via surveys, which are reviewed and used to improve people’s experience of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was ‘Good’ (published 04 December 2019).

Why we inspected

This was a planned inspection based on the previous rating.

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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to governance and oversight of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Welshwood Manor is a residential care home providing personal and nursing care to 26 people aged 65 and over at the time of the inspection. The service can support up to 34 people in one adapted building over two floors.

There was not a registered manager. The previous registered manager de-registered in December 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had recruited a new manager but they had not yet submitted an application to register with the Commission.

People’s experience of using this service and what we found

People and their relatives spoke positively about Welshwood Manor. Staff were kind and caring in their approach and treated people with dignity and respect. People and or their representative were involved in decisions about their care and support and how they would prefer staff to deliver it.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff had a good working knowledge of how to keep people safe and promote their rights.

There were enough staff with the right skills and competence to support people effectively and respond to their needs. There was a strong emphasis on putting people at the heart of the service, promoting good practice and a well-developed understanding of equality, diversity and human rights.

Arrangements were in place to routinely listen and learn from people’s experiences, concerns and complaints. People, relatives and staff spoke positively about the new manager and said they had trust in them to manage the service well. They were continuing to develop effective quality monitoring processes to check the quality and safety of the service and drive improvement. The new manager had already found improvement was needed to ensure care records showed how the service was fully supporting people in a personalised way and how they should be responding to a change in needs and associated risk.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 22 October 2018). At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Welshwood Manor is a care home which provides accommodation, personal care and nursing for up to 34 older people who may also be living with dementia. 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 care home accommodates up to 34 older people with nursing needs in one adapted building comprising of two floors. At the time of our inspection there were 19 people living at the service.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was in the process of standing down from their post and a new manager recruited who would be starting their employment in October 2018.

At the last inspection carried out in November 2016 the service had an overall rating of ‘Good’. At this inspection we found there was a need for improvement and the overall rating of the service was now ‘Requires Improvement’.

Whilst we found a number of health and safety audits in place, there was a lack of overall governance systems to ensure the safety and quality of the service was maintained and risks to people's safety identified with steps taken to mitigate these risks. For example, in relation to the ongoing assessment and review of risks, management of people’s medicines, staff training and the management of incidents and accidents. The lack of supernumerary hours allocated to the registered manager to enable them time away from working ‘hands on’ shifts had impacted on their ability to have sufficient time to support effective oversight, planning and development of the service. The registered provider told us this shortfall had been identified and the new manager, would be employed to work only supernumerary hours to enable them time to develop the service and improve systems and processes to ensure effective oversight of the service.

There was an open and transparent culture with a willingness to learn from incidents and respond to the shortfalls we identified at this inspection. For example, environmental risks we identified such as unsecured wardrobes, risks of scalding from hot surfaces and lack of bed rails checks were responded to promptly once brought to the registered manager’s attention.

Staff had been trained in safeguarding and understood their responsibility to protect people from avoidable harm and abuse. Care was provided from a stable staff team with enough staff of varying skills on duty to support people’s needs. Staff had been recruited as required with relevant checks carried out before they started work.

The premises were well maintained, clean, secure with infection control systems in place. Work had been carried out to improve the premises with building extensions to create larger rooms for people with refurbished bathrooms and en-suites.

Consent to care and treatment was sought in line with legislation and guidance. Staff understood the requirements of the Mental Capacity Act (MCA) 2005 and put this into practice. People received care and support from kind staff who sought their consent and respected their privacy and dignity.

People were protected from the risk of poor nutrition and dehydration. Health care needs were met and where specialist support was needed referred in a timely manner to other healthcare professionals.

People’s needs were assessed on admission to the service and care plans in place to guide staff in meeting people’s needs. Support was flexible and staff responded to individual needs and enabled people to access activities of their choosing. People were consulted as to their wishes in planning for their end of life care.

There was a complaints policy and process in place. However, there were no complaints recorded as received. People told us they would not hesitate to complain and felt confident their concerns and complaints would be responded to appropriately.

Further information is in the detailed findings below.

The service is registered to provide accommodation for persons who require nursing or personal care for up to 34 people who are elderly and physically frail. On the day of the inspection we were informed that 31 people were using the service.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

People were kept safe by staff that could recognise signs of abuse and potential abuse and knew what to do to raise safeguarding concerns. Risk assessments and management plans were developed with people using the service and the multi-disciplinary team of healthcare professionals, nursing and care staff working at the service.

Robust recruitment procedures ensured that only suitable staff were employed to work at the service. Staff did not start working at the service until all of the necessary pre-employment checks had been carried out. The staffing levels at the service ensured there was sufficient staff available to meet people's care and treatment needs.

Robust medicines administration and monitoring systems were in place to ensure that

people received their medicines safely.

All staff were provided with comprehensive training based on best practice and staff supervision and support systems were embedded into the service.

People were fully supported to make decisions about their care and treatment. The registered manager and staff team were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People's capacity to consent to their care and treatment was regularly assessed and any restrictions placed on people's liberty was legally authorised using the least restrictive means.

People's nutritional needs, including those relating to their culture and religion, were identified, and

accommodated. People attended healthcare appointments and they had good access to a range of

healthcare professionals.

Staff treated people with kindness and compassion and people's rights to privacy and dignity were fully respected. Each person had a named keyworker and an independent advocacy service was used by people using the service.

Visitors were welcomed and facilities were available for people to meet their visitors in private.

People's care and treatment needs were fully assessed on admission to the service and the care plans reflected their current needs.

People using the service, relatives and staff were aware of the complaints procedure. Complaints raised with the service were responded to and investigated in line with the complaints procedure.

The ethos of the service promoted an open and inclusive environment where people's

views mattered. Systems were in place for people using the service and staff to provide feedback on how the service could improve. Internal quality monitoring management systems ensured that all aspects of the service were regularly reviewed to identify areas to drive continuous improvement.

We found that the service was safe. There were sufficient staff and care plans contained good information that was up to date and based upon risk assessment and need.