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Inspection carried out on 16 October 2019

During a routine inspection

About the service

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

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.

Inspection carried out on 20 September 2018

During a routine inspection

This comprehensive inspection was unannounced and took place on the 20 September 2018.

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

Inspection carried out on 9 November 2016

During a routine inspection

This inspection took place on the 9 November 2016 and was unannounced.

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.

Inspection carried out on 22 May 2013

During a routine inspection

We found that this service was caring and respected peoples choices. People told us that they experienced good care. One person said, “The staff are very caring. We all like to have a laugh together.” One relative told us how the manager had been responsive and spotted a critical condition of their relative. Overall we found that the service was well led. Everyone we spoke with liked and praised the manager of the service stating that they were approachable and effective. One relative said, “I have confidence and trust in the manager and staff.”

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.

Inspection carried out on 19 July 2012

During a routine inspection

People we spoke with told us that they were very happy with the care and support

that they were receiving at Welshwood Manor. They told us that the staff were

always friendly and cheerful and were also always very polite and respectful when

supporting people.

People told us that the meals provided were always very nice and there was always a pleasant choice made available.

People also told us that they were very happy with the accommodation provided at Welshwood Manor and they really enjoyed accessing the lovely garden areas when the weather permitted.

Reports under our old system of regulation (including those from before CQC was created)