Cullum Welch Court Care Home

Updated 6 October 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 Health and Social Care Act 2008.

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 inspection team consisted of two inspectors, a specialist professional advisor and Expert by Experience. The specialist advisor was a qualified nurse. 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

Cullum Welch Care home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Cullum Welch Care home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 26 July and ended on 3 August 2022.

What we did before the inspection

We reviewed the information we held about the service which included concerns about the service, notifications of events and incidents at the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We also reviewed the report from Healthwatch following their visit to the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spoke with four people, 10 relatives, nine care staff members, two nurses, the manager and the director of care. We looked at six people’s care files, medicines management records, seven staff supervision records, training matrix, incidents and accidents, quality assurance reports and other records relating to the management of the service, including safeguarding and complaints records. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We received feedback from two members of the local commissioning team.

Updated 6 October 2022

About the service

Cullum Welch Court Care Home is a care home providing personal and nursing care to up to 60 people across three separate units over two floors, each of which have separate adapted facilities including dining rooms and sitting areas. At the time of our inspection, there were 32 people were using the service some of whom had dementia and nursing needs.

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

Staff were not supported and supervised to be effective in their roles. People were supported with their needs. However, care plans did not always explore best possible ways to meet people’s individual needs. Staff did not get the leadership they needed as there was inconsistency in management. There was high turnover of staff and managers which had affected the quality of the service and staff performance.

Risks to people were managed to reduce harm to them. There were management plans in place that provided guidance to staff to reduce risks to people. People were safeguarded from the risk of abuse. Staff had received safeguarding training and knew actions to take to report abuse.

Incidents and accidents were reviewed, analysed and actions taken to ensure learning from them. People’s medicines were administered and managed safely. There were enough staff available to support people. Staff were trained in infection control and followed procedures to reduce risks of infection.

People’s needs were assessed in line with best practice guidance. People’s nutritional needs were met. People were supported to eat a balanced diet and drink enough to keep hydrated. Staff had an induction when they started their jobs; and had received training in their roles. People had access to the healthcare services they needed to maintain good health; and staff liaised effectively with other services.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People’s consent was sought for the care and support they received.

The service complied with the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Relatives and healthcare professionals were involved in making decisions for people in their best interests where this was appropriate.

People’s end-of-life wishes were documented in their care plans and followed when required. People were supported and encouraged to participate in activities they enjoyed.

People and their relatives knew how to raise complaints about the service. Complaints were appropriately addressed in line with the provider’s procedure. The provider worked in partnership with other organisations and services to develop and improve the service. The service had effective systems to monitor the quality and safety 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 26 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the management of the service, staffing, poor care, safeguarding concerns and medicine management. A decision was made for us to inspect and examine those risks. We carried out a comprehensive inspection looking at all five domains.

We have found evidence that the provider needs to make improvement. You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

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.