Welbourn Manor Care Centre

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.

Welbourn Manor Care Centre is a residential care home providing accommodation and personal care to 21 people aged 65 and over at the time of the inspection. The service can support up to 31 people.

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

People were not always protected from abuse. Monitoring from the registered manager around staff practices, had allowed a poor staff culture to develop at the service. The provider’s whistle blowing processes had highlighted concerns and the provider had acted swiftly to address the concerns to ensure people’s ongoing safety.

The risks to people’s safety were not always well managed. People’s falls were not managed safely. Fire safety information was not up to date. Management of people’s medicines was unsafe. People were exposed to environmental risks as some sluices and a cupboard containing COSHH chemicals were not locked. Staff recruitment processes were not always robust.

There was a lack of registered manager oversight in several areas of care, this included staff behaviour and practices and management of day to day care and treatment.

Quality monitoring tools had not been used effectively and had impacted on the care people received.

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 Good (published 23 March 2020).

Why we inspected

We received safeguarding concerns regarding the people living at the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make improvement. 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.

The provider took steps to ensure people’s ongoing safety at the service following our inspection

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

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safeguarding, management of risk, monitoring the quality of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Welbourn Manor Care Centre is a residential care home providing personal and nursing care to 19 people aged 65 and over at the time of the inspection. The service can support up to 31 people.

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

People were supported by a group of staff who knew their needs and had appropriate training for their roles. They lived in a safe, well maintained environment. The risks to their safety were assessed and managed to enable them to remain as independent as possible whilst staying safe. People’s medicines were well managed, and they were protected from the risks of infection. Their nutritional and health needs were well managed.

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.

People were treated with care and respect, and their views on their care were listened to. Staff showed a good awareness of supporting people’s privacy and improving their independence.

People received person centred care in a way of their choosing. Their care plans reflected their needs and staff had a good knowledge of people’s needs. People were supported to engage in social activities of their choice. People told us they had no complaints, however there were processes in place to deal with any should they arise.

The service was well-led and the management team worked in an open way with people, their relatives, staff and health professionals to provide a good quality of life for people. There were quality monitoring processes in place to monitor practices and maintain good standards of 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 (published 18 January 2019).

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 improvement had been made and the provider was no longer in breach of regulations.

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.

There was a registered manager in post who was available throughout the inspection. 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.

Environmental risks had not always been assessed and measures put in place to reduce risk to protect people at the service. Although individual risks to people’s safety had been assessed, there was a lack of information in people’s care plans to provide guidance for staff to provide appropriate care to reduce ongoing risks to people’s care. The information was not always up to date and although nationally recognised assessment tools were used to assess people’s needs, the guidance in the tools was not always used to provide people with the level of care required.

Staffing levels, especially at night did not reach the established number identified to provide consistant safe care. People were not always protected from the risks of cross infection ,as staff were not always provided with timely training and support to undertake their roles.

People were protected from potential abuse as staff were aware of their responsibilities to keep them safe and there were clear processes for managing safeguarding concerns. However the service did not always show learning from incidents and accidents to ensure a reduction in reoccurance of incidents. People’s medicines were managed safely.

People were supported to maintain a healthy diet, with staff showing good knowledge of people’s nutritional and health needs. They received support to manage their health needs through well-developed links with local health professionals. The environment people lived in was not always well maintained to meet the needs of the people who lived there.

Staff sought consent from people before caring for them. However, the principles of the Mental Capacity Act, 2005 (MCA) were not always followed. There was a lack of clear assessment of people’s mental capacity to show they were receiving the most appropriate support to have maximum choice and control of their lives, and be supported in the least restrictive way possible.

People at the service, and relatives were treated with kindness and care by staff who supported people with respect and dignity. however there were times when people’s views and opinions on their care was not considered in line with their choices, and care was delivered in a task orientated way.

People could maintain relationships with people who were important to them, and relatives felt their views and opinions about their loved one’s care were listened to.

The care people received was not always person centred and their care plans lack sufficient detail to support staff to meet people’s individual needs. People were supported to take part in a range of social activities to prevent isolation. Their wishes in relation to their end of life care were discussed with them so their wishes were known. There was a complaints procedure in place and people knew who to complain to should they have any issues.

The service was not always well led, the registered manager was visible and supportive towards people, their relatives and the staff who worked at the service. However, there was a lack of consistant support from the senior management team, and the quality assurance systems in place were not used effectively to monitor performance and quality of care.

The home was run by a company who was the registered provider. There was a registered manager 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. In this report when we speak both about the company and the registered manager we refer to them as being, ‘The registered persons’.

At the last inspection we carried out the home was rated ‘Good’.

At this inspection we saw that the registered manager had made our last inspection report available for people who lived in the home and visitors to see and read. We also found the provider had ensured their website contained the current rating for the home.

During this inspection we found some areas in which improvement was needed to ensure people were provided with care that was safe, effective, responsive and well-led and that the provider's regulatory responsibilities were being met in full.

This was because the registered provider had not ensured the arrangements for the safety, and maintenance of the building were consistently being planned for and managed.

Care staff had not received all of the training they needed to ensure they could meet people’s needs in an effective way.

People were supported to make decisions for themselves. However, when people needed additional help to make specific decisions about how care was provided, the detail about which decisions had been made and by whom had not been fully reflected in the care records. In addition, care plan reviews did not give clear enough information about the effectiveness of the care being provided, who had been involved in the reviews or any actions planned or taken after reviews had been completed.

The provider’s quality assurance and audit systems were also not reliably or consistently managed so as to enable them to quickly identify and resolve shortfalls in the services provided for people.

In other areas, the registered persons were meeting people’s needs effectively.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s daily life were assessed and planned for to protect them from harm.

People were supported by enough staff to ensure they received care and support at the times they needed it. Medicines were managed safely and people received their medicines as prescribed.

People were supported to maintain their nutrition and staff were monitoring and responding to people’s health conditions.

People’s emotional needs were recognised and responded to by a staff team who cared about the individuals they were supporting. People were able to enjoy a social life and to develop and maintain their interests.

People were invited to give their views on how the service was run.

As part of our inspection visit we spoke with six people who used the service and three visiting relatives about their view of the home. We also spoke with four staff members and the registered manager.

One person said, 'There is plenty of heating and water. I like the place and it feels homely.' A visiting relative said, 'We as a family are very happy with the care given to xxx.'

We spoke with three staff members who said they felt they had enough time and support to care for people and respond to their changing needs.

We saw systems for staff recruitment were safe and the proper checks were carried out in advance before any new staff member started to work at the home.

Overall we found the service was well led and the manager had training and supervision arrangements in place to support staff to enable them to carry out their work safely.

We also found there was an effective system in place for the provider to monitor and assess the quality of services within the home.

We saw staff had time to interact with people and were attentive to people's needs. Their interaction with people was friendly, respectful and professional.

We saw the cook provided a choice of hot and cold foods at each mealtime. One person said, 'The food is good, really good.'

We looked at how the premises had been maintained. One staff member told us, 'The building is really well looked after, it's so old but they keep it really nice.'