Archived: Welbourn Hall Nursing Home

Welbourn Hall is a residential and nursing care home providing personal and nursing care to 32 people aged 65 and over at the time of the inspection. The service can support up to 40 people. Welbourn hall has been converted into a care home and is divided into two units. The accommodation is spread over two floors.

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

People’s prescribed medicines were not managed safely. This included the ordering, administration, monitoring and guidance available for staff.

Risks associated with people’s individual care needs were not consistently assessed, monitored and reviewed. Guidance for staff about how to mitigate risks were not consistently up to date and reflective of current needs.

Staff deployment was not sufficient in one part of the home. The provider took action and increased staffing levels. The staff training matrix showed gaps in all refresher training and nursing staff had not completed clinical training. Staff were recruited safely.

Staff knew how to report any safeguarding concerns, but guidance for staff on how to manage and mitigate known risks of harm and harm to others was limited.

Incidents were not effectively monitored and analysed to enable learning to reduce further risks.

The systems and processes to assess, monitor and improve quality and safety were ineffective. There was limited continuous learning to make improvements.

People and their relatives and representatives received limited opportunities to share their experience about the service they received.

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.

Overall infection prevention and control practice was good and the service was clean and hygienic.

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 1 September 2021).

Why we inspected

We received concerns in relation to the management of medicines. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led. only. 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 good to inadequate based on the findings of this inspection.

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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Welbourn Hall Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to how risks were assessed and managed, how medicines were managed, staff deployment, staff training and competency, the systems and processes that monitored the service and management oversight and leadership.

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Welbourn Hall is a residential and nursing care home providing personal and nursing care to 34 people aged 65 and over at the time of the inspection. The service can support up to 40 people.

Welbourn hall has been converted into a care home and is divided into two units. The accommodation is spread over two floors.

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

People lived in a safe, well maintained environment. The risks to their safety were assessed and appropriate measures in place to support their ongoing safety. They were supported by a caring and knowledgeable staff group and the registered manager continued to work to recruit staff to ensure people’s needs were met.

Staff managed people’s medicines safely and in line with their preferences. Staff were knowledgeable of and practiced safe infection control and prevention practices. Staff were aware of how to protect people from abuse, and when necessary the registered manager investigated and promoted learning from events.

Staff received regular supervision and training to support them in their roles. People’s 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 received person centred care from a group of caring staff who treated them with respect and dignity. Although people felt there could be more social activities the registered manager continued to work to address this.

There was a clear complaints process in place. There had been improvements to the quality monitoring processes which supported a good oversight of the service for the registered manager and provider.

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 (12 January 2021) and there was a breach of regulations.

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.

This service was registered with us on 10 January 2020 and this is the first comprehensive rated inspection of the service.

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.

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

Welbourn Hall Nursing Home is a residential care home providing personal and nursing care to 36 people aged 65 and over at the time of the inspection. The care home can accommodate 40 people in one building. The building is divided into two areas one of which provides care to people living with dementia.

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

Staff had access to personal protective equipment and followed national guidance around donning and doffing. However, we found staff were not consistently wearing masks in a safe manner. The service was clean and there were effective cleaning schedules in place being followed by the housekeeping staff.

Quality monitoring arrangements were in place, however these did not identify issues we found at inspection. Documentation and care plans were not consistently updated.

People’s medicines were not consistently managed in a safe manner.

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 did not support this practice.

The risks to people’s care were assessed and measures were in place to mitigate these risks.

People were supported with adequate numbers of staff who had received training for their roles. Staff were recruited safely. Staff knew how to keep people safe from abuse and were confident to raise concerns with the registered manager or external agencies. When required, notifications had been completed to inform us of events and incidents.

People and their relatives knew how to raise a complaint and would feel confident to do so if needed.

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 the service under the previous provider was Good, published on 4 July 2019.

Why we inspected

We received concerns in relation to people’s nursing care needs. 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. We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

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 coronavirus and other infection outbreaks effectively.

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.