About the service 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.