23 May 2022
During an inspection looking at part of the service
Wilford View Care Home is a purpose-built residential care home providing accommodation and
personal care for up to 83 people, including people living with dementia over three floors. At the time of the inspection 61 people were living at the service.
People’s experience of using this service and what we found
The risks to people's health and wellbeing were not always clearly documented, assessed or managed. People's records were not always detailed or up to date. People were at increased risk of harm because lessons were not always promptly learnt from incidents that occurred at the service.
There was enough staff to meet people’s needs. However, staff turnover, including management staff, was high. This prevented people and their relatives from building rapport with the staff. People and their relatives told us the support from the agency staff, “Was not the same,” as from the permanent, long standing members of staff. Some people and relatives said the agency staff did not know people well enough to provide good quality, person-centred care.
People were at increased risk of not having their medication administered correctly because their care plans were not always clear. The application of barrier creams to prevent skin from getting sore was often not documented.
People were at increased risk of catching and spreading infections, because staff did not always wear their PPE correctly.
People and their relatives were concerned about the management of the service. They noticed the lack of consistency and opportunities to express their feedback. The service was not led effectively because the systems and processes to monitor the service were not implemented or used efficiently. As a result, the quality of care was negatively impacted upon.
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
The last rating for this service was good (published 13 May 2021).
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.
The inspection was prompted in part due to concerns received about a high level of safeguarding incidents at the service. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only.
The information CQC received about the incidents indicated concerns about the management of risks to people’s health and wellbeing. This inspection examined those risks.
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 requires improvement 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 report.
You can see what action we have asked the provider to take at the end of this full report.
We requested the provider to immediately mitigate the urgent risks identified during the inspection and to provide us with an action plan on how other shortfalls will be addressed. The provider had taken agreed actions to mitigate the risks.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Wilford View 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 monitor the service and will take further action if needed.
We have identified breaches in relation to safe care and treatment and the governance 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.