Background to this inspection
Updated
26 November 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 was completed by 2 inspectors, a pharmacist specialist and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service.
Service and service type
Welbourn Hall Nursing Home Care is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Welbourn Hall Nursing 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 a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with 3 people who use the service and 5 relatives to ask about their experience of the care provided. We observed staff interaction with people who use the service.
We also spoke with the registered manager, the director, two nurses, the registered managers assistant, a senior, 3 care staff, the cook and a domestic.
We looked at 14 care files along with a range of medication administration records. We looked at other records relating to the management of the service including staff recruitment, audits, health and safety, policies and procedures, meeting records, incidents and staff training and deployment.
Updated
26 November 2022
About the service
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.