Welby Croft Residential Home

Updated 19 March 2021

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 Care Act 2014.

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

This inspection was completed by one inspector.

Service and service type

Welby Croft is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This inspection was unannounced.

What we did before the inspection

The provider did not complete the required Provider Information Return. This is information providers are required to send us with key information about the service, what it does well and improvements they plan to make. We took this into account in making our judgements in this report. We sought feedback from the local authority and professionals who work with the service. We reviewed information we held about the location from notifications. We used all of this information to plan our inspection.

During the inspection

We spoke with five members of staff including the, registered manager, the deputy manager, senior care workers, and the housekeeper. We reviewed a range of records. This included four people’s care records and multiple medication records. We spoke with one professional who regularly visited the service. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and schedules.

After the inspection

After the inspection we contacted five relatives who had people using the service by telephone to obtain their views. We also contacted four care staff who were not on shift at the time of the inspection. We continued to seek clarification from the provider to validate evidence found. We looked at training data, quality assurance records and additional policies and procedures.

Updated 19 March 2021

About the service

Welby Croft is a residential care home providing personal and nursing care to 17 people aged 65 and over at the time of the inspection. The service can support up to 24 people.

The home is set across two floors, with bedrooms on both levels. There are communal spaces including a dining room. The garden offers a secure space with seating and there is a conservatory with views of the local area.

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

The provider used a range of audits and systems to monitor the service; however, these had not always identified areas which required improvement. Staff had received training in many areas, however recent training in relation to COVID-19 had not been done or training in relation to specific health conditions.

Risk assessment had not always been completed to cover all aspects of people’s care. These had not been reviewed or monitored to consider changes in the risk or how to reduce it.

People felt supported by kind and caring staff who had information to enable them to share their daily needs or life history. The care plans had been completed, however the provider told us they were making developments in this area to make these more person- centred. This was with the introduction of electronic care planning system.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

There was a relaxed atmosphere in the home and people enjoyed the lunchtime experience. Assistance was provided if required and there were many choices to promote people’s dietary needs.

People and relatives were consulted on aspects relating to the home and the care people received. The staff worked in partnership with health and social care professionals to support peoples ongoing needs.

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 12 January 2019)

Why we inspected

The inspection was prompted in part due to concerns received about infection control and managing risks. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe and welled 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 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.

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