Wythall Residential Home

Updated 26 September 2023

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 team consisted of 2 inspectors on the first day and 1 inspector and an Expert by Experience on the second day.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Wythall Residential Home 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. Wythall Residential Home a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A registered manager from one of the provider's other homes was moving permanently to Wythall Residential Home and had applied to become registered with CQC. We are currently assessing their application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the service since the last inspection. We sought feedback from the local authority who commission the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 5 people’s relatives about their experiences of the care provided. We spoke with a registered manager from one of the provider's other homes who was supporting the service, the area manager, general manager, the nominated individual, 3 care staff and the cook. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 3 people's care plans, medicine administration records (MAR) and 3 staff recruitment files. We viewed a variety of records relating to the management of the service

including audit systems.

Updated 26 September 2023

About the service

Wythall Residential Home is a residential care home providing accommodation for persons who require nursing or personal care for up to 22 people. The service provides support to older people. At the time of our inspection there were 17 people using the service.

Wythall Residential Home accommodates people in one adapted building.

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

We carried out a previous unannounced inspection of this service on 27 and 28 July 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance. At our last inspection, improvements were required around medicines management, managing people's risks, risks within the environment, quality of record keeping and quality assurance systems.

At the last inspection we recognised that the provider had failed to appoint a registered manager. This was a breach of regulation, and we issued a fixed penalty notice. The provider paid this in full.

At this inspection we found the provider remained in breach of regulation. The service remains rated requires improvement.

Whilst some improvements to record keeping and managing people’s risks had been made and a new governance system had been implemented, we continued to find improvements were needed in these areas. Systems and processes to safeguard people from the risk of abuse or avoidable harm needed to be more robust. Staff had not always followed the provider’s medicines procedures or national guidance when ordering, administering, or storing medicines. We identified some shortfalls during our inspection.

Feedback we received from people, relatives, and staff we spoke with during the inspection was positive. People told us they felt safe living at Wythall Residential Home.

People and relatives told us the home was managed well and felt confident to raise matters with the managers. The service still did not have a registered manager in post. However a manager had been appointed and was applying to be registered at the time of our inspection.

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.

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 November 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. This service has been rated requires improvement for the last 3 consecutive inspections.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified continued breaches in relation to safe care and treatment, medicines management and good governance.

Please see the action we have told the provider to take 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.