Welbourn Hall Nursing Home

Updated 13 June 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

This inspection was completed by 2 inspectors, a pharmacy 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 care service.

Service and service type

Welbourn Hall Nursing 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 who was newly registered and had been in post since 1 April 2023.

Notice of inspection

The inspection was unannounced.

What we did before the 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. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 3 visiting relatives and a person's friend for their experience of the service. We observed staff interaction with people, to help us understand people’s experience. We spoke with 12 members of staff, this included the registered manager, the provider, deputy manager, administrator, nurse, senior care staff, team leader, care staff, domestic, the head cook and an activity coordinator. We reviewed in part, 10 people’s care records, 3 staff files, 15 people’s medicine records, and a variety of records relating to the management of the service, including audits and checks, staff deployment, training and supervision records.

Updated 13 June 2023

About the service

Welbourn Hall Nursing Home is a 40 bed residential and nursing care home providing personal and nursing care to people aged 65 and over. At the time of our inspection, 26 people were living at the service and 1 person was in hospital. Welbourn Hall Nursing Home has been converted into a care home and is divided into two areas; The Hall and the Willows and meets the care needs of people with nursing care needs, including people living with dementia. The accommodation is spread over two floors.

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

Medicines management systems and processes had recently changed to an electronic system and new and improved audits and checks introduced. However, people had not consistently received their prescribed medicines when required. Best practice guidance in the management of medicines needed further improvement.

Guidance for staff about people’s individual care, treatment needs and risks were not consistently detailed or reflected current care needs. The registered manager was aware of this had plans were in place to make improvements.

New systems and processes had been introduced to assess, monitor, and review quality and safety. Internal quality assurance procedures were being introduced to gain feedback about people’s experience of the service. Further time was required for new ways of working to fully embed and be sustained. The provider had an ongoing action plan to drive improvements.

Environmental, premises and equipment checks including cleanliness, hygiene and safety were completed. An improvement plan was in place to redecorate and change the flooring. New equipment had been purchased such as new hoists.

Staff deployment was regularly monitored and reviewed to ensure staffing levels were sufficient. Staff had been safely recruited and received opportunities to discuss their work, training, and development needs. Action was being taken to further upskill staff.

People were protected from the risk of abuse and avoidable harm. Action had been taken to further develop the staff’s awareness of external agencies they can report any concerns to in addition to internal procedures.

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.

People were supported with known health conditions, recognised assessment tools were used. Staff worked with external health professionals in monitoring and responding to changes in health needs. People received sufficient to eat and drink.

Staff were caring and understood and knew people’s care and treatment needs, they treated people with dignity and respect.

People’s communication needs and support were assessed and planned for. End of life care wishes were discussed with people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 19 May 2023, and this is the first inspection.

The last rating for the service under the previous provider was Inadequate published on 26 November 2022.

Why we inspected

This inspection was prompted by a review of the information we held about the service.

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.

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 1 breach in relation to medicines management.

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.