Welshwood Manor

Updated 2 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.

This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 17, good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 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

The service was inspected by 2 inspectors.

Service and service type

Welshwood Manor 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. Welshwood Manor is 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 a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 17 April 2023 and ended on 26 April 2023. We visited the service on 19 and 24 April 2023.

What we did before the inspection

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 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. We used all this information to plan our inspection.

During the inspection

We reviewed a range of records. This included 4 people's care records and medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. We spoke to 5 staff members and the registered manager. We observed the care provided to help us understand the experience of all people.

Following the inspection, we continued to seek clarification from the provider to validate evidence found.

Updated 2 June 2023

About the service

Welshwood Manor is a residential care home providing accommodation and personal care for up

to 34 people, including people living with a physical disability. At the time of the inspection, 26 people were living at the service. Welshwood Manor is in a residential area of Colchester, in 1 adapted building set out over 2 floors.

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

People received safe care and treatment from staff who knew them well and understood their needs, including how to manage and reduce known risks. Staff had received training in safeguarding and health and safety. There were sufficient staff deployed across the service to meet people's needs and ensure their safety and safe recruitment practice was used when new staff were employed. Medicines were managed safely and people received their prescribed medicines when they needed. Infection prevention and control measures were used, to reduce the risk of cross contamination. Incidents were reviewed and analysed to consider what lessons could be learnt to reduce further risks and ensure improvements in service delivery were made.

The service was well-led and focused on providing person-centred care for people. The management team were visible and involved in providing care and clearly knew people well. Systems were in place to regularly monitor the service provided. Staff felt supported by the registered manager and their thoughts on the service were sought. People, their relatives and staff engaged in how the service was run through meetings, the use of surveys and day to day conversations with the registered manager and the staff team. There was a strong emphasis on continuous improvement and development of the service. The registered manager worked in partnership with others to make sure people received appropriate safe care and support.

The provider and registered manager operated effective governance systems to ensure the quality, safely and improvement of people’s care. Regular audits were undertaken of all aspects of the service to review the quality of care and identify where improvements were needed.

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 and update

The last rating for this service was requires improvement (2 February 2023) 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. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Please see the safe and well led sections of this full report.

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. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.