Wensum Way care home and supported living service was rated Requires Improvement overall, with Safe, Effective and Caring rated Good, but Responsive and Well-Led deteriorating due to incomplete care plan reviews, absent regular person-led meetings, and inconsistent family communication. The registered manager had proactively identified these shortfalls and was taking action, and staff demonstrated strong knowledge of and commitment to the people they supported.
Concerns (6)
moderateCare planning: “Care plans were currently undergoing a review, causing some of the information recorded to not be of the standard we would expect.”
moderatePerson-centred care: “Not all care documents reviewed listed people's gender preferences when being supported with personal care. This created a risk that people may not be being supported by those who they would choose.”
moderatePerson-centred care: “Regular meetings with people supported were not taking place at the time of the inspection.”
moderateGovernance: “Progress had been made but due to unforeseen reasons the progress had not been as extensive as the registered manager wanted and changes had not become fully embedded.”
minorCommunication with families: “Feedback from families was mixed in relation to communication. Some families had maintained regular communication with the service where others felt this was an area that required development.”
minorRecord keeping: “There was no record to indicate where on the body the patch had been applied, causing a potential risk that this item would not be applied as per manufacturer's instructions.”
Strengths
· Medicines were stored securely and well audited; MAR counts completed daily to maintain a clear running balance.
· Staff knew people they supported well and were consistent in reducing risks.
· Full COVID-19 infection prevention and control measures were in place and effectively implemented.
· External healthcare professionals were engaged proactively to support people's wellbeing.
· Staff supported people in a caring, kind and respectful manner; families described carers as 'amazing'.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Engaging and involving people using the service, the public and staff; duty of candourNot rated
well-led: Promoting a positive culture; continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated
Wensum Way, a care home for up to eight people with physical and learning disabilities, was rated Good across all five key questions at its July 2015 inspection. The provider had successfully addressed previous regulatory breaches relating to staffing, consent, care planning and quality assurance, with improvements confirmed across all areas.
Concerns (3)
moderateCare planning: “Overall reviews of care plans were not recorded in detail and it was not clear where any changes to care had occurred as there was only a date and signature and 'no change' recorded.”
minorRecord keeping: “risk assessments were not always cross referenced to the care records and details were not always clear or up to date.”
minorPerson-centred care: “these monthly meetings had not always occurred and that there were a number of gaps. We saw in one person's records that the last three meetings had been held in October and December 2014 and February 2015.”
Strengths
· Sufficient staffing levels maintained, with bank and agency staff available to meet changing needs.
· Medicines safely stored, audited monthly, and administered with competency checks in place.
· Staff trained in safeguarding, MCA and DoLS, and felt confident reporting concerns.
· Person-centred care plans written in easy-read/pictorial formats to aid understanding.
· Positive feedback from relatives, healthcare professionals and local authority care managers.
Wensum Way, operated by FitzRoy Support, was rated Good across all five key questions at its May 2018 inspection, maintaining the rating awarded at the previous July 2015 inspection. No breaches of regulation were identified; the service demonstrated safe medicines management, strong person-centred care planning, effective staff training, and robust quality monitoring overseen by an experienced registered manager.
Strengths
· People felt safe and staff demonstrated clear knowledge of safeguarding responsibilities and abuse types
· Sufficient staffing levels confirmed by people using the service and evidenced in records
· Medicines administered safely with daily audits and stock checks; people received medicines on time
· Staff received comprehensive induction, mandatory training, regular supervision, annual appraisals and direct observations
· Person-centred support plans written in conjunction with people, detailing likes, dislikes and preferences
Quality-Statement breakdown (20)
safe: Safeguarding and risk managementGood
safe: Staffing levelsGood
safe: Medicines managementGood
safe: Infection controlGood
safe: Incident learningGood
effective: Needs assessment and care planningGood
effective: Staff training and competencyGood
effective: Nutrition and hydrationGood
caring: Dignity, respect and privacy
Good
caring: Involvement in care decisionsGood
responsive: Care planning and reviewGood
responsive: Activities and social engagementGood
responsive: Complaints handlingGood
well-led: Leadership and managementGood
well-led: Governance and quality assuranceGood
well-led: Staff engagement and supportGood
effective: Healthcare access
Good
effective: Mental Capacity Act and DoLSGood
caring: Kindness, compassion and dignityGood
caring: Independence and person-centred supportGood