Welbourn Hall Nursing Home

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