Ensuring ‘Confidence in Care’
through proactive and positive change
Ensuring ‘Confidence in Care’
through proactive and positive change
Thank you for taking an interest in finding out more about all the good work and superb progress that has been underway at Wulfrun Rose since the last CQC inspection, undertaken over 30 months ago.
The following information has been collated to provide transparency and assurance for those considering residential care at Wulfrun Rose for a loved one, to help ensure that such an important choice is fully informed.
About CQC methodology
The CQC is currently undertaking a whole system review of its inspection services, with new methodology yet to be published but expected to come into force in the latter part of 2023.
For the MACC Care Group this means that services are no longer being inspected based on CQC’s frequency model in line with the current gradings.
CQC continues to regularly inspect services whilst it undergoes transformation and its current decision to inspect is based on knowledge of their locations and through that knowledge, perceived ‘risk.’
Date of last CQC published inspection report – 19 March 2021 (This inspection focused on only two key lines of enquiry ‘Safe’ and ‘Well Led’ – there are five in total.)
Ratings from a previous inspection for the key lines of enquiry, ‘Effective,’ ‘Caring’ and ‘Responsive’ were automatically generated from the last inspection as ‘Good’ which was published on 27 November 2017.
Overall rating: Requires Improvement
Key findings indicated that:
- ‘As and when’ required medicines did not always have guidance for staff to ensure that people only received these when they needed them.
- Where people required support to apply creams, there were multiple missed signatures which the Manager was already aware of and working to address.
- A delay was noted for one person as staff were supporting other people at the time.
- Isolation procedures (at the time of Covid) were not followed for one resident.
- Staff were not always wearing face masks appropriately where residents were present.
- Quality checks were in place but had not always highlighted areas for improvement.
Highlights from the CQC report
The report also identified many positive examples of best practice:
- Lessons learnt were immediately shared across the Company.
- People were supported to engage with testing during the pandemic.
- The home was clean and tidy and additional staff had been employed to support the enhanced cleaning systems put in place during the pandemic.
- Accidents and incidents were regularly reviewed to see what could be done differently.
- People and relatives raised no concerns over safety.
- Risks to people’s health and wellbeing were considered, assessed and reviewed.
- Staff knew how to recognise and report potential abuse and had received training.
- There were procedures in place to ensure people were protection from potential harm and appropriate referrals made where required.
- Staff felt supported by the management team.
- The Manager notified CQC of statutory notifications when required by law.
- Staff, residents and relatives felt supported by the management team.
- Throughout the inspection, positive interactions were noted between the staff and residents.
- The service worked closely with other agencies.
- Feedback was sought from people who lived at the home. The information was analysed and shared.
Driving changes for the better
Following the CQC inspection, MACC Care has taken the following steps to improve the service:
- A comprehensive action plan was provided to CQC detailing how we planned to make the required improvements.
- Since this inspection, a new Home Manager has been appointed and registered with CQC as a responsible person following their assessment.
- The Group established its own internal review processes to measure and benchmark its services against MACC Care’s own expectations. These reviews are conducted by ex CQC Inspectors, a Dementia Care Specialist and an experienced Nurse Auditor.
- The Group established a Quality & Compliance Working Group to review the quality of the audit processes for all care services.
- Lessons learnt were written and shared with other Managers within the Group so that insights could be shared. Changes in practice (where identified) were made to further improve and drive quality.
- Since the last CQC inspection, we have undertaken a Survey with key people who work in and visit our services and developed a ‘you said, we did’ response to this.
Other key themes from their survey feedback included:
- 100% of the staff felt confident that full investigations would be undertaken where incidents occurred.
- 83% of respondents felt the environment and equipment was well maintained.
- 83% rated the value placed on their work by their Manager was outstanding.
- 100% of the staff team felt leaders shared relevant best practice to ensure they worked safely.
Internal Review processes
Frequent and thorough appraisal of services for your peace of mind
- Internal home audits are completed in line with MACC Care’s Internal Governance Schedule – any patterns or trends are reviewed and added to the home’s service progression plan. This is regularly reviewed to ensure actions are sustained and embedded before they are authorised as closed.
- Insight Reviews have been developed and rolled out (MACC Care’s internal review methodology mapped to CQC’s methodology and regulations) and these are undertaken every six months.
- Follow-up Reviews are undertaken in between Insight Reviews to ensure that any areas for focus are addressed and the change in practice embedded.
- Regular Operational Visits are conducted to support the home manager in service development and a reporting structure is in place to provide organisational assurance.
- Regular visits are also conducted by the Director of Regulation and Director of Operations.
- Regular ‘Meet the Manager’ events are held for families and friends of Wulfrun Rose.
Wulfrun Rose is currently rated 9.5/10 by significant others
We welcome feedback from our residents and relatives.
To view the most recent comments, please visit the Wulfrun Rose page at carehome.co.uk
“We listen; we learn; and we grow. The team at Wulfrun Rose is always striving to make the lives of our residents better and if we as staff are happy in doing what we do best, that makes such a difference in residents’ lives.”
Jackie Scott, Wulfrun Rose Manager
To find out more about the great things that are happening at Wulfrun Rose and the compassionate care and support available to your loved one, please email Jackie or call her on 01902 653284.
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