Wykeham House

Wykeham House is a nursing care home providing personal and nursing care to up to 76 people. The service provides support to older people, people living with dementia and mental health conditions. At the time of our inspection there were 70 people using the service. Wykeham House accommodates people across four separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia.

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

Records of the medical decision agreed with people to not attempt resuscitation when it may be clinically futile to attempt to do so were not always clear and consistent. The presence of Do Not Attempt Resuscitation (DNAR) forms did not always correspond with an easy access colour coded system and staff handover paperwork, meaning there is a risk that staff may not have the correct information in an emergency.

People and their relatives told us they had concerns about staffing levels at weekends. Feedback was given to the provider and the registered manager acknowledged there was less administrative staff and management presence at weekends, however we found during this inspection that staffing levels were satisfactory to meet the needs of people.

Incidents and accidents were investigated, and lessons learnt on an individual basis with changes made to people’s care plans to manage risk. There was a lack of oversight of trends in incidents and accidents to establish potential service wide improvements. Quality assurance processes were not always effective to provide managerial oversight of systems and drive improvements. Audits of care plans and incidents and accidents were not always thorough. It had not been identified that some care records contained inconsistencies regarding DNAR information. The registered manager told us how they would make improvements on these issues.

People told us they felt safe, and relatives told us they were confident in the care provided to people. People were supported to have choice and control of their day to day lives. Staff supported people in the least restrictive way and in their best interests. Staff, people and relatives were supported to engage with the service. People and relatives told us the management team were approachable and accessible. Staff told us they felt well supported, empowered to develop and that Wykeham House had a positive culture to work within.

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

Rating at last inspection

The last rating for this service was good (published 6 November 2021).

Why we inspected

We received concerns in relation to an incident involving a person using the service and the accuracy of records relating to their care and treatment. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report. The registered manager has told us they have mitigated risks. They have audited all care records and adapted processes to update changes to people’s information more promptly.

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

Enforcement

We have identified breaches in relation safety monitoring and management, and governance at this inspection.

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.

Wykeham House Care Home is a nursing home providing personal and nursing care for up to 76 older people with a variety of care needs including dementia. At the time of the inspection there were 52 people living at the service.

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

We found improvement had been made since our last inspection, people and their relatives spoke positively about the service and the provider had taken action to improve peoples experience living at the home.. This meant that there was sufficient staffing to support people’s needs and staff had the appropriate skills to support people. People told us that they felt safe with staff. Staff knew how to recognise a safeguarding concern and how to report this. Risk assessment were in place to enable staff to support people safely and staff had a good understanding of peoples needs.

Medicines were managed safely by staff who had received appropriate training. People received their medicines on time and were supported with their medicine needs.. Good infection control was maintained and people were protected from infection. Lessons were learnt when things went wrong and practice was improved.

People were supported to have maximum control and choice in their lives and staff supported people in the least restrictive way possible and in their best interests. A variety of activities were available to people when they wished to be occupied. We observed staff spending time with people and providing meaningful occupation throughout the day.

Quality assurance was effectively carried out with a wide variety of audits being undertaken and actions completed. Assessments were carried out by the registered manager prior to people moving into the home. These were detailed and personalised. Staff were aware of people’s needs and received appropriate training to support them.

People told us that the staff were kind and caring, we observed staff interacting positively with people who they knew well. The registered manager completed daily walk arounds to monitor the service including the interactions had between staff and people to ensure the atmosphere was kind and caring.

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

Rating at last inspection The last rating for this service was requires improvement (published 21 October 2019) and there were multiple 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.

Why we inspected

This was a planned inspection based on the previous rating.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Wykeham House is registered to provide accommodation and personal care for up to 76 people who may have a nursing need, a disability or may be living with dementia. There were 63 people living at the service at the time of our inspection.

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

There were not always sufficient staff to support people when they needed care. Although staff received training and supervision, this was not effective in ensuring good practice within the service. Staff were not always maintaining good infection control. Risk assessments were not always up to date or accurate and staff were not always moving and handling people in a safe way.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. People did not always have access to meaningful activities and people in their rooms were at risk of social isolation. Care plans did not always have accurate information about people’s care and staff did not always understand people’s needs.

Quality assurance was not always effective. Where shortfalls in care had been identified with staff this had not been addressed robustly. The leadership on each unit needed to be more effective in ensuring staff were delivering appropriate care. There had been several changes in management and the provider had failed to maintain robust oversight of the service. As a result, the level of care had deteriorated from the last inspection.

Recruitment records lacked detail around staff’s previous employment. People told us that they did not always feel safe as action had not been taken to ensure other people did not wander into their rooms. We found that staff did not always interact with people whilst going about their care duties. We have made recommendations around these three areas.

People and relatives told us that staff were kind, caring and respectful towards them. We saw examples of this during the inspection. People were supported and encouraged to remain as independent as possible and were involved in decisions around their care. Relatives and visitors were welcomed as often as they wanted.

People and relatives knew how to complain and were confident that complaints would be listened to and addressed. People, relatives and staff thought the leadership of the service had improved. Staff told us that they felt listened to and were encouraged to be involved in the running of the service.

Previous Inspection

The last rating for this service was Good (Report published 1 November 2017)

Why we inspected

This was a planned inspection based on the previous rating. We have found evidence that the provider needs to make improvement. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this full report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

On this inspection we were following up on concerns that related to a lack of governance, a lack of supervision of staff, a lack of safe care and treatment, people not always being treated with dignity and respect, a lack of meaningful activities and that complaints were not always investigated. We found significant improvements in all of these areas.

Although there was no registered manager in post a new manager had started at the service and had submitted their applications. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were appropriate plans in place to ensure that risks to people were managed. Staff understood what to do to minimise risks in relation to people. Emergency evacuation plans were in place and staff understood what to do if an emergency occurred at the service. Where people had accidents and incidents actions were taken to reduce this risk of them reoccurring.

People told us that they felt safe with staff. Staff had received training in safeguarding people from abuse and they had a good knowledge of what they needed to do if they suspected abuse. Staff at the service had robust recruitment undertaken before they started work.

Although people and staff told us at times there were not enough staff this did not impact on care. The Provider assured us that staff levels were going to be maintained to ensure that people’s needs were met in a safe way. Other people and staff felt there were sufficient staff levels in other areas of the service and we confirmed this with our observations.

People understood the reason and purpose of the medicines they were given. The management of medicines was safe by staff who had the appropriate training.

People and relatives felt that staff were competent in their role. Staff received appropriate training and supervision and staff felt supported.

People’s rights were protected because staff acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Appropriate assessments had been completed where people’s capacity was in doubt and applications to the Local Authority were submitted if people were being restricted in their best interest.

People enjoyed the meals at the service and said they had sufficient choices. People’s health care needs were monitored included weight loss and any changes in their health. People had access to appropriate health care professionals where needed.

People and their relatives told us that staff were kind and caring and treated people in respectful and dignified way. This was confirmed through our observations. People had choices around their care and felt involved in their care planning. Relatives and friends were welcomed at the service to visit people. People and their relatives were given support when making decisions about their preferences for end of life care.

People had a range of activities that they could be involved in and trips out were arranged for people. People that were socially isolated in their rooms had one to one activities arranged for them.

Care plans were detailed and included specific guidance for staff to ensure that people’s needs were met. Staff communicated changes to each other about any changes in people’s care.

Complaints were investigated, recorded and responded to appropriately.

People and staff felt the management of the service had improved significantly. Staff said they felt more empowered and valued. We could see that they staff team worked well together and that staff enjoyed working there.

There were effective systems in place to assess the quality of care and to make improvements. This included audits, meetings and surveys where feedback was sought. Improvements were made as a result of this. The manager had informed the CQC of significant events including incidents and accidents and safeguarding notifications.

We could not improve the rating for well-led from inadequate to good because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

There was a registered manager in post and present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our inspection in August 2016 we had identified a breach of regulation in relation to person centred care, dignity and respect, consent, safe care and treatment, the competency skills of staff, acting on complaints and lack of good governance. We issued warning notices in relation to the lack of competencies of staff and governance. The provider sent us an action plan in October 2016 that stated that they would meet these regulations by the 30 November 2016. However, we found at this inspection a systematic failure to identify and put right the shortcomings in the service as we found the warning notices had not been fully met and we identified further breaches of regulation.

People were not always protected from the risks of unsafe care. Risks to people had not always been identified and acted upon including risks around behaviours, lack of nutrition and bed rails. However there were other aspects to the risks to people that were addressed by staff including environmental risks. Personal evacuation plans were in place for every person and staff had received fire safety training.

Staff were not always suitably qualified, skilled and experienced to meet people's needs. This was particularly in relation to new staff and staff that did not have knowledge of people’s needs. Staff however had received appropriate support that promoted their professional development and had regular supervisions with their line manager.

There were times where staff did not treat people with dignity and respect and choices were not always offered. However people's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. We did see times where staff were kind and attentive to people’s needs.

People did not always have access to activities that were important and relevant to them.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided.

Complaints were not always investigated with the necessary action taken.

Although the provider actively sought, encouraged and supported people's involvement this was not always used to improve the quality of care. Although staff were encouraged to contribute to the improvement of the service staff did not always feel listened to or valued.

People’s records were not always up to date or accurate. People’s care plans did not always have the most up to date care needs recorded and food and fluid charts were not always completed accurately.

People told us that they felt safe and we found staff understood how to protect people from the risks of abuse. Recruitment practices were safe and relevant checks had been completed before staff started work. We found that there had been improvements made to staffing levels and there was now sufficient numbers of care staff deployed at the service to meet people's needs.

Staff understood how to support people to make decisions. Where people had restrictions placed on them there was evidence that these were done in their best interests. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) and their responsibilities in respect of this.

On the whole people had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People were given choices of meals. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment. Medicines were managed safely and people received their medicines when they needed. Staff competencies with medicines were assessed.

People's needs were assessed when they entered the service and on a continuous basis to reflect any changes in their needs. Care plans showed that people and relatives (where appropriate) were involved in the planning of their care.

People told us the staff and management were friendly and approachable.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Well-led for this service is rated as 'Inadequate' and the service therefore has been placed in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service.

This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There was a registered manager in post and present on both days of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was insufficient numbers of care staff deployed at the service to meet people's needs. This resulted in people waiting for their care and for their meals.

Fire evacuation arrangements for people were not in place and there were risks to people in the environment that were not being managed well. However there were other aspects of the risks to people that were addressed by staff.

Medicines were not managed safely and there was a risk that people did not receive their medicines when they needed. Staff competencies with medicines was not being assessed.

Staff had not received appropriate clinical supervision that ensured the most appropriate clinical care was provided. However other staff were having one to one support with their manager that promoted their development. We found the staff team were knowledgeable about people's care needs. People told us they felt supported and staff knew what they were doing.

Staff were not knowledgeable about current guidance to support people to make decisions. Where people had restrictions placed on them there was not always evidence that these were done in their best interests or necessary. Staff did not always have a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) or their responsibilities in respect of this.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. However people were not always given choices of meals. The recording of what people ate and drank was not always being undertaken. People were supported to have access to healthcare services and were involved in the regular monitoring of their health.

There were times where staff did not treat people with kindness, dignity and respect. However people's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy was respected and promoted when personal care was undertaken.

People's needs were assessed when they entered the service and on a continuous basis to reflect changes in their needs. However care plans were not always updated with the changes to care.

Concerns and complaints were not always responded to appropriately and people did not always feel listened to.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided and to make improvements as a result. There were continued breaches from the previous inspection around the competencies of staff and people’s care plans not being updated that had still not been addressed.

Although the provider actively sought, encouraged and supported people's involvement this was not always used to improve the quality of care. People’s records were not always up to date or accurate.

People told us they were safe at the service. Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from harm.

Recruitment practices were safe and relevant checks had been completed before staff started work.

People had access to activities that were important and relevant to them. People were protected from social isolation and there were a range of activities available.

People told us the staff were friendly and management were always approachable. Staff were encouraged to contribute to the improvement of the service. Staff told us they would report any concerns to their manager. Staff felt that management were very supportive.

We found several breaches of regulations. You can see what action was taken at the end of the report.

People told us they liked living in the home and the staff were kind and caring. We saw staff spoke to people and explained what they were going to do prior to undertaking a procedure.

Relatives told us they were satisfied with the home and the care their relatives received. They said the home seemed welcoming when they were shown around. A relative said they felt the home met their relative's needs, but they had nothing to compare it to as it was their first experience of a nursing home.

We saw the home was clean and hygienic. Individual bedrooms were comfortable and communal areas were well decorated and nicely furnished.

Meals were well presented and we saw a high staff ratio available on Memory Lane to provide help and support for people who required this support during lunch.

Staff told us they liked working in the home and said they had the appropriate training and support to undertake their roles.

We saw there were appropriate systems in place to monitor the quality of service provision.

We asked people if they would recommend Wykeham House to others, they told us they would. One person who lived in the service said, 'Oh definitely.' A relative told us, 'Oh yes dear, its got a very good reputation.'

People said that staff gave them their medication when they needed it, and confirmed that staff had never missed a dose.

People told us if they had any concerns, that they felt comfortable to tell staff. One person told us they, 'Could talk to anyone, they (staff) would all listen to you, whatever is wrong they would put it right.'

Relatives shared with us that they had no concerns over the standard of hygiene and cleanliness. One relative said staff kept it, 'Clean and tidy.' Another relative who described the standard of cleanliness as, 'Very good,' said, "It always looks clean and tidy.'