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Archived: Wombwell Hall Care Home Good

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating


Updated 6 December 2016

We inspected Wombwell Hall Nursing Home on 19, 20 and 21 October 2016. The inspection was unannounced. Wombwell Hall Nursing Home is a residential care home providing nursing support and accommodation for up to 120 older people. At the time of our inspection there were 116 people living at the service. Wombwell Hall Nursing Home is split into 4 units each being able to accommodate up to 30 people. Each unit had its own food service area, communal area, dining area, medicine room and staff room. There was also an additional building which contained a kitchen, laundrette, manager’s office, meeting room and staff rooms.

There was a registered manager in post who was registered with the CQC. A registered manager is a person who has registered with the Care Quality Commission 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 last inspection on 14 July 2014, we found 7 breaches of the Health and social Care Act 2008 (Regulated Activities). These breaches were in relation to not being fully compliant with the Mental Capacity Act 2005 (MCA), not enough staff on duty, medicines not being stored or administered safely, poor infection control practice, people receiving treatment during lunch service, people being left in wheelchairs for long periods of time and poor quality auditing systems. The provider sent us an action plan stating that they would address all of these concerns by June 2015.

At this inspection, we found that the provider had taken action on all these areas and was fully meeting the regulations where breaches were found.

People were protected against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. The registered manager had robust systems in place to record and investigate any concerns. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns.

Medicines were stored securely and administered safely. Staff had received training on medicines handling and administration, and checks had been undertaken to ensure staff were competent to administer medicines safely. However, we found that some people’s medicine records had not been updated and that some required further details. We have made a recommendation about this in our report.

The provider had ensured that the home was well maintained. Up to date safety checks had been carried out on electrical and gas installations. Equipment, such as hoists, were being checked and serviced. However, we found a back up syringe driver that had not been serviced since 2014.

The service appeared clean and tidy and there were cleaning rotas in place to ensure that all areas were cleaned. The provider had ensured that the premises were safe for use and had up to date safety certificates.

There were sufficient staff to provide care to people throughout the day and night. The registered manager used a dependency tool to identify the amount of hours required to provide support. When staff were recruited they were subject to checks to ensure they were safe to work in the care sector.

People’s needs had been assessed and detailed care plans had been developed. Care plans had appropriate risk assessments that were specific to people’s needs.

The principles of the Mental Capacity Act 2005 (MCA) were adhered to. People were being assessed appropriately and best interests meetings took place to identify the least restrictive methods of keeping people safe. Staff had training on MCA and had good knowledge. The provider had recently introduced new MCA forms that ensured that records were being completed appropriately.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate application

Inspection areas


Requires improvement

Updated 6 December 2016

The service was not always safe.

Medicines were stored and administered safely. However, we found that records of people�s �when required� medicines were not always accurate.

The provider had ensured that the service was well maintained carrying out appropriate safety checks and servicing. However, we found that a backup syringe driver had not been recently serviced.

People were protected against abuse by staff who had the knowledge and confidence to identify safeguarding concerns.

The provider had ensured that there were sufficient numbers of staff in place to safely provide care and support to people.



Updated 6 December 2016

The service was effective.

The principles of the Mental Capacity Act 2005 (MCA) were applied in practice.

The provider had ensured that appropriate applications were made regarding Deprivation of Liberty Safeguards.

Staff received training that gave them the skills and knowledge required to provide care and support to people.

People had access to a range of food options that was nutritious and met their needs. People were supported to maintain their diets when required.



Updated 6 December 2016

The service was caring.

People spoke very positively about staff. People and relatives told us they were happy with the service they were receiving.

Staff had good knowledge of the people they supported. Staff communicated in ways that were understood by the people they supported.

People�s privacy and dignity was respected by staff.



Updated 6 December 2016

The service was responsive.

People were encouraged to make their own choices at the service. Staff would respect people�s choice.

People at the service had access to a wide range of activities. People told us they were happy with the choice on offer. However, people did tell us they would like more opportunities to go on outings.

The manager investigated complaints and the provider had ensured that people were aware of the complaints procedure.



Updated 6 December 2016

The service was well-led.

The registered manager ensured there were good links with the community through working with local schools and arranging summer fetes.

The registered manager carried out audits of the service to identify any shortfalls within the service. The manager acted on the outcomes of the audits positively.

People, friends and staff were encouraged to give feedback through surveys and meetings. The manager listened and acted on these appropriately.

People�s records were not being consistently updated by staff.