Wyndham Manor Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Records did not always evidence that an effective system was in place to ensure lessons learned were identified and shared with staff.

Lessons learned in relation to accidents and incidents, safeguarding allegations and complaints had not always been identified, analysed and shared with staff.

The provider had already identified most of the issues we found and had introduced new recording and monitoring systems as well as a new electronic care management system. It was not possible to check how effective these new systems were since they had just been introduced and were not yet embedded into practice. They had also formulated an action plan to ensure that improvements were made in a timely manner and make sure the new improved systems were embedded into practice.

An effective preadmission process was not in fully place. Prior to the assessment, staff relied on assessments carried out by the local authority and other external agencies and did not complete their own documented preadmission assessment or visit the person to check that the person’s needs could be met when they moved into the home.

The provider had recognised this shortfall and had introduced a new admission process to ensure people’s needs could be met. It was not possible to check how effective this new system was, since it had just been introduced and was not yet embedded into practice.

Due to the concerns identified prior to our assessment, the provider put a voluntary suspension on admissions to the home to allow improvements to be made and embedded at the home to ensure people’s safety.

An effective safeguarding system was not fully in place. It was not always clear how safeguarding concerns were reported, recorded, investigated and analysed. We read 1 person’s daily records; staff had recorded 2 safeguarding incidents which were not recorded in the accident and incidents log or safeguarding log. There was a lack of evidence that lessons learned were identified and shared with staff.

The provider had introduced a new safeguarding logging system; no new safeguarding concerns had been raised, so it was not possible to check how effective the new system was.

The local authority was monitoring the quality of home and supporting them to ensure the correct procedures were in place to keep people safe.

Records did not always evidence that risks relating to people’s care and support were effectively assessed, monitored and managed.

We identified shortfalls in relation to the assessment of risk relating to medicines management, distressed behaviours, nutrition and continence care. Assessments relating to the risk of malnutrition and choking were not always accurate and advice from the speech and language therapist could not always be located. Several people sometimes displayed distressed behaviours. Information to guide staff on the triggers and actions they should take was not detailed.

The provider had introduced a new electronic care management system which provided tools to help staff document and manage risks. It was not possible to check how effective this new electronic care management system was since it had just been introduced and was not yet embedded into practice.

An effective system was not fully in place to assess, monitor and manage risks relating to the environment, including the outdoor space.

Certain rooms which could cause a risk to people should they access these areas were open. A door which was operated by a keypad with an automatic closure did not close in a timely manner and window restrictors did not meet the safety requirements as described by the Health and Safety Executive (HSE).

Excess equipment and laundry detergent were stored under the stairwell which was a fire risk. Personal emergency evacuation plans were not always accurate or detailed. There was a large amount of rubbish awaiting collection outside. Staff explained that this had been there for about a month. The bin store and clinical waste bin was not locked and was accessible via the public street. These issues posed a fire safety risk due to unauthorised access.

Following our site visits, senior management told us the above shortfalls had been addressed. They also explained that a comprehensive health and safety audit was going to be completed imminently by an external contractor.

An effective system was not fully in place to ensure staff were trained and supported. Prior to our assessment, supervision and appraisal meetings had not been carried out as planned, and where they had been carried out, issues identified had not always been followed up. There were gaps and shortfalls in staff knowledge and skills in relation to areas such as catheter care, the Mental Capacity Act (2005) and nutrition.

The provider had already identified shortfalls relating to training and support. Training was being organised and a new supervision and appraisal planner had been implemented.

Recruitment checks were carried out before staff started to work at the home. Records did not always evidence that best practice guidelines were followed.

There were sufficient staff deployed at the time of the assessment to meet people’s needs. Agency staff were sometimes used. People and relatives told us the permanent staff were knowledgeable about people's needs. However, they were not as positive about the skills of the agency staff.

Improvements were being made in relation to infection control practices at the home.

Prior to our inspection, we received feedback from an infection control practitioner that the storage of PPE was not in line with best practice guidance. They explained this issue had been raised previously and insufficient action had been taken. During our site visits, we found that PPE was still being stored on handrails, in addition, not all bins were pedal operated, which posed a risk of cross infection. Senior management explained that these issues were being addressed and PPE wall mounted storage stations had been ordered.

People and relatives raised no concerns about the cleanliness of the home. Most areas of the home and equipment were clean.

Records did not always evidence that an effective system was in place to ensure medicines were managed safely. We identified shortfalls with the management of topical medicines and medicines administered on a ‘when required’ basis.

The provider had formulated an action plan and introduced regular checks to ensure that any shortfalls were identified and actions were taken in a timely manner.