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Wombwell Hall Care Home Requires improvement

The provider of this service changed - see old profile

We are carrying out a review of quality at Wombwell Hall Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 16 March 2018

The first day of the inspection was unannounced on the 29 January 2018, and the second and third days of the inspection the 30 January and 5 February 2018 were announced.

Wombwell Hall Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service comprises of four separate houses, Pickwick House, Weller House, Copperfield House and Micawber House, together with a main administration building. Each house provides residential and nursing care for up to 30 people making a total of 120 people when the service is full. There were 114 people living in Wombwell Hall Care Home at the time of our visit.

The service was run by a registered manager and they were present on the days of our visit. 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.

This is the first time the service has been rated since the change in ownership in December 2017.

People and their relatives told us staff were kind and caring and made people feel safe. They said staff had the necessary skills to respond to people’s needs, monitored their health and that people enjoyed their meals. However, we found inconsistency in care practices across the service which meant that people did not always receive the level of care expected.

Systems to monitor the quality of care were not always effective. Potential risks were not always accurately monitored and recorded and records were not always legible, accurate and up to date which could result in people receiving inappropriate staff support.

There was evidence to show that there were at times insufficient numbers of staff on duty to meet people’s needs.

Shortfalls had been identified in staff training and plans were not in place on the first day of the inspection visit, to ensure staff received relevant refresher training for their role. Not all staff felt well supported both informally and through formal processes such as staff meetings and supervisions.

Recruitment practices were robust in ensuring only suitable staff were employed at the service.

People’s needs were assessed and a plan of care was developed which included their choices and preferences. Guidance was in place for staff to follow to meet people’s needs. However the care plans were not always legible, accurate and up to date to ensure that people’s needs were met.

People’s health needs were assessed and monitored and the service worked in partnership with healthcare professionals to ensure people received appropriate care and treatment. However, there were examples where the provider had not effectively managed and responded to risk.

Medicines were on the whole managed safely and people received them as prescribed.

The views of people and their relatives were sought through meetings and an annual survey.

Health and safety checks were effective in ensuring that the environment was safe and that equipment was in good working order.

Management systems were in use to minimise the risks from the spread of infection and keep the service clean, although records did not always support this.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Inspection areas


Requires improvement

Updated 16 March 2018

The service was not always safe.

People’s needs were not always met as there were times when insufficient numbers of staff were on.

Potential risks to people’s health and welfare were not always acted on, or guidance in place followed to ensure people’s safety.

Checks were in place so only suitable staff were employed.

People were supported by staff who had received training and understood their responsibilities in relation to safeguarding.

People's medicines were administered by trained staff.


Requires improvement

Updated 16 March 2018

The service was not always effective.

Staff required updates in training. Some staff had not been supported through regular supervision

People had a choice of foods which supported them to stay healthy and people’s nutrition was monitored.

People gave verbal consent to care and support. Staff supported people in line with the principles of the Mental Capacity Act 2005 and the requirements of the Deprivation of Liberty Safeguards.

People were supported to access health care as needed.



Updated 16 March 2018

The service was caring.

People spoke very positively about staff.

Most 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 16 March 2018

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

The views of people and relatives were sought.


Requires improvement

Updated 16 March 2018

The service was not consistently well-led.

There was a lack of oversight of quality which resulted in people receiving inconsistent care.

Quality assurance systems were not always effective in highlighting areas where improvement was needed.

Records did not always accurately reflect people’s care and treatment and some records were not all easily accessible.