Wyndthorpe Hall & Gardens Care Home

Wyndthorpe Hall & Gardens Care Home is a residential care home registered to provide personal and nursing care for to up to 82 people. Some people using the service were living with dementia. The home had two separate buildings, Wyndthorpe Hall and Court and Wyndthorpe Gardens, each with a registered manager. Wyndthorpe Hall and Court provides residential dementia care and Wyndthorpe Gardens provides nursing dementia care. At the time of our inspection there were 54 people using the service.

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

The provider had made some improvements following the last inspection. This inspection identified that the provider required continued improvement.

The systems in place that promoted safety through the layout and hygiene practices of the care environment were not effective.

Medicines were generally managed safely but the provider could share knowledge and learning across the different elements of the service to improve consistency. We made a recommendation about this.

People were safeguarded from abuse. Staff were able to describe the process for reporting safeguarding concerns. People and their relatives told us that they felt safe at Wyndthorpe Hall and Gardens.

There were enough staff on duty to provide care and support to people. Staff demonstrated care and compassionate when they supported people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Management oversight and leadership was not effective and there were gaps in management audits and checks. For example, daily management reviews of the care environment had not picked up some aspects of care that were not person-centred.

Following the last inspection, the provider had appointed a compliance and support manager who had started to make changes and improvements to the care planning and management audit systems.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 December 2023). 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 regulation 15 of the Health and Social Care Act 2014. However, we found the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

We carried out an unannounced focused inspection of this service on 14 September 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, premises and equipment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements.

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.

We have found evidence that the provider needs to make improvements. The overall rating for the service has remained requires improvement based on the findings of this inspection. Please see the safe and well-led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and recommendations

We have identified breaches in relation to the cleanliness of the premises and the leadership of the service in this inspection. We have made a recommendation about how the provider could encourage its staff to share knowledge and learning about managing medicines.

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

Wyndthorpe Hall & Gardens Care Home is a residential care home registered to provide personal and nursing care to up to 82 people. At the time of our inspection there were 64 people using the service. Some people using the service were living with dementia. The home had two separate buildings, Wyndthorpe Hall and Wyndthorpe Gardens, each with a registered manager.

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

The provider had a system in place to monitor the quality of the service, however, this was not always effective. There was a lack of leadership and governance and this impacted on the service provided to people. Areas of the environment were worn and dirty. We carried out a tour of the home and found some concerns regarding infection prevention and control. Some areas of the home needed a deep clean and some areas were poorly maintained. There was little evidence to show lessons had been learned when things went wrong.

People's medicines were managed safely, and people received their medicines as prescribed.

People were safeguarded from the risk of abuse. There were sufficient staff available to meet people’s needs although, there was no effective system used to determine staffing levels based on people’s assessed needs. Staff were recruited safely and had pre-employment checks to determine their suitability for employment.

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 22 December 2020).

Why we inspected

The inspection was prompted in part due to concerns received about infection control, care planning, governance and risks. A decision was made for us to inspect and examine those risks. We looked at the key questions of safe and well led only. 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.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Wyndthorpe Hall & Gardens Care Home on our website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good 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.

We found the following examples of good practice.

Tests for COVID-19 were being carried out in line with guidance. Staff were regularly tested and tests had helped the provider identify and take action to deal with an outbreak of COVID-19.

Visitors were effectively prevented from catching and spreading infection by staff who followed the provider's infection prevention and control (IPC) procedures. The provider was following guidance on visiting and where visiting was not permitted, such as during an outbreak of infection, window visits were being facilitated.

The provider had a record of staffs’ vaccination status. Checks were in place to help prevent visitors to the home spreading the COVID-19 infection, such as a negative lateral flow test.

Additional cleaning was taking place, including an increase in cleaning of high touch surfaces.

Staff breaks were staggered to ensure social distancing rules were applied.

Staff encouraged people to sanitise their hands regularly. There were ample supplies of PPE available and staff carried hand sanitiser with them.

We found the following examples of good practice.

The provider is looking at ways for people to have safe visits with their loved ones. Plans were underway to convert a designated room into a visiting area. When completed, it will enable comfortable visits.

Additional cleaning was taking place, including an increase in cleaning of high touch points.

Staff praised the support they received from the management team. Extra emotional support was available to staff should they need this.

The service had a number of lead staff in infection prevention control (IPC). One of their roles and responsibilities was to observe and embed the importance of hand washing and good IPC practices within the team.

Staff breaks were staggered to ensure social distancing rules were applied.

Staff encouraged people to sanitise their hands regularly. There were ample supplies available of PPE available and staff carried hand santiser with them.

Further information is in the detailed findings below.

This inspection took place on 28 June 2018. At the last inspection, the service was rated overall as requires improvement. You can read the report from our last inspections, by selecting the 'all reports' link for ‘Wyndthorpe Hall and Gardens Care Home’ on our website at www.cqc.org.uk. At this inspection we found the service had improved to good.

There was a registered manager who had been in post for just over 12 months. 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.

Care and support was planned and delivered in a way that made sure people were safe. People were protected, as any risks associated with their care were identified and appropriately managed. Systems were in place to safeguard people from abuse.

There was enough staff employed to meet the needs of the people living at the home at the time of our inspection. The process for recruiting new staff ensured they were suitable to carry out their roles and responsibilities in a safe manner. Staff were trained and supported to develop their skills and provide people with the standard of care they required.

The systems in place to make sure people’s medication was managed safely had been improved and were effective. Medication was administered by staff who had completed appropriate training.

Staff received training and support to enable them to meet people’s needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received a varied and healthy diet that offered choice and had good access to community healthcare services.

Staff supported people in a compassionate, caring, responsive and friendly manner. They encouraged people to be as independent as possible, while taking into consideration their abilities and any risks associated with their care. The people we spoke with made positive comments about how staff delivered care and said they were happy with the way the home was managed.

People’s needs had been assessed and care plans put in place to highlight where they needed support, and telling staff how each person preferred their care to be delivered. People’s care had been reviewed regularly to make sure plans reflected people’s changing needs. There was a range of activities and events people were supported to take part in. Complaints were dealt with in a fair and timely way.

The systems in place to continuously assess and monitor the quality of the service had been improved and were effective. This included obtaining people’s views and checking staff were following the correct procedures. Further improvements to the premises were underway with a clear action plan as to what areas needed attention.

Further information is in the detailed findings below.

This inspection took place on 6 July 2017 and was unannounced. This was the first inspection of the service since it was taken over by the current registered provider. At the time of the inspection 80 people were living in the home.

There was no registered manager at the time of the inspection. 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. The provider had appointed a new manager, who had started work a number of weeks before the inspection. The manager told us they were preparing to apply to become registered.

We found that medication was not well managed in the Hall and Court parts of the home.

For the most part assessments identified potential risks to people, and management plans were in place to reduce these risks. However, this was not always the case for everyone, and in some cases, the records staff kept about the care they delivered to people were not sufficiently detailed.

It was a very warm day and we noticed a smell of urine in two particular areas of the home. However, all other parts of the home looked clean and did not smell.

For the most part, positive caring relationships were developed with people who used the service. Staff spoke to people respectfully, and in a gentle and caring way.

People told us they felt safe living at the home. Recruitment processes were safe and we saw there were sufficient staff on duty to meet people’s needs.

Most of the feedback from people living in the home and their visiting relatives was complimentary regarding how nice the staff were, and about the care that people received.

Staff completed an induction and essential training at the beginning of their employment. This was followed by additional training and periodic refresher sessions, although there was a need to provide training to staff in caring for people at the end of their life. Staff also received support and supervision to help them meet people’s needs.

People said they were happy with the meals provided, and drinks and snacks were available between mealtimes.

For the most part people were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People had been involved in planning their or their family members’ care. In most cases, care plans reflected people’s needs and had been reviewed and updated to reflect their changing needs.

People had access to social activities, as well as outings into the community.

There was a system in place to tell people how to raise concerns and how these would be managed. People told us they had no complaints, but would feel comfortable raising any concerns with the manager.

There were systems in place to assess if the home was operating correctly, however these had not been effective as they had failed to identify the shortfalls we found at this inspection, including some inconsistencies in staff practice.

Although people using the service and their relatives told us they were involved and consulted about the care, they had not been provided with specific forums to share their opinions, such as ‘residents’ or ‘relatives’ meetings. There had been asked to fill in any quality surveys since the new registered provider had taken over the running of the home.

We found breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of governance, safe care and medication. You can see what action we told the provider to take at the end of this report.