Wyncroft House

Updated 10 November 2023

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors and an Expert by Experience. An Expert-by-Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Wyncroft House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used all of this information to plan our inspection.

During the inspection

We spoke with 5 people using the service and 2 relatives about their experience of the care provided. We spoke with 7 members of staff, including the nominated individual, manager, the clinical lead, nurses, and care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with an Advanced Nurse Practitioner.

We reviewed a range of records, this included 8 people's care records and multiple medication records. We looked at 4 staff files in relation to recruitment and supervision. We reviewed a variety of records relating to the management of the service, including policies and procedures.

Updated 10 November 2023

About the service

Wyncroft House is a residential care home providing personal and nursing care to up to 38 people. The service provides support to people living with dementia and people living with a range of complex health care needs. At the time of our inspection there were 19 people using the service.

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

Care plans contained contradictory information about how to manage people’s wounds. Topical creams were not administered as prescribed. There were no processes in place to ensure peoples pain relief medicines were monitored to ensure they were still in situ.

Appropriate checks were not carried out to ensure staff were recruited safely. Several staff files contained gaps in employment history, and risk assessments had not been completed for staff who had used their Disclosure and Barring Service certificate from their previous employer.

There were measures in place to prevent the spread of infection.

Incidents and accidents were recorded and analysed to identify trends however, there was no process in place for the provider to check if actions were consistently followed up.

There were systems and processes in place to protect people from the risk of abuse. People and relatives told us they felt safe. There were enough staff to keep people safe.

The systems and processes in place to monitor the service were not effective and did not consistently identify where improvements were needed. We were not assured the provider had embedded a culture of continuous learning.

People told us the manager was approachable and they felt comfortable raising their concerns. The provider engaged with people using the service. Staff worked with external health care professionals to ensure people received partnership care to meet their needs.

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.

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 (09 March 2020).

At our last inspection we found breaches of the regulations in relation to safe care and treatment and good governance. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection, we found the provider remained in breach of regulations. We also identified a new breach in relation to fit and proper persons employed.

Why we inspected

We received concerns in relation to the management of people’s nursing care needs. As a result, we undertook a focused inspection to review 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 not changed following this inspection and remains requires improvement

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

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.

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

Enforcement

We have found breaches in relation to safe care and treatment, fit and proper persons employed and good governance at this inspection.

Please see the action we have told the provider to take at the end of the full version 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.