Wyndthorpe Hall & Gardens Care Home

Updated 26 May 2023

The inspection

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 2 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

Wyndthorpe Hall and Gardens is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Wyndthorpe Hall and Gardens is a care home with nursing care. CQC regulates both the premises and the care provided and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection the service had 2 registered managers in post. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority and local Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return (PIR). 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 used all this information to plan our inspection.

During the inspection

We spoke with 6 people and 2 relatives about their experience of the care provided. We spoke with the 2 registered managers, the compliance and support manager for the organisation, the deputy manager and 5 members of staff from the care, administration and maintenance teams. We reviewed a selection of records which included 4 people's care records and 4 staff recruitment files. We reviewed a range of medication records in each of the buildings and looked at a variety of records relating to the management of the service.

Updated 26 May 2023

About the service

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