13 April 2023
During an inspection looking at part of 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