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Inspection on 20/12/05 for Wyndthorpe Hall & Court

Also see our care home review for Wyndthorpe Hall & Court for more information

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager and staff team are dedicated to the people in their care, and are keen to make changes to meet the standards required. Despite the problems with the care plans the needs of the service users do seem to be being met, and carers knew about the people in their care.

What has improved since the last inspection?

There has been a significant amount of redecoration to the interior and exterior of the home, mainly in the communal areas such as the large entrance lounge, and the dining room in the Hall. This has significantly improved those areas. The majority of requirements from the previous inspection have been met or are in the process of being met.

What the care home could do better:

There are some outstanding requirements that need to be addressed urgently regarding the lack of hot water to bedrooms, location of night staff, and improving the care plans, to ensure the safety of residents. There were a lot of minor issues to do with the building that collectively offer a poor standard forservice users and these should be addressed and systems put in place to prevent a recurrence. Medication administration did not ensure the safety of resident`s as the decanting of tablets is not acceptable as a safe practice. A full medication review and refresher training is required of all staff.

CARE HOMES FOR OLDER PEOPLE Wyndthorpe Hall & Court Wyndthorpe Hall High Street Dunsville Doncaster DN7 4DB Lead Inspector Ms Stephanie Kenning Unannounced Inspection 20th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wyndthorpe Hall & Court Address Wyndthorpe Hall High Street Dunsville Doncaster DN7 4DB 01302 884650 01302 890032 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Four Seasons Homes (No 6) Limited (A wholly owned subsidiary of Four Seasons Healthcare) Mrs Susan Howden Care Home 44 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (20) of places Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A service user with a mental disorder, named on variation dated 3rd May 2005, may reside at the home. 26th July 2005 Date of last inspection Brief Description of the Service: Wyndthorpe Hall and Court are one registered service providing two types of service in separate parts of the building. The old Hall is a converted building for up to 20 older people who do not require nursing care. The Court is an extension for up to 24 older people who have dementia, but who do not require nursing care. It is set in large gardens at the edge of the village of Dunsville near Doncaster. Another home, also owned by Four Seasons, is located in the grounds of the home, and the regional offices of the company are based in Wyndthorpe Hall. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the daytime (9 hours) of the 20th December 2005 and involved an inspector and the regulatory manager. This was the third unannounced inspection of the year in order to look at some of the outstanding issues identified on earlier inspections. A partial tour of the building was undertaken to assess the environment that the service users were experiencing. Some records and documents including 4 care files were examined, and the opinions of some service users, relatives and staff were obtained during the day. All of the key standards had already been assessed at previous inspections, and therefore only a few standards were examined on this occasion What the service does well: What has improved since the last inspection? What they could do better: There are some outstanding requirements that need to be addressed urgently regarding the lack of hot water to bedrooms, location of night staff, and improving the care plans, to ensure the safety of residents. There were a lot of minor issues to do with the building that collectively offer a poor standard for Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 6 service users and these should be addressed and systems put in place to prevent a recurrence. Medication administration did not ensure the safety of resident’s as the decanting of tablets is not acceptable as a safe practice. A full medication review and refresher training is required of all staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9,10 Care plans continue to require more clarity and accuracy for service users to receive the correct care. EVIDENCE: A number of care plans were seen selected from both areas of the home. Care plans did not give clear instructions, and were not up to date and accurate. This was a requirement of the previous inspections, the last one being 31/12/05 so not timely for this inspection, however, the care plan offered as using the new system was no clearer in its instructions for staff. Two previous requirements regarding privacy have been addressed. The decorators that were accommodated in service user areas were moved to separate accommodation. Bedroom doors were not propped open except at the request of the service user, ensuring more privacy. Medication was seen as being decanted into medicine pots with resident’s names on. This is unacceptable as a practice as errors can be made. A full review of the medication administration procedure and all staff who administer must receive further training. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection. EVIDENCE: Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection. EVIDENCE: Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25, 26. There were many problems associated with the maintenance, presentation and comfort of the service users rooms and some other areas. Communal areas have been redecorated and are better maintained. EVIDENCE: There has been an extensive programme of redecoration and refurbishment to most of the communal areas that has greatly enhanced the overall appearance of the home. In addition the exterior of the building has been decorated helping to maintain the fabric of the building as well as improving the appearance. During the tour around the building the following list of items requiring attention was made. At least 9 rooms plus a bathroom had no hot water and several had water that was not hot enough to wash. There have been ongoing problems with the hot water supply that have not been rectified. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 13 Chemicals/ cleaning products were found in unlocked cupboards putting the safety of service users at risk. Bedrooms had a range of problems affecting the comfort and safety of service users, as follows Leak under sink. Light shades missing. Curtains too short and held on track by elastic bands. Window lock broken off. Broken television Ariel in a bedroom No nurse call lead Dirty bedding. Hole in door where a lock had been. Bed rail covers not secure. Dirty commodes, one also broken Radiators not covered. Loose taps. Part of a frame to a door is off in one bedroom. Door lock broken to a bedroom. Carpets loose in some bedrooms. Leak on windowsill. Wardrobe was leaning forwards and the back of it coming loose. Loose headboard. Poor quality light fittings are in bedrooms. The following problems were identified in communal areas affecting the comfort and safety of service users. Cereal containers without lids found in cupboards in dining area. Dirty medicine pots with names on. Dirty dining chairs. Poor picture on TVs in lounges. Dirty fish tank. Many light bulbs are not working. Radiator covers loose. Handrail is missing on corridor. Staff smoking in sluice room that has clean and dirty clothing stored Combined medicine room/ smoking room/ activities room. Medicine room has a drinks machine to which access is given. Bits of wheelchairs were in lounges such as footrests. The following problems were identified in bathrooms and toilets affecting the comfort and safety of service users. Tiling is unfinished in a bathroom. Decorating is unfinished in a bathroom. Damage to ceiling in bathroom. Wheelchair toilet has leak, sink loose, no handrail. No light cover in gents or ladies. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 14 Dirty extractor fans and some covers hanging off. No lid on bin in toilet. Urinal was stained and dirty. Creams (with no tops on) left in toilets. Personal items in bathrooms Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The layout of the building requires more staff on duty at night. EVIDENCE: There is insufficient staff cover for all the building at night. This was a requirement at the previous inspection and though occupancy is reduced the building is on two floors and is split in to two distinct units only accessible on the ground floor. Currently there are 3 staff members on duty at night. Some other previous requirements to do with recruitment, responsibilities, and training were stated to have been addressed, and were not inspected on this occasion. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36 The management of the home has been reviewed and has changed some of the practices in the best interests of service users. EVIDENCE: The routines and practices of the home have been reviewed to promote the interests of the service users as required by the previous inspection. None of the service users stated that they had been asked to get up very early for the work to get done. Shift handovers have also been reviewed and the use of communal communication books has ceased. Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X X Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP38 OP19 Regulation 16 23 Requirement Ensure chemicals are locked away according to COSHH and health and safety regulations. Address the many problems noted in respect of the environment, providing an action plan with dates to achieve the work required. Provide sufficient staff to cover all the building, including at night. Ensure that work on the hot water system is completed and adequate. Previous timescales of 1/5/05, 1/7/05 and 1/12/05 not met. Care plans should give clear instructions, be up to date and accurate. Previous timescale of 31/12/05 was after this inspection. The practice of administering medicines in pots with names on must cease immediately, and a full review of medication administration must be undertaken and all staff fully trained. Timescale for action 28/02/06 31/03/06 3. 4. OP27 OP19 18 23 28/02/06 28/02/06 5. OP7 15 17/03/06 6. OP9 13 (2) 31/03/06 Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyndthorpe Hall & Court DS0000048425.V269658.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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