Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 26/07/05 for Wyndthorpe Hall & Court

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

This inspection was carried out on 26th July 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

People who use the service were generally happy with the care they received, and found most of the staff kind and hard working. Staff members were knowledgeable about the service users in their care and had all received some training. Meal times were calm and relaxed with people being assisted appropriately. The home was clean despite the decorating in progress.

What has improved since the last inspection?

The building was in the process of being decorated externally and some of the interior, especially the sitting and dining areas. This has significantly improved those areas along with new carpets/ flooring and some new furniture. One of the bathrooms on the first floor was cleaner, had locks on the cupboards, new curtains and ornaments. The sluice room door is now locked improving safety for service users. Essential work to the lift has been carried out to try to prevent the frequent breakdowns. Work has been done on the boilers to try to address the problems with the hot water, though it still takes a long time for some rooms to get hot water so further work is being planned.

CARE HOMES FOR OLDER PEOPLE WYNDTHORPE HALL & COURT High Street Dunsville Doncaster DN7 4DB Lead Inspector Stephanie Kenning Unannounced 26 July 2005 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 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 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wyndthorpe Hall & Court Address High Street Dunsville Doncaster South Yorkshire DN7 4DB 01302 884650 01302 890032 Telephone number Fax number Email 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 Ms Susan Howden PC Care Home only 44 Category(ies) of DE Dementia - Over 65: 24 registration, with number OP Old Age: 20 of places WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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. Date of last inspection 08 April 2005 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 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 05.30 in the morning when night staff were still on duty. It involved one inspector who spoke to staff on duty, service users as they got up and throughout the day, and visitors to the home. A partial tour of the building took place and a sample of staff files and care plans were looked at. The inspection took about 9 hours. What the service does well: What has improved since the last inspection? What they could do better: The workmen sleeping in vacant service user rooms should be accommodated in separate facilities. Consideration should be given to staffing levels, especially at night due to the layout of the building, and to cease the practice of getting service users up early in the morning. A review of routine practices WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 6 during the night should be done to look at things like bedroom doors being propped open, radios on whilst people are sleeping, and ways of promoting sleep and a quiet environment. Communication between staff and the quality of information passed on about service users could be improved, including organising the work and directing the staff. The attendance of night staff on courses provided was poor and should be improved. There is still only one hoist for the whole building that is based on the hall, though there are 3 service users on the court side that require it for moving and handling. Care plans have not been improved as required at the previous inspection. 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 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 standard(s) The key standards were assessed and met at the previous inspection. EVIDENCE: WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 standard(s) 7, 10. Care plans still require updating and improving in order to clarify the care needed. The home is a busy place at night and early in the morning, and many people were up before the day staff came on duty. EVIDENCE: The previous inspection identified that care plans required improvements though this has not yet happened due to awaiting the advice of the contract monitoring team. A meeting with the staff is planned to address this in the very near future. The night routines described by staff indicated that the home was very busy, and some service users were up and about during the night, or very early in the morning. It is usual for night staff to get a significant number of service users up before the day staff arrive, as they are at risk from falls once they are awake, though several people were seen to be dozing in the sitting rooms and others were complaining of the cold. Some service users had their doors propped open during the night risking disturbance and lack of privacy. One service user with the door propped open had a radio on that could be heard on the corridor and could potentially disturb others. Some people were up early and did stay in the privacy of their own rooms. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 10 The workmen doing the decorating were found to be staying in vacant rooms registered for service users, and were sharing the same bathroom and toilet facilities. This is not acceptable for the privacy and dignity of the service users. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 11 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 standard(s) 14 There are aspects of service users lives where they do not feel in control, such as when they get up. EVIDENCE: From early in the morning the home was busy, with a number of service users up and staff attending to others. Some people stated that they would have preferred to stay in bed, though some of the care plans indicated that they normally did get up early. Staff also explained that a number of service users are at risk if they are left in bed, as they get up by themselves and may fall. It is expected that a number of service users get up before the day staff start, which means that service users do not get a choice realistically. It is required that the issues of choice, risk and routines are looked at for each individual. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 12 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 standard(s) 16 There is a clear structure in place for complaints to be dealt with and this has been followed appropriately. EVIDENCE: Complaints are recorded and action taken including those referred initially to other organisations such as CSCI. The home management have initiated some changes as the result of complaints and adult protection investigations and are working on implementing improvements from a recent review of their service. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 13 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 standard(s) 19, 25, 26 The services and appearance of the home have improved, though some of the work is not yet finished. EVIDENCE: The lift has had essential work done that should prevent the frequent breakdowns. The hot water does get through to the areas where there have problems though it still takes a long time, and further work is being planned. There is still only one mobile hoist that is located in the hall despite 3 people on the court needing to use it regularly. A bathroom has been cleaned, with new curtains, ornaments, locks on cupboards and is a much more pleasant room than previously. Redecoration of sitting and dining rooms, and some service user bedrooms has greatly improved them, and some new furniture and flooring has also been provided. The external decorating has been done and is a great improvement to the structure of the building. During the decoration the manager provided a risk assessment for managing the health and safety of service users. The sluice door was found to be locked as required for the safety of service users. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 14 Despite the amount of upheaval due to decorating the home was very clean. There are some areas that have acquired some untidiness such as items being left in bathrooms, and store- rooms were overcrowded. One bathroom had 6 bars of soap that presumably cannot be returned to their rightful owners. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staffing levels are low especially at night, and may not be allowing service user choice. EVIDENCE: Staffing levels have been reduced due to lower occupancy and the night shift were very busy, following routines requiring them to get up a number of people before the day shift. There are now 3 carers on duty at night for the hall and court and as both units are on two floors it is difficult for staff to monitor all areas. There was some uncertainty as to which member of night staff was in charge of the home, which may have been a problem if an incident had occurred. Several staff files were seen including night staff and people that had left the home within the last 6 months. These showed that recruitment procedures had mainly been followed although one person did not have any references on file. The night staff training records show that only a few courses have been attended, usually fire and moving and handling. Care staff should be appropriately trained, and it is essential that staff on night duty, (without a senior member of staff), are well trained for the safety and comfort of service users. Of the staff leavers’ minimal information was recorded about their reasons for leaving, and no exit interviews were recorded. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36. The home is improving on the management of health and safety issues, but needs to look at how it is run to be in the best interests of the service users. EVIDENCE: Staff members were aware of service users needs and were busy attending to these needs throughout the inspection. The morning handover from night staff only referred to one service user and then day staff read independently from a diary that had information from previous days. No discussion of the work took place and no direction from the senior. The staff have routines that they follow and rely on lists, for example bathing, to determine their work. The previously mentioned routines of getting service users up early may not be in their best interest and should be looked at. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 x COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x 3 x x WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? 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. Standard 7 Regulation 15 Requirement Care plans give clear instructions, are up to date and accurate. Previous timescale not met. Ensure the respect and privacy of service users regarding propping open doors at night. Workmen should not be accomodated in service user areas. Ensure that each individual has choices in getting up, and that risks are managed individually Ensure that work on the hot water system is completed and adequate. Previous timescale of 1/1/05 and 1/7/05 not met. Provide sufficient staff to cover all the building Ensure that the person in charge is identified and is aware of the reponsibilities of the role. Timescale for action 31/12/05 2. 10 12 1/12/05 3. 10 12 immediate 4. 14 12, 15 immediate 5. 19 23 1/12/05 6. 7. 27 28 18 18 immediate immediate WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 19 8. 9. 29 30 18 18 Ensure that references are taken for all staff prior to employment Ensure all staff receive the training to do their job competently. Ensure that the routines of the home are in the best interests of the service users. Cease the use of the communal communication books immediate 31/12/05 10. 33 12, 15 immediate 11. 36 17 immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 19 29 36 Good Practice Recommendations Provide another hoist for the safe moving and handling of service users in each part of the home. Conduct and record exit interview with staff leaving the service to highlight areas of concern. Review the handovers, shift management, and communication systems. WYNDTHORPE HALL & COURT 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 20 Commission for Social Care Inspection First Floor, Barclay Court Heavens Walk 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 20050726 Wyndthorpe Hall X00015 UI Stage 4 S48425 V178511 J55.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!