Inspection on 08/04/05 for Wyndthorpe Hall & Court

This inspection was carried out on 8th April 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.

Other inspections for this house

Wyndthorpe Hall & Court 03/05/07

Wyndthorpe Hall & Court 06/06/06

Wyndthorpe Hall & Court 20/12/05

Wyndthorpe Hall & Court 26/07/05

Wyndthorpe Hall & Court 25/11/04

Wyndthorpe Hall & Court 09/06/04

Wyndthorpe Hall & Court 15/12/03

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Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE WYNDTHORPE HALL AND COURT High Street Dunsville Doncaster DN7 4DB Lead Inspector Stephanie Kenning Unannounced 8th April 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 AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wyndthorpe Hall and Court Address High Street, Dunsville, Doncaster, South Yorkshire. DN7 4DB 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) 01302 884650 01302 890032 Four Seasons (No 6) Ltd Mrs Susan Howden CRH 44 Category(ies) of DE(E) 24; OP 20 registration, with number of places WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 25 November 2004 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 AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 9 hours and included reading service users care plans, speaking to 9 service users and 2 relatives, reading other documentation, observing meal times and medication, discussion with staff members and the manager, and a partial tour of the building. Some of the care plans and document reading were undertaken jointly with the contracting officer for Doncaster Metropolitan Borough Council due to an Adult Protection investigation at the same time. What the service does well: What has improved since the last inspection? There has been some refurbishment of the lounge and dining room in the Court that has brightened up this area significantly. Other areas are also being refurbished in the near future. The service had taken on board the recommendations of a previous Adult protection investigation, by giving clear written instructions for staff to follow, that staff members explained in detail when questioned. The service responded quickly to problems with the medication once identified during the inspection. Moving and handling practices have improved and the hoist is working. Recruitment of staff to vacancies has improved staffing levels. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 6 What they could do better: 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 AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 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 AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 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) 3, 4 and 5 The home admits people following an assessment of their needs, but is not always proactive in obtaining a review when circumstances change. Most service users get the care that they need from staff that they like. Potential service users are encouraged to visit the home before deciding about residency, though in reality it is usually their relatives who visit and assess on their behalf. EVIDENCE: Five care plans and assessments were read and discussed with service users, their relatives and care staff. They were variable in their level of detail, some information, particularly in risk assessments was excellent, though not often followed through in the care plans with clear instructions, for example, offer assistance when required. One case file was studied in more detail due to an incident and was found to have omissions in assessment, care planning, daily recording, and recording of accidents through correct procedures. The assessment relating to someone recently admitted covered all the required areas, but again did not give clear instructions for staff to follow. This person had been admitted to the EMI unit, but does not have dementia. A variation to WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 9 their registration has been applied for in order to provide continuity of care to this person with regular support from mental health services. Service users were mainly happy with how their needs were being met and were complimentary about the staff, using the words helpful, very good, patient and understanding. The exception to this is when they are short staffed and service users said that some staff members were not as patient on those occasions. Relatives confirmed that they had visited prior to selecting the home for the service users. Sometimes staff had visited service users at home or in hospital prior to the admission. One person had visited the home with the social worker. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 10 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, 8, and 9. Care plans were variable in their quality, but many did not give clear detailed instructions to follow. This makes it difficult to judge if the care is appropriate to an individual, including health care. There have been a number of requirements for care plans over previous inspections including one for management to audit them, and some progress has been made. Medication practices require some attention to detail to ensure safety for service users. EVIDENCE: Within the care files for individuals are separate assessed areas of need with identified risks, long and short - term goals and then care team actions. The risk assessments often had very good information in them, though could benefit by being simpler. For example under health care needs someone had both a mental health problem and a urine problem in the same paragraph. This complicates both the goals and care team actions which require separating to be clear. Some of the action statements were not clearly written, for example, “maintain regular observations throughout waking hours”. Of the five care plans read all had these problems in some of the areas of need. Not all risk assessments were dated, not all areas were completed such as wishes WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 11 regarding death and dying, and the wrong name was noted in at least one plan. Issues identified in daily records were not always referred to again, though when discussed with service users and staff they had been resolved, indicating that the recording was at fault rather than the care. Some of the daily entries do not explain what has happened, such as ‘safety maintained’. Several falls or accidents recorded in the daily records were not found in the accident book. One person was on medication to reduce aggressive behaviour, but did not have a care plan for aggression management potentially putting everyone at risk. All of which makes it difficult for staff to have instant information to maintain care needs. Community nurses attend the home several times a week. Appointments to hospitals, opticians, dentists and other health care services were noted. The local GP visits the home each week and was said to offer a good service. This ensures that the service users health needs are provided for affectively. Medication practices were observed and discussed with staff. Cigarettes were stored in one of the trolleys and removed immediately upon request as these are not medicines and could contaminate other products. One person was prescribed two painkillers, but was only given one, this may not have been adequate for their pain relief. Another service user was prescribed medication that did not have a dosage on either the bottle or the administration record so staff, were unsure what should be given putting service users at risk. The staff member immediately contacted the pharmacist and GP for instructions. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 12 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) 12, 13and 15 . Service users have a fairly quiet life with some organised activities. Visitors are able to see service users as they wish including in the privacy of their own rooms if required. Meals are generally enjoyed, but do not appear to contain sufficient fruit and vegetables. EVIDENCE: There are five lounge areas and two dining areas between the two parts of the home, each with a regular group of occupants. Most areas had a television or music playing during the day and some people spent part of the day asleep in these areas. Staff members initiated some activities with individual service users or small groups. Some people stated that they liked to watch the comings and goings at the home, or to pursue their own interests. Some people spent time in their own rooms and had books, music, televisions, crafts, and other occupations available. Two service users stated that they would like more outings. Staff vacancies at the home have meant less time available recently for outings, though that has now been addressed. The menu for the day was tomatoes and poached egg for breakfast, baked or fried fish, chips or mashed potatoes, mushy peas, then semolina at lunch, assorted sandwiches, sausage roll and buns for tea. No fruit was seen around the home, and the menu did not offer the minimum recommended 5 portions of fruit or vegetables to maintain health. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 13 Service users were generally content with the meals and enjoyed the lunch on the day of inspection. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 14 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) 18 The home was able to identify potential or suspected abuse situations and have initiated action on more than one occasion. However the number of referrals raised a concern requiring monitoring. EVIDENCE: An adult protection investigation advised a change to a service users care plan and risk assessment. This was seen and was recorded clearly and in detail. The situation was discussed with staff members who were able to explain what they do and why, and this linked to the care plan. There are now two further referrals to Adult Protection under investigation. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 15 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, 21, 25 and 26. This home has some poor services that affect the comfort of the service users despite attempts to rectify the problems. The building requires a lot of maintenance and some refurbishment has improved the internal appearance. EVIDENCE: The lounge and dining room in the Court has been redecorated with some new chairs and new flooring and is a big improvement. Further redecoration is underway in other areas of the home. The exterior redecoration did not get done last year as planned though is expected shortly. The gardens are much tidier than last year. A number of bedrooms and a bathroom were found to have no hot water despite running the tap for several minutes. Work has been done on the boilers to try to rectify the situation though it has not worked. Service users were also unhappy about having to use bathrooms that are not near to their WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 16 rooms due to two bath hoists being condemned. The lift has a history of frequent breakdowns and three service users recently had to sleep downstairs overnight in the lounge areas. The lift is currently working, and the manager explained the circumstances of that particular situation. It had not been notified to CSCI as required. A previously broken mobile hoist has been repaired and it is still the only one for the home to provide safe movement of service users who need assistance. An upstairs bathroom contains a wobbly wardrobe, an unstable chair, shelves containing toiletries including prescribed creams, and the shower cubicle had a bucket and a number of cleaning products, including one unlabelled bottle. These are all unsafe practices that should cease. Generally the home was clean and odour free. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 17 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 The staff team are hard working and knowledgeable about the people in their care. There were sufficient staff to meet the basic needs of the service users, but there are times when absence causes problems. EVIDENCE: The staff rota was examined and minimum staffing levels are maintained most of the time. Staff and service users confirmed that there is sometimes a problem if someone is absent, leaving the home short staffed. The manager has recruited to vacant posts and also has two relief staff that can be contacted at short notice. This is an improvement since the previous inspection. A senior carer is in charge of each shift, with 2 teams of care assistants located in the different parts of the home. At busy times more staff including seniors are on duty. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 18 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) 31, 37 and 38 Lack of attention to detail and monitoring of situations has resulted in the number of requirements identified including some unsafe practices. Some of these items are not new and should have been dealt with before. EVIDENCE: The manager has been at the home for many years and is experienced in both management and with the service user group. She is undertaking a management qualification. There are clear lines of accountability in the home and with the external management of the company. A monthly visit by the regional manager is recorded and a copy sent to the CSCI, which should be used to inform both parties about the practices in the home and how the service users feel about the care they receive. As previously reported the care plans and accident recording are not as clear or accurate thus preventing the information to be assessed as part of risk , management WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 19 Risk assessments are available and cover a wide range of activities. Adequate storage is available for cleaning materials and hazardous substances, though some were found in a bathroom and one container was unlabelled which is poor practice. WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 20 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x x x x x 2 2 WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 21 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Standard 7 7 7 7, 37, 38 9 9 9 9 18 19 19 19 Regulation 15 15 15 17 13 13 13 13 13 23 23 13 Requirement Ensure care plans give clear instructions, are up to date and accurate . Ensure issues reported are are followed up and recorded Daily entries should descibe actual care given. Ensure all accidents are reported and recorded in the accident book. Remove non medication items from medication storage. Ensure medication is recorded accurately Check medication dosage prior to administration. Implement a system for auditing medication. Monitor the Adult Protection referrals and comply with any recommendations. The peeling exterior paintwork should be addressed (previous timescale of 1 /3/05 not met) Investigate the cause and address of the frequent breakdown of the lift. Remove unstable furniture from service user areas. J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Timescale for action 1/8/05 ongoing 1/6/05 ongoing actioned immediatel y. ongoing ongoing 1/8/05 ongoing 1/7/05 1/7/05 1/6/07 WYNDTHORPE HALL AND COURT Version 1.30 Page 22 13. 14. 19 25 13 23 Remove hazardous materials from service user areas and store securely Ensure the work on the heating and hot water is completed and adequate.( previous timescale of 1/1/05 not met) immediate 1/7/05 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 7 12 15 Good Practice Recommendations Separate different areas within risk assessments Consider outings and staff availability Review menus to provide adequate fruit and vegetables WYNDTHORPE HALL AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire 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 AND COURT J55-J07 S48425 Wyndthorpe Hall V206416 80405.Stage 4.doc Version 1.30 Page 24 - 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. 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