Wyndham House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection (publish 31 May 2018) the rating for this key question was Good. At this assessment the rating for this key question has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We found that the service did not effectively implement systems to assess and mitigate risk to the health, safety and welfare of people using the service and the management of their medicines. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have a robust systematic approach to determine and review the number of staff required in order to meet the needs of people using the service and keep them safe at all times. This was a breach of Regulation 18(1) (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Some improvements were needed in relation to infection prevention and control. People and their relatives told us they felt safe living at the service and were complimentary about the support received from staff. The provider took our feedback on board and immediately developed an action plan to address the concerns we identified during the assessment. They have been engaging with CQC to provide updates on the progress made.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at the service and their relatives did not share any concerns in relation to people’s safety. People we spoke with did not share any concerns in relation to the level of involvement they had in planning and reviewing their care. They were happy with the actions the service and staff were taking in relation to this. One relative told us; “Yes they do (know her well)- they call her [name of the person]- it feels personal- they always have banter with my mum which she loves.” Another relative told us; “It’s excellent (the care at the service)- we’re very happy with the care they’re receiving – no concerns.”

Senior staff described to us the processes followed, starting with pre- admission, to identify, assess and mitigate people’s risks. They talked to us about systems of monthly reviews they used to re-evaluate people’s risks and care needs, involving people and their relatives. They explained how the person and their families were involved in this process. Staff we spoke with gave us the impression they knew people well.

During the site visits we did not observe any unsafe practices in relation to supporting people to manage their risks. For example, we witnessed a person being hoisted by two staff members and people being supported to eat and identified no concerns. On the first day of the assessment, we observed very person-centred interaction from 2 staff members in particular, with people over the lunch time period.

We identified there was a lack of clarity regarding the criteria for a person having a risk assessment regarding access and use of the stairs. Staff who were responsible for creating and reviewing risk assessments gave different answers about who they would carry out an assessment for and what they reviewed as part of the ‘resident of the day’ which is a process used by the provider to carry out monthly reviews of people’s care. Other risks related to people’s care and support needs were not always robustly assessed and mitigated and the care documentation contained conflicting information in relation to levels of risk or measures in place. We identified serious concerns in relation to the management of risk related to skin integrity and repositioning regimes in relation to 2 people cared for in bed. For one person healthcare professionals asked for a repositioning regime to be implemented to maintain skin integrity. The service failed to incorporate this into the care plan, and we did not see recorded evidence that this was being carried out. Where people’s diabetes was managed through diets, there was minimal information available for staff about the specific requirements of their diets and no information to indicate that healthcare professionals were involved in supporting with this. Other concerns found included risks related to allergies, to people who were prescribed anticoagulant medicine and to personal care. Care documentation did not always provide clear and consistent information in relation to people’s capacity to make decisions in specific areas or to guide staff where there was a risk a person might become distressed and what actions to take to support them. This meant the service had failed to effectively implement systems to assess and mitigate risk to the health, safety and welfare of people using the service. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

A large proportion of the people and relatives we spoke with shared concerns about staffing levels. Some people told us that they had to wait when they required assistance. Comments included; “Have to wait a long time”, “Sometimes long waits” and “About 15 minutes wait”. One relative told us; “I do understand they are short staffed- it’s spread thinly. It’s probably the weekends there aren’t quite so many staff on.” People we spoke with did not share any concerns in relation to staff training and skills. Comments included; “Everyone is very caring, always asking if I need anything. They really care for people” and “We are given a certain independence; they are very good.” Feedback from people’s relatives was mixed when we asked if they felt staff had the training needed to support their relative. One relative told us; “Staff have been there a long time and seem to know what they’re doing – generally I would say staff seem to know what they’re doing.” Another relative told us; “I’d say yes on the whole apart from when they’re short staffed –agency staff not up to same as long term workers. I do know most of the staff, not very often agency staff, more at the weekends.”

All staff we spoke with shared concerns in relation to staffing levels. One staff member told us that while they were not concerned about people’s safety, a lot of the care staff were upset because they could not deliver a high standard of care. They said the use of agency staff, in their view, also posed difficulties. Another staff member described the difficulties they were having to meet people’s needs due to people’s needs increasing and staffing levels staying the same. The registered manager told us they had explained to staff about the providers dependency tool used to assess staffing levels and what the expected baseline was. They explained when needed they tried as much as possible to use consistent agency staff who are block booked to cover gaps in the rota and as a management team, they help out where they can. They explained that after busy or more difficult shifts, staff were supported through debriefs. The operations director spent time with us explaining how the provider’s dependency tool was calculated and how information inputted into this was informing the provider of the correct number of staff required for each shift. They told us that based on evidence they assessed; the number of agency staff used in the service was not at a concerning level. Staff confirmed that they were receiving training, predominantly completed online. Some of the staff told us about the recent dementia face to face training they completed and how they found it informative. The agency staff we spoke with were positive about the induction they received when they started working at the service. The registered manager described to us the staff induction program which consisted of training, shadowing and testing of staff competencies. They also provided information about the process of agency staff induction. The registered manager talked to us about their plans to schedule additional face to face training in subjects such as moving and handling and dementia.

During the two days of our site visits we observed call bells ringing for a long periods of time before they were answered. On the second day of the site visit, wait times ranged between 13 minutes to 78 minutes for the call bells we monitored. The operations director told us that their expected response time was 3 minutes and after 5 minutes the call bells go into priority mode.

The registered manager carried out a monthly call bell audit. They chose a one-hour window for one day per week, this varied from week to week. These were not effective in identifying long call times. When they did identify poor response times, no action was being recorded. Where falls audits and behaviour chart audits were identifying concerns related to staff’s availability, these issues were recorded, however no actions were identified and completed. At the last provider led audit, it was identified that call bells were ringing for a long time however, no action was identified. When completing the provider’s dependency tools, they did not take into account other sources of information such as falls analysis, the layout of the home, infections or behaviour charts. They only used information from people’s individual dependency tools which were updated by staff each month. We found that these were not always updated with the corrected information which might generate an incorrect dependency score. It was not clear if, when calculating staffing levels, the provider considered that the senior staff, who were allocated to support people’s care needs, had daily additional tasked assigned such as administering medicines, carrying out audits and care plan reviews, which took them away from direct support. The provider did not have a robust systematic approach to determine and review the number of staff required to meet the needs of people using the service and keep them safe at all times. This was a breach of Regulation 18(1) (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider followed safe recruitment practices to ensure people were cared for by staff who were suitable. The provider identified gaps in staff training and support, such as supervisions and appraisals and had a plan in place to address these. We looked at the progress made since the concerns were identified and noted consistent improvements.

People and relatives, we spoke with did not share any concerns in relation to the cleanliness of the home or infection prevention and control. One relative told us; “Very nice yes. It doesn’t feel like a care home.”

Staff we spoke with about infection prevention and control were able to tell us how they used PPE in accordance with best practice guidance. A member of staff from the domestic team talked to us about the cleaning regimes to minimise the spread of infection such as cleaning touch points around the home.

Our observations in relation to the cleanliness of the home and use of PPE during the site visit were mixed. While people’s bedrooms, en-suites and communal bathrooms were clean and odour free, we observed that in some of the corridors the carpet was heavily stained. On the first day of the site visit we observed some of the corridors to be cluttered, and some of the banisters to the stairs had chipped paint which meant they were more difficult to keep clean to reduce the risk of spread of infection. We observed a staff member walking around the home wearing full PPE and another staff member entering the toilet with a kitchen apron on. We discussed our observations with the deputy manager on the day. On the second day of the site visit, the corridors had been tidied up and were clutter free and the chipped paint on the bannisters was being addressed and painting had started.

The provider had systems to monitor the environment in the home. Cleaning schedules were in place to instruct staff of the tasks they needed to complete; however, these were not always maintained. We identified gaps in some of the cleaning schedules. The registered manager explained they hold a verbal discussion with staff in relation these, however no records were held to explain the gaps. The service, through their quality monitoring systems, had identified that some of the carpets needed changing and this had been passed onto the provider’s relevant department. However, it was not clear from the audits we looked at which areas had been identified as needing the carpet replaced. During our site visits, representatives of the provider were present on site, assessing the environment and approving the required carpet replacement. Prior to our assessment, the service did not have a regular schedule in place for carpet cleaning. Domestic staff and the management team told us that this was done when required. We have been told by the provider that they had developed a new carpet cleaning regime for all their services, however this had not yet been implemented. Following our feedback, the registered manager told us that they had organised for a professional contractor to come to the home to carry out cleaning of the carpets.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.