This was an unannounced inspection that took place on 31 July and 1 August 2015. We carried out this inspection to check that improvements had been made following our previous inspections of the 15 and 28 January 2015. The findings of these previous visits led us to rate the home as inadequate and serve warning notices and compliance actions as the provider failed to meet all the requirements of the regulations.
At the inspection in January 2015 we found the home was in breach of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010:
Regulation: 9 Care and Welfare of people who use services
Regulation: 10 Assessing and monitoring the quality of service provided
Regulation: 11 Safeguarding people who use services from abuse
Regulation: 12 Cleanliness and infection control
Regulation: 13 Management of medicines
Regulation: 14 Meeting nutritional needs
Regulation: 16 Safety, Availability and suitability of equipment
Regulation: 18 Consent to care and treatment
Regulation: 20 Records
Regulation: 23 Supporting staff
Regulation: 21 Requirements relating to workers.
In addition the home was failing to notify us of events they are required to by law. Which was a breach of Regulation: 18 of the Care Quality Commission (Registration) Regulations 2009; Notification of other incidents.
The above regulations have now been replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We had asked the provider to make improvements in meeting people’s health and welfare needs, infection control, records, nutrition needs, safeguarding, safety and suitability of equipment, assessing and monitoring the quality of service and completing statutory notifications appropriately. We received an action plan from the provider detailing how these improvements would be made.
At this inspection of 31 July and 1 August 2015 we looked at all the areas where the home had breached the regulations set out above, and other areas to ensure that we carried out a fully comprehensive inspection. We found that there had been improvements across all areas that we looked at.
We found that the home was no longer in breach of the above regulations with the exception of Regulation: 14 Meeting nutritional and hydration needs.
We also found two new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation: 18 (Staffing) and 10 (Dignity and respect).
We found that the provider had not taken appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff to meet people’s needs . This was in breach of Regulation: 18(1) Staffing.
We found a breach of Regulation: 10 Dignity and respect. The provider had not actively worked with people to maintain their involvement in their local community and had not ensured that people were not unnecessarily isolated.
There was no registered manager in post at the time of our inspection. This is a breach of the provider's condition of registration and we are dealing with this matter outside of the inspection process.
A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Wyndham Manor is a purpose built residential care home situated in a residential area of Cleator Moor, Cumbria and is within walking distance of the local amenities. Accommodation and communal space is over three floors and all rooms are for single occupancy and have en-suite facilities. There are suitable shared areas and a garden. The home provides accommodation for up to 60 older people some of whom may be living with dementia.
We found that people’s care needs were being better met. People looked well cared for with good attention to detail to ensure people were well dressed and to their own taste. Call buzzers were answered promptly, and everyone we spoke to said they were well cared for by staff that were kind and caring. The atmosphere in the home was calm and orderly.
We judged the home to be safer because the provider had ensured that all staff had been given training to identify and report any potential harm or abuse of vulnerable adults. We had evidence to show that senior staff understood how to report, and where appropriate, manage any issues related to possible abuse.
Risk assessments related to the environment and the delivery of care were up to date. Accidents and incidents were managed correctly and reported to the appropriate authorities, including ourselves, CQC.
The home had recently employed a number of new staff and a further 11 where due to start once all employment checks had been completed. The home’s manager had introduced the paperwork for a staffing dependency tool to work out the right levels of staff to meet people’s needs. However this had not yet been put into action and we found that the staffing levels on the middle floor of the home were not sufficient to meet people’s needs, with staff reporting being “over stretched” on this floor. On the other floors the care needs of these people were generally being met with the exception of enough staff to allow people to go out of the home and engage in the local community. People living in the home told us they didn’t get out enough. Care staff also held this view.
We saw that the way staff were being utilised and deployed in the home had improved, with the addition of a “breakfast person” on each floor to help at this busy time and with more activity co-ordinators hours. We saw that senior staff were giving more of a lead and direction to staff to ensure people’s needs were met in an orderly and timely manner.
New staff were recruited properly and disciplinary action had been taken when staff were not fulfilling their job role.
We found that the provider had significantly improved the way medicines were managed. People received their medicines at the times they needed them and in a safe way.
Infection control had improved. The staff team had been suitably trained and had access to personal protective equipment. The home was clean and orderly.
All of the staff had received induction training. This had been followed up by training in all the core subjects the provider felt the team needed. Some staff had received further specialist training.
We did however identify a need for senior staff, including the manager, to have more in-depth training in the care and support of people who were living with dementia. We recommended that this should include developing a full dementia care strategy for the home on best practice in promoting consistent personalised care for people living with dementia.
We checked on staff supervision and appraisal and we found that the manager was in the process of updating these records and making them more in-depth. We saw good practice at a recently introduced staff handover session that used newly developed paperwork to communicate people’s changing needs.
People continued to tell us about the lack of variety in the food and menus offered. We found that there was a lack of detail in the dietary requirements of those people prone to weight loss, malnutrition and with specialist dietary requirements.
We observed mealtimes being much more orderly and staff were spending time and giving appropriate support and care to those people who needed more help. However we found that there was no overall strategy to focus on the quality and types of food offered to people who were at risk of malnutrition due to old age and for those who were living with dementia.
We saw evidence to show that the staff team sought support and advice from local GPs, community nurses, dieticians and mental health workers to promote peoples health and well-being. Healthcare and social services professionals told us that they had seen a marked improvement in the appropriateness of the referrals the home was making as staff were gaining confidence in their own skills and judgments.
The home’s environment had improved with new furniture purchased and suitable redecoration and refurbishment being done.
We judged that the care staff approach was much more individualised. Staff had been trained in delivering person centred care and we saw a much more focussed approach on the needs and strengths of people in the home. People told us the staff team were caring, respectful and supported them to retain as much dignity and independence as possible.
Assessment and care planning had been developed in more depth. A new style care plan had been introduced that was much clearer and with more detailed assessments of people’s needs. These plans were more person centred and were being regularly reviewed. There was a good level of detail that gave clear instructions to care staff. Care staff were given time to read these and both staff and people in the home were more involved in the development of the care plans.
Risk assessments were better developed and tools were being used to assess risks to people’s health and wellbeing. We found that some care plans still required more detail, particularly when a person had a more complex healthcare needs. We saw that some staff required more training on how to use risk assessment tools associated with these more complex healthcare needs.
Care planning now identified in more detail the needs of those people whose behaviour may challenge the service. These now gave staff more detailed guidance on the most appropriate approach. These had been based on training and guidance given by social and healthcare professionals. Staff told us they were more confident in supporting people.
While we found people’s personal care needs were being better met we found that community involvement and socialising outside of the home was limited due to staffing levels.
Activities and entertainments within the home had improved significantly, with activity coordinators engaging people in activities they found interesting and stimulating. The arts and crafts session was now a very positive feature of the home, with people’s art work being displayed in the corridors and communal areas of the home. However, this was currently limited to weekdays only and people expressed being bored at other times, especially those who could not leave the home without family or staff supervision. The manager discussed plans to extend the activity coordinators hours to cover evenings and weekends.
We found that the home was now meeting the requirements of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Assessments were being carried out of people’s capacity to make decisions. Where people lacked the ability to make a decision about living at the home or when restrictions had been placed on them in their best interests we saw that appropriate application had been made for a DoLS assessment. Staff had received training in this area.
Measures had been put in place to improve the running of the service. Staff meetings, unit meetings, supervisions and the newly developed training matrix were now being monitored by the manager.
The home had developed a more robust quality assurance system. However this had yet to be embedded into the running of the service in a way that identified the issues we had found and continued to find at this inspection.
We saw improvements in most areas of concern highlighted at our previous inspections. However we felt that sustaining and building on these improvements was crucial to offering people a consistently good level of care and support. This would require commitment from the provider in appointing a registered manager and to offer support to the staff team so that they provide an effective service. This is concerning given that we found new breaches and one continuing breach relating to people’s nutrition. The registered provider gave us assurances that every effort was being made to secure a registered manager.
You can see what action we told the provider to take at the back of the full version of this report.