CQC report explained · a nursing home
What the CQC found at Wyndthorpe Hall & Gardens Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected from abuse and there were enough staff, but cleanliness and infection control were not reliable. Medicines were generally managed safely, although some records and sharing of learning needed improvement.
- Effective?
- Good
- This focused inspection did not assess the Effective key question.
- Caring?
- Good
- This focused inspection did not assess the Caring key question, although inspectors observed staff providing caring and compassionate support.
- Responsive?
- Good
- This focused inspection did not assess the Responsive key question.
- Well-led?
- Requires improvement
- Management oversight and audits were not effective enough to identify problems. New systems had been introduced, but they were not fully implemented and some staff did not feel that raising concerns led to change.
What inspectors found, May 2023
Requires Improvement; inspectors found kind and safe support in some areas, but cleanliness and management checks were not good enough.
This was an unannounced focused inspection on 13 and 18 April 2023. Inspectors spoke with people, relatives, managers and staff. They reviewed care records, medicines records, recruitment files and management checks.
The home had made some improvements since the previous inspection. People were safeguarded from abuse, there were enough staff, and staff were caring and compassionate. Risks, fire safety and equipment checks were generally managed appropriately.
However, some areas were not clean, including hairdressing rooms and a bedroom floor. Food and drink fridge checks were incomplete, and one fridge was too warm. Management audits had also failed to identify several problems, including gaps in safety checks and an incomplete legionella risk assessment.
The overall rating remains Requires Improvement. This inspection only assessed Safe and Well-led. Both were rated Requires Improvement, and the home remained in breach of regulations about safe care and treatment and good governance.
People felt safe
People were safeguarded from abuse, and staff knew how to report concerns. People and relatives told inspectors they felt safe.
“People were safeguarded from the risk of harm and abuse.” from the report
Caring staff
Inspectors saw staff being caring, compassionate and thoughtful. People also spoke positively about the staff.
“We observed that staff were caring, compassionate and thoughtful in their care and support for people who lived at Wyndthorpe Hall and Gardens.” from the report
Enough staff
Inspectors found there were enough staff on duty to provide care and support. Recruitment checks were completed before staff started work.
“There were enough staff on duty to provide care and support to people.” from the report
Premises safety improved
The home had improved its checks of the building and equipment since the previous inspection. It was no longer in breach of the premises and equipment regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 15.” from the report
Cleanliness and food storage
seriousSome rooms and a bedroom floor were not clean. Fridge temperature records were incomplete, and one fridge was too warm for safe storage of food and drinks.
“The hair dressing rooms in both Wyndthorpe Hall and Court and Wyndthorpe Gardens were not clean.” from the report
Weak management checks
seriousDaily walkrounds and audits did not identify several problems. Water, shower, fridge and legionella checks were incomplete or ineffective.
“Systems had not identified all of the shortfalls we found during this inspection.” from the report
Medicines records
needs fixingMedicines were generally managed safely, but records for medicines given when needed and fridge checks could have been better organised. Inspectors recommended more sharing of learning between the two parts of the home.
“Medicines were managed safely but paperwork for people's as and when (PRN) medication could have been better organised.” from the report
Slow sharing of lessons
needs fixingThe home reviewed accidents, incidents and safeguarding referrals, but staff feedback about lessons learned could take up to six weeks.
“Lessons learned were identified but there were long gaps of up to 6 weeks between lessons learned being identified and subsequent feedback to staff.” from the report
- 01What has been done to clean the hairdressing rooms, the sticky bedroom floor and other areas identified by inspectors?
- 02How are fridge temperatures, food dates, water temperatures and shower head cleaning now checked and recorded?
- 03What action has been taken to complete and update the legionella risk assessment?
- 04How do managers now check that care products, personal items and medicated lotions are stored appropriately?
- 05How are medicines learning and good practice shared between the nurse-led and residential units?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key questions were not assessed in this inspection. This explanation was written from the published report of 26 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Requires Improvement; inspectors found medicines and safeguarding were managed well, but the home had serious maintenance, cleanliness and leadership weaknesses.
This was an unannounced inspection on 14 September 2022. Inspectors looked only at Safe and Well-led because the inspection followed concerns about infection control, care planning, governance and risks. They spoke with people, relatives, managers and staff, and checked care, recruitment and management records.
The home managed medicines safely, had safeguarding procedures and had enough staff on the inspection day. However, parts of the building were worn, dirty or poorly maintained. Inspectors found problems with infection control, fire safety and equipment, and staffing levels were not clearly based on people's needs.
Leadership and quality checks were not effective. Problems had not been identified or dealt with, including concerns previously raised by the local authority. The overall rating fell from Good at the previous inspection, published in December 2020, to Requires Improvement. The report found breaches of regulations and issued a warning notice about governance.
Medicines
Medicines were managed safely. Records matched the medicines held, and staff had training and competency checks.
“People's medicines administration records (MARs) were completed correctly and medicines stock held by the service was consistent with stock levels documented on the MARs.” from the report
Safeguarding
There were systems to protect people from abuse. Staff knew how to report concerns, and people told inspectors they felt safe.
“Care staff had received training in safeguarding people and knew how to report concerns.” from the report
Safe recruitment
The home completed checks before employing care staff, including references and criminal record checks.
“A range of checks were completed. These included obtaining references and undertaking a criminal record check” from the report
Team support
Staff said they felt supported and valued. Inspectors also found positive working relationships between staff.
“We are a good team, and all pull together.” from the report
Poor maintenance and safety risks
seriousParts of the home and equipment were not properly maintained. Inspectors found problems involving baths, fire extinguishers, an electrical socket, fire escape access and worn surfaces.
“The provider had failed to ensure the premises was properly maintained. This placed people at risk of harm.” from the report
Infection control and cleanliness
seriousSome areas needed a deep clean. Flooring, waste bins and staff mask use did not always support effective infection prevention.
“Areas of the home were in need of a deep clean.” from the report
Weak management checks
seriousThe home's audits and quality systems did not identify or resolve important problems. This included concerns already raised by the local authority.
“The lack of effective management oversight and governance arrangements meant people were at risk of harm.” from the report
Staffing decisions
needs fixingThere were enough staff on the inspection day, but staffing levels were not clearly worked out from people's assessed needs and changing dependencies. Some people said they sometimes waited a long time for help.
“Staffing levels were not demonstrably based on people's care needs.” from the report
Limited family involvement
minorThe report found limited evidence that people and families had been involved in the service. One relative said they had to ask to see a person's care plan.
“There was limited evidence that people and their families had been involved in the service.” from the report
- 01Which repairs, deep cleans and fire safety improvements identified in this report have now been completed?
- 02How do you now check infection prevention, cleanliness and correct use of protective equipment?
- 03How are staffing levels calculated from each person's needs and changing dependencies?
- 04What changes have been made after the warning notice about governance?
- 05How are residents and families now involved in care plan reviews and service meetings?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 17 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Wyndthorpe Hall & Gardens Care Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Wyndthorpe Hall & Gardens Care Home →
- December 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Wyndthorpe Hall & Gardens Care Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017
Registered with the Care Quality Commission on 28 April 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
92 live-in carers within about an hour of Doncaster
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“I can honestly say without Petros I don't believe he would have lived an extra 2 years”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.