CQC report explained · a nursing home
What the CQC found at Dean Wood Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
Inspected but not rated; inspectors found good infection control, safe visiting arrangements and appropriate management of COVID-19 risks.
This was an announced, targeted inspection on 24 February 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.
The home was clean and tidy. Inspectors were assured that it was using personal protective equipment safely, arranging testing, managing outbreaks and admitting people safely. Visits were supported in line with the guidance in force at the time.
The home was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement for the five areas of care.
Clean surroundings
Inspectors found the home clean and tidy, with cleaning schedules covering frequently touched areas.
“The service was clean and tidy throughout. There were robust cleaning schedules inclusive of high touch point areas, to promote safe infection control practices.” from the report
Safe use of PPE
Staff had received infection control training and inspectors saw them wearing personal protective equipment correctly.
“Staff were observed to be wearing PPE correctly.” from the report
Visits were supported
The home had visiting procedures and had enabled people to receive visits safely and regularly during the pandemic.
“The registered manager has facilitated visits for people safely and regularly during the pandemic.” from the report
Outbreak management
The home used isolation and separated areas to manage risks during outbreaks.
“The registered manager had managed risks to people from outbreaks through appropriate isolation and separation of areas within the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently manage visits, including checks for visiting professionals?
- 02What arrangements are in place now to isolate people and separate areas if there is an infection outbreak?
- 03How do you manage staffing pressures when staff are absent because of COVID-19?
- 04How often are staff trained in infection prevention and the safe use of PPE?
- 05How do you arrange testing for people living in the home and for staff?
This was a targeted inspection of infection prevention and control, with questions about COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 16 March 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.
What inspectors found, November 2017
Dean Wood Care Home was rated Good overall; inspectors found safe, kind and responsive care, but the home was not consistently well-led.
Inspectors visited unannounced on 16 and 18 October 2017. They spoke with people living in the home, relatives and staff. They observed care, meals and medicines, and checked care records, medicines records, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines practice, suitable training, good access to health care, kind relationships and personalised care. People could take part in activities and keep in touch with family and friends.
The Well-led rating was Requires Improvement. Audits and checks were in place, but they had not always found or fixed gaps in care records. Records about people's mental capacity, consent, topical medicines and accidents were not always complete or consistent.
The overall rating improved from Requires Improvement at the previous inspection in September 2016. Staff support and morale had improved. Inspectors said the documentation issues had no direct impact on the quality of care people received, but the home's quality checks needed strengthening.
Safety and staffing
Inspectors found safe recruitment, safeguarding arrangements and staffing levels that met people's assessed needs.
“People were protected, as far as possible, by a safe recruitment system.” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy, choices and independence.
“People were treated with dignity and their rights and choices were respected.” from the report
Personalised support
Care plans included people's routines, preferences, communication needs and interests. Activities were available every day, including individual activities for people who preferred to stay in their rooms.
“People received care and support that was responsive to their needs.” from the report
Food and health support
People spoke positively about the food and could choose what to eat and drink. Inspectors found effective support for nutrition, diabetes, catheter care and feeding tubes.
“People spoke highly of the food provided.” from the report
Care records were not always accurate
needs fixingRecords about mental capacity and consent were sometimes contradictory or incomplete. This included records about consent for catheter changes and whether people had capacity to make decisions.
“Shortfalls and omissions with documentation had not consistently been identified as part of the provider's internal quality assurance framework.” from the report
Topical medicines records
needs fixingInspectors found discrepancies in records for creams and other topical medicines. One person's records showed that a barrier cream prescribed daily was not recorded as being applied daily.
“Documentation reflected that it was not being applied daily.” from the report
Falls monitoring needed more work
needs fixingFalls without injury were being recorded, but the home had not completed its further analysis or put an action plan in place to reduce the risk of future incidents.
“There was no root cause analysis of why this might be and there was no action plan in place to identify how improvements could be made to mitigate the risk of future incidences and accidents.” from the report
Some refresher training was overdue
minorThe training records showed that some moving and handling and fire drill refresher training was overdue. The manager later provided dates for planned training.
“The training programme identified that a number of staff's training on moving and handling was overdue, alongside fire drill training.” from the report
- 01What has changed since the inspection to make sure mental capacity and consent records are complete and consistent?
- 02How do you now check that prescribed creams and other topical medicines are applied and recorded every day?
- 03What action plan is in place to analyse and reduce falls, particularly during the afternoon and evening?
- 04Have all moving and handling and fire drill refresher training identified in the report now been completed?
- 05How do your current audits check that improvements are embedded and sustained?
This was an unannounced inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 24 November 2017 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 Dean Wood Care Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 2 May 2013.
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.
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