CQC report explained · a residential care home
What the CQC found at Deansfield Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and that risks, staffing, medicines and infection control were managed safely. They also found systems for learning when things went wrong.
- Effective?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- Staff were described as kind and caring. People were supported to make choices, and their privacy, dignity and independence were respected.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found approachable management, systems to monitor care and a culture of learning and improvement. Issues found during the inspection were dealt with straight away or had a plan in place.
What inspectors found, April 2023
Deansfield Residential Care Home was rated Good; inspectors found safe, kind and better-managed care, with a few minor premises and record-keeping issues.
This was an unannounced focused inspection on 31 March and 3 April 2023. Two inspectors spoke with people living at the home, relatives, staff and managers. They also reviewed three care records and management records.
The home was rated Good for Safe, Caring and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable safeguarding systems and kind, respectful care. People were involved in decisions and their privacy and independence were supported.
The previous rating was Requires Improvement, published in February 2023. The provider had made improvements and was no longer in breach of regulations. The overall rating was calculated using this inspection and ratings from the previous inspection for Effective and Responsive, which were not reviewed this time.
People felt safe
Risk assessments were updated when people's needs changed, and staff had safeguarding training. Inspectors found people were protected from abuse.
“People were protected from the risk of abuse.” from the report
Safe medicines
Medicines were received, stored, given and disposed of safely. Staff handling medicines had suitable training and records were checked.
“Medicines were received, stored, administered, and disposed of safely.” from the report
Kind and respectful care
People and relatives said staff were caring. Staff supported people's choices, privacy, dignity and independence.
“The provider ensured people's privacy and dignity were respected and promoted.” from the report
Improved management
Audits were used to find gaps, and lessons were shared with staff. The home had a culture of learning and improvement.
“There was a culture of continuous learning and improvement.” from the report
Minor premises issues
minorInspectors found a broken toilet lock, a sticking conservatory door and issues with PAT testing. These were dealt with straight away or had a plan put in place.
“During this inspection, we identified issues with a broken toilet lock, a sticking door to the conservatory and PAT testing.” from the report
Care note dates
minorAn audit found that some daily care notes were missing dates. Management addressed this through staff meetings and a memo.
“When an audit of daily care notes identified missing dates, this issue was addressed by the registered manager in staff meetings and by sending a memo to staff.” from the report
- 01What has been done to make sure the broken toilet lock and sticking conservatory door remain safe?
- 02How do managers now check that daily care notes are dated and complete?
- 03What were the previous ratings for Effective and Responsive, and when will those areas next be fully reviewed?
- 04How are medicines checked now, including records and any changes to pain management?
- 05How will you maintain the improvements made since the Requires Improvement rating?
This was a focused inspection of Safe, Caring and Well-led only; the Effective and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 27 April 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, February 2023
Deansfield Residential Care Home is rated Requires Improvement; inspectors found safe staffing and medicines practice, but important records and quality checks were not reliable.
This was an unannounced focused inspection. One inspector and an Expert by Experience visited on 9 January 2023. They spoke with people living at the home, relatives, the manager and staff, and reviewed records and audit checks.
People told inspectors they felt safe. Staffing, recruitment, training, safeguarding, medicines and infection control were found to be generally satisfactory. Staff understood people's needs and knew how to respond to risks.
However, one risk assessment was missing and outdated health documentation meant a health concern was not escalated promptly. The manager corrected these issues during or shortly after the inspection, but the home's checks had failed to find them.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had improved since the previous inspection but remained in breach of Regulation 17 because its governance and audit systems were still not consistently effective.
Staffing and recruitment
Inspectors found enough staff to meet people's needs safely. Staff were trained, checked for competence and recruited with the required safety checks.
“People were supported by a sufficient number of staff to meet their needs safely.” from the report
Medicines
Medicines were stored and administered safely. Records and protocols were in place, and audits identified and acted on errors.
“Robust medicines audits were in place and action was taken where any medicines errors were identified.” from the report
Safeguarding
Staff understood different types of abuse and how to report concerns. Accidents and incidents were recorded, and action was taken to reduce repeat risks.
“Staff had completed safeguarding training and understood how to keep people safe.” from the report
Listening to people
The home gathered views through residents' meetings, newsletters and relative surveys. Inspectors said feedback was acted on.
“Residents meetings were held to obtain people's views regarding the service.” from the report
Missing risk assessment
seriousA risk assessment was not in place for a person's complex health need. The manager put one in place immediately, but the home's checks had not identified the gap.
“However, we found one risk assessment was not in place to guide staff how to manage a person's complex health need.” from the report
Outdated health records
seriousStaff used outdated documentation for a person's daily health needs. This meant a clinical concern was not escalated as quickly as it should have been.
“Records showed that a clinical concern had not been escalated in a timely manner but there had been no impact on the person.” from the report
Weak quality checks
needs fixingAudits did not reliably identify missing or outdated documents. The CQC said further improvement was needed to make these checks fully effective and embedded.
“Further improvements are required to ensure audit processes are robust and fully effective and the improvements that have been made are fully embedded within the service.” from the report
- 01What checks are now in place to make sure every person's risk assessment is present and up to date?
- 02How do you make sure staff use the current health documentation and escalate concerns at the right time?
- 03What action plan did you send to the CQC after the Regulation 17 breach, and what progress has been made?
- 04How are medicines errors reviewed, and how do you check that lessons have been learned?
- 05How will you show that the improvements from this inspection are now embedded in everyday practice?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 16 February 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.
Every inspection of Deansfield Residential Care Home
8 rated inspections over 7 years: the service has slipped, from Outstanding to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Deansfield Residential Care Home →
- February 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Deansfield Residential Care Home →
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2022Requires improvementup from InadequateSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- May 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- October 2021GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- June 2019Outstandingstayed OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- March 2016OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 12 August 2011.
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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