CQC report explained · a nursing home
What the CQC found at Deepdene Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2022
Rated Good overall; inspectors found kind, safe and responsive care, but the service was not always effective.
Inspectors visited unannounced on 30 September 2022. They spoke with people living there, relatives, staff and managers. They observed care and reviewed care plans, medicines records, audits, policies and recruitment files.
People said they felt safe and were treated with kindness and respect. Inspectors found enough staff, safe medicines practices, suitable food and drink, good access to healthcare, and improvements in activities and personalised care.
The main shortfalls were in some mental capacity assessments and the lack of regular staff supervision. The overall rating was Good. Safe, caring, responsive and well-led were Good, while effective was Requires Improvement.
Safe staffing
People and relatives said staff were available when needed. Inspectors saw that people did not have to wait for care.
“People and relatives told us they received care when they needed it and we saw that people did not have to wait for staff.” from the report
Kind and respectful care
Inspectors saw good relationships between staff and people. Staff supported personal choices, comfort, dignity and independence.
“People told us, "Staff are friendly and focused on me and what I need", "Staff are always very caring and considerate" and, "They are very kind and caring.” from the report
Personalised care and activities
Care plans described people's individual needs and preferences. The activities team had grown and provided more engagement, including one-to-one activities.
“Since our last inspection, the activities team had grown and the service now had three activity staff.” from the report
Improved leadership
The home had regular audits and meetings, and managers acted on identified shortfalls. The service was no longer in breach of regulations found at the previous inspection.
“The quality of service provided was monitored through regular and comprehensive audits with identified shortfalls addressed.” from the report
Incomplete capacity assessments
needs fixingSome assessments did not explain clearly how information was presented to people or how they responded. The manager said these were being reviewed.
“We found some capacity assessments were not specific though.” from the report
Irregular staff supervision
needs fixingStaff felt supported, but they had not routinely met their line managers to discuss their work, performance or training needs. The home planned regular supervisions after the inspection.
“However, staff told us with the recent changes in registered managers they had not had opportunity to meet with their line manager on a regular basis in the form of supervision” from the report
- 01How have you updated people's capacity assessments so they explain how information was presented and how each person responded?
- 02Are staff now receiving regular supervision, and how do you check that this is happening for all staff?
- 03How will you keep staffing levels suitable when people's needs change?
- 04How do you make sure people who stay in their rooms receive regular activities and social contact?
- 05When will the closed top floor refurbishment be finished, and what effect does this have on the service at present?
This was an unannounced inspection covering all five key questions and infection prevention and control; it followed up breaches and recommendations from the previous inspection, with the effective rating remaining Requires Improvement. This explanation was written from the published report of 21 October 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, July 2021
Requires Improvement overall; inspectors found kind care and some recent progress, but care planning, staffing, activities and management controls were not reliable enough.
This was an unannounced inspection on 17 June 2021. Three inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management documents. The inspection was partly prompted by concerns about unsafe care, but inspectors found no evidence that people were at risk of harm from those concerns during this visit.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. People generally said they felt safe, received their medicines and were treated kindly. Infection control, staff recruitment, training and responses to complaints were also described positively.
There were important shortfalls. Staff did not always follow risk guidance, staffing was inconsistent, records did not properly support some restrictive care, and activities and personal information were limited. The provider had begun making changes, including increasing staffing on one floor, reviewing care plans and introducing audits, but inspectors said these improvements needed to be sustained.
Medicines
People received the medicines they needed. Records showed no gaps suggesting medicines had been missed, and staff explained medicines and checked that people had taken them.
“We found no gaps on people's medicine administration records (MARs) which indicated they had been given their medicines.” from the report
Infection control
Inspectors were assured that the home used protective equipment safely, supported visiting safely and had suitable infection prevention arrangements.
“We were assured that the provider was using personal protective equipment (PPE) effectively and safely.” from the report
Kind and respectful care
Staff were seen speaking gently, supporting people patiently and protecting their dignity and privacy. Some people and relatives also described staff as kind.
“We observed staff chatting to relative's in a relaxed manner which indicated good relationships with them.” from the report
Recent improvement work
The acting management team had introduced audits, an action plan and changes to equipment, handovers and risk information. Inspectors noted good progress on completing actions.
“We noted good progress in relation to completing actions.” from the report
Risk guidance was not always followed
seriousSome care plans did not give enough detail, and staff did not consistently check one person's whereabouts or record how to respond to another person's seizures or agitation.
“Risks to people had been identified, although staff were not always following guidance.” from the report
Mental capacity records
seriousThe home did not have enough evidence to show that restrictions and covert medicines had been agreed lawfully, in people's best interests and using the least restrictive option.
“Some people were on covert medicines (medicines given to them without their knowledge).” from the report
Personalised care and activities
seriousCare plans did not consistently include people's histories, preferences or end-of-life wishes. Inspectors saw little meaningful engagement, particularly for people cared for in bed.
“The lack of person-centred care and meaningful activities for people was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak oversight
seriousManagement had started to improve the service, but earlier systems had not identified the problems soon enough. Inspectors said the improvements needed to be maintained after the temporary manager left.
“The lack of good governance within the service was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
- 01What staffing levels are now in place on each floor, especially during mornings and lunch, and how do you check that call bells are answered promptly?
- 02How have you updated care plans to include people's risks, past lives, preferences, communication needs and end-of-life wishes?
- 03How do you record mental capacity assessments and best-interests decisions for restrictions and covert medicines?
- 04What meaningful activities are now available for people who spend most of their time in bed or who live with dementia?
- 05What evidence can you show that the action plan and new audits have been completed and that improvements have been sustained?
This was an unannounced inspection covering all five CQC key questions; the previous Good rating from 2018 was under the former provider and was used to inform planning. This explanation was written from the published report of 29 July 2021 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 Deepdene Care Centre
5 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020
Registered with the Care Quality Commission on 14 January 2020.
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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