CQC report explained · a nursing home
What the CQC found at Deepdene Court
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 2023
Deepdene Court is rated Requires Improvement because inspectors found risks from indoor smoking, cleaning shortfalls and weak oversight.
This was an unannounced focused inspection on 29 June 2023. Inspectors looked only at Safe and Well-led, after concerns about risk management. They spoke with people, relatives, staff and health professionals, and reviewed care, medicine, recruitment and management records.
The home was not always safe. Some people smoked in bedrooms despite the smoking policy, including near combustible items. Risk assessments did not fully address this. Some areas also needed deeper cleaning, and audits did not always lead to action.
The home was not always well-led. Managers knew about some problems, but quality checks did not consistently identify or resolve them. Some incidents had also not been notified to CQC.
People generally said they felt safe and supported. Staff understood people's mental health needs, medicines were managed safely, and people were involved in their care. However, the overall rating changed from Good to Requires Improvement because of the Safe and Well-led findings.
People felt safe
People told inspectors they felt safe and could raise concerns with staff or managers. Staff knew how to report safeguarding concerns.
“People told us they felt safe at the service.” from the report
Support matched people's needs
Mental health support plans described signs of relapse and the level of help people needed. Staff were observed responding to an incident in a person-centred way.
“People's mental and physical health needs were assessed.” from the report
Medicines were managed safely
Trained nurses administered medicines, with suitable guidance for medicines taken when needed. Storage and records were completed in line with current guidance.
“Medicines were stored, ordered, and managed safely.” from the report
People had a say
People contributed to care plans and could give feedback through meetings, surveys, a suggestion box and an online system. The home showed what it had done in response.
“People contributed to their support plans and received person-centred care tailored to their needs.” from the report
Staff worked with professionals
The home worked with social workers, mental health teams, psychiatrists and other professionals to support people's needs.
“The registered manager and staff worked with other agencies to promote good outcomes for people.” from the report
Indoor smoking and fire risk
seriousSome people smoked in bedrooms despite the home's policy. Inspectors found smoking near combustible items and burns on flooring, while risk assessments did not fully address the ongoing risk.
“A person smoked cigarettes indoors where combustible items were stored.” from the report
Cleaning was not consistent
needs fixingSome communal areas, kitchens and shower rooms needed deeper cleaning. Paint damage and unclean surfaces made some areas difficult to sanitise.
“The communal kitchen and shower rooms required deep sanitation.” from the report
Checks did not always lead to action
needs fixingAudits identified cleaning issues, but actions were not always recorded or completed. Communal spaces were also missing from the infection control audit.
“Quality assurance processes were effective in identifying areas for improvement; however, these were not always actioned.” from the report
Some notifications were missed
needs fixingMost required notifications were sent to CQC, but inspectors found some incidents that had not been notified. The manager said this was an oversight.
“We identified some incidents where we had not been notified.” from the report
Mixed views about staffing
minorInspectors observed enough staff during the visit, but people, relatives and professionals gave mixed views about staffing levels.
“People and staff gave mixed feedback about staffing levels.” from the report
- 01What has been done to stop people smoking in bedrooms, and how are fire risks now assessed for each person?
- 02How often are kitchens, shower rooms and communal areas deep cleaned, and who checks that the work is completed?
- 03How have infection control audits been changed so that all communal spaces are included?
- 04What action has been taken to make sure all incidents that must be reported to CQC are notified on time?
- 05How do current staffing levels compare with the needs of the people living in the home, including at night?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 5 October 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, August 2021
Rated Good; inspectors found safe, kind care and good leadership, but noted staffing vacancies and an out-of-date infection-control policy.
This was an unannounced, focused inspection on 17 June 2021. One inspector spoke with seven people and nine staff, reviewed care and medicine records, checked staff files and examined management records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that risks were assessed, medicines were given as prescribed, safeguarding systems worked and staff understood people's needs.
People described staff warmly and inspectors saw person-centred care that promoted independence. The home used agency staff when needed because it still had vacancies. The new manager had started the CQC registration process.
The inspection did not assess Effective, Caring or Responsive. Their previous ratings were used in the overall rating. Inspectors noted that the infection prevention and control policy did not fully reflect current COVID-19 guidance, and that medicine storage temperatures had previously exceeded recommended levels, although action had been taken.
Clear risk planning
Care plans described people's risks, warning signs and preferred support. People were involved in agreeing how to stay safe.
“Risks to people's health and safety were appropriately assessed, provided detail and were regularly reviewed.” from the report
Kind, individual care
Staff knew people well and supported their independence, activities and personal goals. People spoke positively about the staff.
“People were treated with compassion and respect and were encouraged to participate in activities to promote their independence and improve their wellbeing.” from the report
Safe medicines support
People received medicines as prescribed, including medicines taken when needed. Staff were trained and supported people who wanted to manage their own medicines.
“Medicines were managed safely and people received their medicines as prescribed and in the way they preferred.” from the report
Learning from incidents
Managers investigated incidents and changed medicine checks after identifying that the previous process was not strong enough.
“Lessons learnt were that the previous system was not sufficiently robust to mitigate the risk of further errors, therefore action was taken to revise the process.” from the report
Good leadership systems
Staff felt supported and able to raise concerns. Audits and other checks were used to identify risks and make improvements.
“Quality assurance and management systems provided managers with sufficient oversight and enabled effective governance of the service.” from the report
Staff vacancies
needs fixingThe home still had vacancies and was recruiting. Agency staff were being used to keep staffing at a safe level.
“Although the service continued to have vacancies, the manager was in the process of recruiting new staff.” from the report
Infection policy not fully up to date
minorInspectors were only somewhat assured that the infection-control policy was current because it did not reflect the latest COVID-19 guidance. The provider was signposted to resources.
“However, the infection prevention and control policy had not been recently updated to reflect government guidance for the management of COVID-19.” from the report
Medicine storage temperatures
needs fixingChecks found that medicine storage temperatures had exceeded recommended levels. The report says action had been taken to resolve this.
“Quality assurance systems for managing medicines identified a shortfall in medicine storage facilities; storage temperatures were found to have exceeded recommended levels.” from the report
- 01How many staff vacancies are there now, and how often are agency staff used?
- 02What is the current position on the new manager's CQC registration?
- 03Has the infection prevention and control policy been updated to reflect current guidance?
- 04What action was taken after medicine storage temperatures exceeded recommended levels, and how are temperatures checked now?
- 05How are you ensuring that care remains consistent when agency staff work at the home?
This was a planned, focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 19 August 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 Court
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021GoodSafe: GoodWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 January 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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