CQC report explained · a nursing home
What the CQC found at Dene Grange Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by regular risk reviews, safe medicines systems, fire safety checks and safe recruitment. Inspectors found some PPE use and cleaning of high-touch points needed attention.
- Effective?
- Good
- People received suitable assessments, training, food and drink support, healthcare support and care that followed consent requirements. Refurbishment was still ongoing, and some pureed food presentation could be improved.
- Caring?
- Good
- This key question was not rated in this follow-up inspection.
- Responsive?
- Good
- This key question was not rated in this follow-up inspection.
- Well-led?
- Good
- Quality checks had been improved, issues were followed up quickly and people, relatives and staff were asked for feedback. Inspectors found a positive culture and good communication.
What inspectors found, March 2023
Dene Grange Care Home rated Good; inspectors found improved safety, care and management, with some infection control and refurbishment work still to complete.
This was an unannounced follow-up inspection after the previous rating of Requires Improvement. One inspector and an Expert by Experience visited on 7 March 2023. They spoke with people, relatives, staff and healthcare professionals, and checked care records, medicines, recruitment files and management records.
The home was rated Good overall and was rated Good for Safe, Effective and Well-led. People said they felt safe and that staff were kind. Medicines, risk assessments, staffing, staff training and healthcare support were found to be managed well.
There were some remaining issues. Touch points were not always cleaned as often as needed, two staff members did not use personal protective equipment correctly, and there was a shortage of domestic staff. These concerns were raised during the inspection. The manager took immediate action on PPE and had agreed to increase domestic staffing. Refurbishment was still under way.
Improved risk management
Risks to people and the environment were identified, reviewed and monitored. Fire safety arrangements had also improved.
“All aspects of people's care and support were risk assessed and regularly reviewed and their safety was monitored.” from the report
Kind staff
People and relatives described staff as kind and said they were well looked after.
“People and their relatives said staff were kind and looked after them very well.” from the report
Safe medicines
Medicines were ordered, stored, given and disposed of safely. They were given in line with prescriptions and at the right times.
“Medicines were managed safely. Safe procedures were followed to order, store, administer and dispose of medicines.” from the report
Better management systems
The home had strengthened its quality checks. Managers followed up issues and monitored improvement plans.
“Quality assurance systems were in place and had been enhanced to identify shortfalls and ensure people's needs were met.” from the report
Staff training
Staff received induction, supervision, appraisal and regularly updated training, including training for agency staff.
“Staff received a range of tailored training which was regularly updated.” from the report
Cleaning frequency
minorThe home was clean and tidy, but high-touch areas were not always monitored and cleaned as often as they should have been.
“high touch points were not always fully monitored.” from the report
PPE use
minorTwo staff members did not follow effective PPE guidance. The manager addressed this immediately.
“Two members of staff did not follow effective PPE guidance.” from the report
Domestic staffing
minorThere was a lack of domestic staff. The manager said agreement had been confirmed to increase domestic staffing on shifts.
“There were enough staff to meet people's needs, although there was a lack of domestic staff” from the report
Refurbishment unfinished
minorThe home was still being refurbished. Completion was expected within the next few months.
“The service continued to be refurbished in line with the provider's improvement plans and was due for completion in the next few months.” from the report
Pureed food presentation
minorPureed food was provided, but inspectors said some of it could look more appetising. The manager planned to buy moulds.
“some pureed food would benefit from the use of moulds to make them look more appetising.” from the report
- 01Has the agreed increase in domestic staff now happened, and how often are high-touch areas cleaned?
- 02What action was taken after the two staff members were found not to be following PPE guidance?
- 03When will the refurbishment be completed, and which areas are still affected?
- 04Have the missing as-required medicines protocols and topical medicine charts been completed and checked?
- 05How are families involved in care planning and kept informed about changes in their relative's health?
This was a follow-up inspection focused on Safe, Effective and Well-led; Caring and Responsive were not rated in this report. This explanation was written from the published report of 18 March 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, September 2022
Rated Requires Improvement; inspectors found kind, responsive care, but safety, premises and management systems were not robust.
This was the home’s first full inspection since it registered with the CQC under the new provider. It was unannounced and took place on 28 July, 1 August and 2 August 2022. Inspectors spoke with people, relatives, staff and professionals, and checked care records, medicines, staff files and quality checks.
People generally said they felt safe. Staff were kind and compassionate, and people received personalised support, activities and healthcare. However, fire safety, maintenance, risk assessments, some care records and quality monitoring were not reliable enough.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. The CQC found breaches relating to safe care and treatment, premises and equipment, and good governance.
Kind and respectful staff
People and relatives described staff as kind, caring and approachable. Inspectors saw staff comfort someone who was upset.
“People and relatives told us staff were kindhearted and treated them with empathy.” from the report
People felt safe
People and relatives said they felt safe, and staff understood how to protect people from abuse.
“People and their relatives told us they felt safe.” from the report
Personalised support
People and relatives were involved in care planning and choices. Staff supported independence and individual preferences.
“People and their relatives were included in care planning and choices.” from the report
Healthcare support
Staff worked with healthcare professionals and contacted outside services when people needed help.
“Staff worked closely with other agencies to ensure people received the care they needed.” from the report
Fire and other safety risks
seriousFire safety issues remained after a recent visit by the fire authority. Other checks did not always identify problems such as exposed wires, missing call bells and incomplete risk assessments.
“The local fire authority had recently visited and issued an enforcement notice.” from the report
Premises needed repair
seriousSome areas needed maintenance, redecoration or refurbishment. The garden and parts of the building were not always safe or suitable for people.
“The provider had not always ensured service design, decoration or maintenance met people's needs.” from the report
Weak quality checks
seriousThe provider’s monitoring systems had not found or resolved several problems. This included issues with fire safety, infection control, medicines, maintenance and care records.
“Systems were not robust enough to ensure the quality of the service and ensure that essential tasks had been completed and that people's needs were met.” from the report
Incomplete care records
needs fixingSome care plans and monitoring charts did not contain all the information staff needed or were not fully completed. The report says there was no impact on people from the record gaps found.
“Although we found no impact on people, not all care records and monitoring charts were fully completed.” from the report
Mealtime choice and presentation
needs fixingPeople were not always offered the meal they had chosen, particularly people with cognitive impairment. Some soft or pureed meals were not presented attractively.
“People were not always given choice at mealtimes, particularly those with cognitive impairment.” from the report
- 01What action has been completed in response to the fire authority’s enforcement notice, and what outstanding fire safety work remains?
- 02Have all risk assessments been reviewed, including risks linked to lone working and people using kettles independently?
- 03Which repairs, redecoration and refurbishment work has been completed in bedrooms, bathrooms, lounges and garden areas?
- 04How are you checking that care records, food and fluid charts, personal care charts and bed-setting information are complete?
- 05How do you now make sure people are offered their chosen meal and that soft or pureed meals are presented well?
This was the first comprehensive inspection and rated all five key questions; a focused inspection on 28 January 2022 had only reviewed infection control and was not rated. This explanation was written from the published report of 22 September 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 Dene Grange Care Home
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2022Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2020
Registered with the Care Quality Commission on 1 June 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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