CQC report explained · a nursing home
What the CQC found at Deneside Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Rated Good overall, but Safe requires improvement because medicines records and some parts of the environment were not always satisfactory.
This was an unannounced focused inspection on 11 November, 23 November and 6 December 2021. Inspectors looked at Safe, Responsive and Well-led after concerns about staffing and managing known risks. They found no evidence that people were at risk of harm from those concerns.
The home had enough suitably skilled staff, protected people from abuse and managed risks and incidents appropriately. However, records and guidance for some ‘when required’ and covert medicines were not always clear. Some areas also needed more cleaning, maintenance and repair. The home had action plans and dealt quickly with immediate issues.
Responsive and Well-led were rated Good. Safe was rated Requires Improvement, as it had been at the previous inspection. The overall rating stayed Good. Effective and Caring were not inspected during this visit, so previous ratings were used when calculating the overall result.
Safeguarding and risk management
Staff understood safeguarding procedures and how to raise concerns. Risk assessments, incident reviews and actions helped protect people and reduce repeated problems.
“People were protected from abuse. Staff followed up to date guidance and had received training in safeguarding people.” from the report
Personalised care
People and, where appropriate, their relatives and advocates were involved in care planning. Plans were reviewed as needs changed and included people’s goals and future aspirations.
“People, and where appropriate their relatives and advocates were involved in planning their care. Regular evaluations of care and support ensured care remained relevant.” from the report
Support for independence
The home supported people to make choices, develop skills and work towards greater independence. Inspectors found examples of people achieving positive outcomes.
“Case studies evidenced how peoples support from the service had led to positive outcomes with a focus on achieving maximum possible independence.” from the report
Open and supportive leadership
Inspectors found clear responsibilities, visible senior leadership and a supportive culture. The provider used feedback, complaints and quality checks to make changes.
“The management team responded robustly and comprehensively to our feedback throughout the inspection process.” from the report
Medicine records and guidance
seriousSome records for ‘when required’ and covert medicines were not clear enough. Guidance was not always available or detailed enough for staff, and some medicines were missing from a covert plan.
“Records of administration of these medicines was not always clear and associated guidance was not always available for staff use in people's records as required.” from the report
Cleaning and maintenance
needs fixingSome areas needed deep cleaning, repair and maintenance to keep environmental and hygiene standards at a good level. The provider had action plans and addressed immediate issues.
“Some areas of the home were in need of deep cleaning and maintenance to improve environmental and hygiene standards.” from the report
Registered manager application
needs fixingA manager was in post, but the application to register with the CQC had started and had not yet been submitted. Inspectors took the circumstances into account in their judgement.
“The manager's application process had been commenced but not progressed to the submission of an application as required due to events outside of the provider's control.” from the report
- 01What changes have been made to the recording and administration of ‘when required’ and covert medicines?
- 02How do staff find the correct guidance for each person’s covert medicines, and how is this checked?
- 03Which cleaning, repair and maintenance actions identified during the inspection have now been completed?
- 04How do you manage staffing shortages, and how often are agency staff used?
- 05Has the manager’s application to register with the CQC now been submitted?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 19 February 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, April 2020
Rated Good and no longer in special measures, but inspectors found medicines management still requires improvement.
Inspectors visited unannounced on 28 and 29 January 2020. They spoke with people living in the home, relatives, staff and healthcare professionals. They also checked care records, medicine records, staff files and management records.
The overall rating was Good. Effective, caring, responsive and well-led were all rated Good. Safe was rated Requires Improvement because some medicine processes were not yet reliable, including medicines taken on home leave, recording topical medicines, thickener records and medicines that must be taken with food.
The home had improved substantially since its previous Inadequate rating. It was no longer in special measures and was no longer in breach of the regulations identified at the previous inspection. Staff numbers, recruitment, cleanliness, risk management, care planning and activities were found to be suitable.
Major improvement
The home had improved from Inadequate and had come out of special measures. The provider was no longer in breach of the regulations found at the previous inspection.
“During this inspection the provider demonstrated that substantial improvements had been made.” from the report
Caring staff
People and relatives said staff were kind and caring. Inspectors found that staff promoted dignity, independence and individual choice.
“People and their relatives told us staff were very caring in their role.” from the report
Suitable staffing
Inspectors found staffing levels were suitable for people's needs. Recruitment checks were also in place.
“Staffing levels were suitable to care for people safely.” from the report
Personalised care
Care plans included people's likes, dislikes and interests. Staff supported people to maintain relationships and take part in activities.
“Care plans were person centred and were appropriate to each individual person.” from the report
Improved leadership
The home had quality checks at local and regional level. Action plans were reviewed regularly and incidents were used to improve care.
“Audits were used by the manager and the senior leadership team to drive improvements within the service.” from the report
Medicine instructions
seriousSome medicines with special instructions, such as needing to be taken with food, were not always given as prescribed. This created a risk that people might not receive their medicines correctly.
“Medicines which had specific administration requirements such as to be taken with food were not always adhered to.” from the report
Medicines on home leave
needs fixingThe policy for managing medicines when people went on home leave lacked detail. Risk assessments were not in place for this situation.
“The home's policy lacked detail and risk assessments were not in place for the handling of the medicines in this situation.” from the report
Medicine records and thickener checks
needs fixingRecording the use of topical medicines and thickeners still needed to become more consistent. Inspectors recommended that these processes and their audits were reviewed.
“A system was in place for the recording of thickener use in food and drinks to prevent aspiration.” from the report
- 01How do you now manage and risk-assess medicines when someone goes on home leave?
- 02How do you check that medicines which must be taken with food are given correctly every time?
- 03How are topical medicines recorded, and who checks that these records are complete?
- 04How do you audit the recording of thickeners in food and drinks?
- 05Who is currently responsible for the home while there is no CQC-registered manager in post?
This was an unannounced planned reinspection of all five key questions, checking improvements after the previous Inadequate inspection and period in special measures. This explanation was written from the published report of 10 April 2020 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 Deneside Court
12 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2020Goodup from InadequateSafe: Requires improvementResponsive: GoodWell-led: Good
- February 2020Inadequatestayed InadequateSafe: Inadequate
- November 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementup from InadequateSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- June 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- May 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvement
- February 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 9 November 2012.
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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39 live-in carers within about an hour of South Tyneside
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,140 a week. 34 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.