CQC report explained · a nursing home
What the CQC found at Denham Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Safeguarding procedures, medicines recording and some risk assessments were not always followed consistently. Inspectors said there was an increased risk that people could be harmed, although action was taken during the inspection.
- Effective?
- Good
- People had thorough assessments, trained staff, appropriate health support and help with eating and drinking. The home was working in line with the principles of the Mental Capacity Act.
- Caring?
- Good
- Staff were observed to be warm, kind and respectful. People and relatives said they were involved in care decisions and that privacy, dignity and independence were promoted.
- Responsive?
- Good
- Care plans reflected people's preferences and communication needs. People had access to activities, visitors were welcomed and formal complaints were recorded and investigated.
- Well-led?
- Good
- The management team used audits and action plans to monitor quality and had made improvements. People, relatives and staff were asked for feedback, which was used to plan changes.
What inspectors found, December 2019
Rated Good overall, but Safe required improvement because safeguarding and medicines systems were not always followed.
This was an unannounced inspection over three days. The inspector spoke with people, relatives, staff and visiting professionals. They reviewed care plans, medicines records, recruitment files and management records.
People and relatives were generally positive about the home. Inspectors found kind staff, personalised care, good activities and effective support with health, food and communication. The home was clean and staffing levels were judged sufficient.
The main problems were in safety systems. A safeguarding concern had not been handled or recorded properly at first. Medicines checks did not always identify gaps or errors. Risk assessments for welfare checks and storage of equipment also needed improvement. The home took action during the inspection to address some issues.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, which means some aspects of safety were not always reliable and there was limited assurance about safety.
Kind and respectful care
Staff knew people's preferences and supported their privacy, dignity and independence. People and relatives gave consistently positive feedback about the care.
“We saw staff interactions with people were warm and caring.” from the report
Personalised support
Care plans included detailed information about people's likes, dislikes, routines and care needs. Staff supported people to make choices in daily life.
“Care plans contained personalised and detailed information about the way people liked to be supported and what was important to them.” from the report
Staffing and training
Inspectors found enough care staff and nurses to meet people's needs. Staff had thorough inductions, regular supervision and training covering specific care needs.
“People benefitted from staff who received thorough inductions and were up-to-date with their training.” from the report
Activities and relationships
Two activity coordinators organised daily activities, including one-to-one sessions for people who preferred them. Relatives and friends were welcomed.
“Two activity coordinators worked daily, who organised arts and crafts, quizzes and visiting entertainers such as singers and musicians.” from the report
Quality improvement
The management team used audits and an action log to track improvements. Feedback from people and relatives had led to changes, including more activities.
“Quality assurance systems, such as audits, checks and observations were used to monitor all aspects of the service.” from the report
Safeguarding response
seriousThe manager was not always clear about when abuse allegations needed to be reported. A previous concern had not been investigated or recorded properly, although action was taken during the inspection to reduce the risk of ongoing harm.
“The registered manager was not always clear about when to report allegations of abuse” from the report
Medicines records and checks
seriousThere were gaps in two medicines administration records and a miscount of pain relief medicines. Daily checks had not identified these issues, although extra monitoring was introduced.
“During our inspection we found a gap in two people's medicines administration records and a miscount of 'when required' pain relief medicines.” from the report
Individual welfare checks
needs fixingThe home used a general approach to deciding how often people should be checked. Inspectors recommended that checks should be based on each person's physical and emotional needs.
“The service had a generic approach to the frequency of visual welfare checks.” from the report
Equipment storage
needs fixingThere was not enough suitable storage for mobility aids and other equipment. A hoist in a corridor was considered a potential trip hazard and action was taken to assess it.
“There was a lack of storage for mobility aids and other equipment.” from the report
End of life records
needs fixingSome people's recorded end of life wishes were not transferred into their end of life care plans until they were nearing the end of life. The manager said this would be reviewed and recorded more regularly.
“This information was not transferred into a person's end of life care plan unless they were at the end of their life.” from the report
- 01What changes have you made to ensure every safeguarding disclosure is reported, investigated and recorded correctly?
- 02How do you now check medicines records each day, and how do you make sure near misses are followed up?
- 03How are welfare check times decided for each person's physical and emotional needs?
- 04Where are mobility aids, hoists and other equipment stored now, and how do you prevent trip hazards?
- 05How are each person's end of life wishes reviewed and kept in their care plan?
This was an unannounced comprehensive inspection covering all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 13 December 2019 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, March 2017
Rated Good in all five areas; inspectors found safe, kind and individual care, with some staff vacancies still being recruited to.
Inspectors visited the home without warning on 13 and 18 January 2017. They also spoke by telephone with relatives on 17 January. They spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management audits.
The home was rated Good overall. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found accurate and regularly reviewed care records, enough staff to meet people's needs, safe medicines practices and staff who understood safeguarding and consent.
People and relatives spoke positively about the care. Inspectors saw respectful relationships, support for people's choices and independence, personalised care plans, activities and a complaints process. At the previous inspection in November 2014, the home was rated Requires Improvement because records were inaccurate. Inspectors found this problem had been addressed.
Improved records
The problem found at the previous inspection had been addressed. Inspectors found care records and other documents were accurate, current and regularly reviewed.
“During this visit we found records in relation to people's care and other documents were accurate, up to date and regularly reviewed.” from the report
Safe care
Staff understood safeguarding responsibilities and risk plans covered areas such as falls, medicines, moving and handling, and nutrition.
“People benefited from a safe service where staff understood their safeguarding responsibilities.” from the report
Respectful relationships
Inspectors saw staff speaking warmly with people and supporting their dignity, choices and independence.
“Caring relationships were formed with staff and the people they provided care and support to.” from the report
Personalised activities
People had individual and group activities available and could choose whether to take part.
“People had a range of activities they could be involved in and were able to choose what activities they took part in.” from the report
Quality monitoring
The home used audits, meetings and reviews of incidents to monitor safety and improve the service.
“The service had systems in place to assess, monitor and improve quality and safety of people's welfare.” from the report
Staff vacancies
minorThe home had some vacant posts and was still recruiting. Inspectors found staffing was sufficient, but one relative said it could sometimes be difficult to find staff.
“Personally, I do think there could be more staff, sometimes you have to wander around before you can find staff but overall, staff are good.” from the report
- 01How many staff posts were vacant at the inspection, and have they now been filled?
- 02How do you make sure people can quickly find staff when they need help?
- 03How will you keep my relative's care records accurate and regularly reviewed?
- 04What activities would be suitable for my relative, and how would you support their choice not to take part?
- 05How would you involve us in decisions about health needs and end of life care preferences?
This was an unannounced inspection covering all five key questions, with checks of care records, medicines, staff files and management systems. This explanation was written from the published report of 18 March 2017 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 Denham Manor
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- December 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 4 July 2013.
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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