CQC report explained · a residential care home
What the CQC found at Denmead Grange Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse, risks were assessed and environmental safety was well managed. Inspectors found incomplete guidance and monitoring records, some medicines management improvements, and feedback that staff were not always available.
- Effective?
- Good
- People received appropriate assessments, training, food, drink and healthcare support. Food and fluid monitoring records were not always totalled or signed as reviewed, and the dining experience varied between areas.
- Caring?
- Good
- Inspectors observed kind and patient interactions, and staff understood people's needs, privacy and independence. Feedback was mixed because some people felt staff did not have enough time to spend with them.
- Responsive?
- Good
- Care was planned around people's preferences, communication needs, interests and relationships. Some care plan information needed updating, while activities were varied and available seven days a week.
- Well-led?
- Good
- The home had clear leadership, regular meetings and quality checks, and staff described managers as open and approachable. Inspectors found some audit actions were not signed or added to the overall improvement plan.
What inspectors found, June 2023
Rated Good; inspectors found safe, kind and personalised care, but identified some staffing, record-keeping and meaningful-contact concerns.
This was the home’s first inspection. It was unannounced and took place on 09 May 2023 and 11 May 2023. Inspectors spoke with people, relatives and staff, observed care and activities, and checked care, medicines, accident and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People generally felt safe, received their medicines and healthcare, and had their dietary needs met. Inspectors saw kind interactions, personalised care and a varied programme of activities.
The home acted promptly on several issues found during the inspection. These included incomplete risk and monitoring records, some medicines guidance and audit records, food and fluid records, care plan updates and dining arrangements. Some people and relatives also said staff were not always available or had enough time to spend with them.
A Good rating means the inspectors found that people were safe, had consistently good outcomes, were treated with dignity and respect, had their needs met, and that the service was consistently managed and well-led.
People felt safe
People and relatives said people were safe. Staff understood how to recognise and report abuse.
“People told us they felt safe living at Denmead Grange, relatives agreed and a relative said "I feel that [person] is safe and looked after here.” from the report
Learning from falls
The home analysed falls and introduced extra measures, including staff deployment checks, reviews and reflective learning. Inspectors found this had reduced falls significantly.
“This had resulted in a significant reduction in people falling.” from the report
Activities and interests
People had a broad programme based on their interests, including music, exercise, reminiscence, crafts and pet therapy. People who stayed in their rooms also received individual activities.
“There were a wide variety of activities available including physical exercise, musical events, word games and reminiscence sessions, pet therapy, cheese and wine, arts and crafts and book club.” from the report
Support at the end of life
Relatives and healthcare professionals gave positive feedback about compassionate end-of-life care. The home was also working with a hospice to develop this further.
“The service had received positive feedback from relatives about how they provided compassionate and sensitive care for people at the end of their lives.” from the report
Staff availability
needs fixingSome people and relatives said staff were not always available quickly, especially in the morning. Inspectors saw call bells answered in a reasonable time, and the manager said this would be investigated further.
“The staff don't always come when I press the buzzer, I seem to be waiting from some time especially in the morning.” from the report
Incomplete records
needs fixingSome risk guidance, monitoring records and care plan information were incomplete or needed updating. Managers acted during or after the inspection to address these issues.
“However, care records to ensure guidance was available for staff and monitoring records were not always fully completed.” from the report
Medicines records and guidance
needs fixingPeople received their medicines as prescribed, but inspectors found that staff guidance, storage arrangements and audit documentation needed improvement.
“The registered manager acted promptly when we noted some improvements were needed in relation to staff guidance to support the person-centred administration of people's medicines, medicines storage, and audit documentation.” from the report
Time for personal contact
needs fixingSome people said staff did not have enough time to chat or spend time with them, making them feel staff did not always care. The home had introduced an allocated carer for one-to-one time.
“Some people told us staff didn't always have enough time to spend with them which left them feeling staff didn't always care about them.” from the report
Food and fluid monitoring
needs fixingRecords for people at risk of poor nutrition were not always totalled or signed as reviewed. The home introduced a daily meeting to improve completion and checking.
“We noted the food and fluid monitoring records were not always totalled or signed as reviewed which meant they were ineffective.” from the report
- 01What has changed since the inspection to make sure there are enough staff available, especially in the mornings?
- 02How quickly are call bells answered now, and can you show us the recent response-time checks?
- 03How do you check that medicines guidance, storage and audit records are complete and up to date?
- 04How are food and fluid monitoring records totalled, signed and reviewed for people at risk of poor nutrition?
- 05How much one-to-one time is available for people, and how is this recorded?
This was an unannounced first inspection covering all five key questions, including infection prevention and control; the report says there was no previous inspection rating to carry over. This explanation was written from the published report of 24 June 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, March 2021
Denmead Grange Care Home was inspected but not rated; inspectors found good infection-control arrangements during a COVID-19 outbreak.
This was an announced, targeted inspection on 11 February 2021. Inspectors checked infection prevention and control because the home had a COVID-19 outbreak. The home was newly registered and 20 people were living there at the time.
Inspectors found good practice. Staff used protective equipment safely, the home was clean, and visitors had clear safety checks. Staff and residents were tested regularly, and there were plans for safe admissions and managing an outbreak.
The home was inspected but not rated. This was not a full assessment of all aspects of care, so the report does not give an overall quality rating or ratings for most of the five key questions.
Safe use of PPE
Staff used, removed and disposed of protective equipment safely and followed the relevant guidance.
“Staff donned, doffed and disposed of personal protective equipment (PPE) safely and in line with the relevant guidance.” from the report
Safe visiting arrangements
Although ordinary visiting was suspended during the outbreak, the home had a suitable visiting room and supported exceptional visits.
“Visiting was suspended at the time of this inspection due to an outbreak of Covid 19 but a designated room with appropriate infection prevention and control measures had been set up enabling safe visiting.” from the report
Testing and outbreak planning
Regular testing was carried out for staff and residents. The home also had plans for managing outbreaks and for safely admitting new residents.
“Regular testing was completed for staff and people living at the home.” from the report
Clean environment
Inspectors found the home clean and hygienic, with extra attention to frequently touched areas.
“The home was clean and hygienic. Robust cleaning measure were put into place.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection-control and visiting arrangements are in place now?
- 02How are visitors checked and supported when visiting people at the home?
- 03How are new residents admitted and supported during any required period of isolation?
- 04How often are staff and residents tested when there is an infection risk?
- 05What is the current plan for managing a COVID-19 or other infection outbreak?
This was a targeted inspection of infection prevention and control during a COVID-19 outbreak; the service was inspected but not rated and other areas of care were not assessed. This explanation was written from the published report of 9 March 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 Denmead Grange Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- June 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- March 2020
Registered with the Care Quality Commission on 13 March 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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