CQC report explained · a nursing home
What the CQC found at Denville Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Inspected but not rated; inspectors were assured about infection control, visiting arrangements and staffing during the COVID-19 pandemic.
This was a targeted inspection on 11 January 2022. Inspectors checked infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures were affecting care. The inspection was announced 24 hours beforehand.
The inspectors found good infection control practice. Staff used protective equipment safely, received infection control training and had access to work stations throughout the building. The home was also carrying out testing and following national visiting guidance.
Staff retention was good and the provider had arrangements to cover rota gaps. Family visits were taking place despite a small COVID-19 outbreak, while people receiving end of life care had full visiting access.
The service was inspected but not rated. This report does not give a full rating for the quality of care across all five areas.
Infection control
Staff had infection control training and used protective equipment safely. There were many protective equipment stations around the building.
“There were numerous PPE work stations throughout the building for staff to easily utilise PPE.” from the report
Staffing cover
Staff retention was good, with minimal staffing pressures. Regular agency staff and members of the management team covered rota gaps.
“Staff retention was good which meant there were minimal staffing pressures.” from the report
Working with health professionals
The management and staff team worked with local health professionals to reduce the spread of COVID-19.
“The registered manager and staff team worked with local health professionals to minimise the spread of COVID-19.” from the report
Visiting arrangements
Visits were taking place in line with national guidance despite a small outbreak. People receiving end of life care had full visiting access.
“Visiting by family and friends was taking place in line with national guidelines, given there was a small outbreak of COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How would family visits be managed if there were a COVID-19 outbreak now?
- 02How would full visiting access be provided for someone receiving end of life care?
- 03How do you cover staff rota gaps, and how often are agency staff used?
- 04How are staff and visitors tested for infections now?
- 05When was the service last given a full inspection and rating?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 4 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, August 2019
Rated Good; inspectors found safe, kind and personalised care, with some staff training and end-of-life planning to strengthen.
This was an unannounced inspection on 27 June 2019. Two inspectors, a medicines inspector and an Expert by Experience spoke with people, relatives, staff and professionals. They observed care and checked care plans, medicines records, staff files and management records.
The inspectors found that people were protected from avoidable harm, received medicines safely and had their health, nutrition and personal care needs met. The home was clean and well maintained. Staff treated people with kindness, respected their choices and provided activities suited to their interests.
Some staff had not yet received training about diabetes or end-of-life care. Not everyone had been consulted about their end-of-life wishes. The manager said training had been booked and confirmed after the inspection that end-of-life plans had been put in place for everyone.
The overall rating was Good, with Good ratings for all five areas. This was an improvement from Requires Improvement at the previous inspection, published on 5 July 2018.
Safe medicines
Medicines records were complete and medicines were given as prescribed. Staff had medicines training and their competence was checked.
“Medicines were now managed safely. Staff recorded when they had supported people to apply prescribed creams.” from the report
Kind and respectful care
People said staff were caring and respectful. Inspectors saw staff supporting people gently and maintaining their privacy and dignity.
“Throughout our inspection, we saw staff supported people in a kind and caring way.” from the report
Personalised care
Care plans included people's backgrounds, preferences, needs and goals. Staff knew people's individual choices and adapted support accordingly.
“Care plans were written in a person-centred and respectful manner and included all aspects of the person's life” from the report
Activities and inclusion
People were offered activities linked to their interests, abilities and backgrounds. The home also provided individual activities for people who preferred to stay in their rooms.
“The activities co-ordinator demonstrated a sound knowledge of people's individual choices in relation to activities.” from the report
Strong quality checks
The manager and management team carried out regular checks covering areas such as care plans, medicines, maintenance and infection control. Actions were followed up.
“There were robust systems in place to monitor the quality of the service.” from the report
Training gaps
needs fixingAt the inspection, staff had not received training in diabetes or end-of-life care, although some people needed support in these areas. The manager said training had been booked for the end of July.
“although some people were living with diabetes, staff had not received training in this subject, or in end of life care.” from the report
End-of-life discussions
needs fixingNot everyone had been consulted about their end-of-life wishes. The manager said they would seek advice and training, and later confirmed that plans had been put in place for everyone.
“However, not all the people who used the service had been consulted about this.” from the report
- 01Has all staff training in diabetes care now been completed, and how is competence checked?
- 02Has all staff training in end-of-life care now been completed?
- 03How do you make sure each person is offered the chance to discuss and record their end-of-life wishes?
- 04How are changes in people's care needs reflected in their care plans and staffing levels?
- 05How can residents and relatives raise concerns, and how are suggestions from meetings or the suggestion box acted on?
This was an unannounced planned inspection covering the home, the care provided and all five CQC questions, following the previous Requires Improvement rating. This explanation was written from the published report of 9 August 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.
Every inspection of Denville Hall
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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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