CQC report explained · a nursing home
What the CQC found at Derham House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks were assessed, staff understood safeguarding, medicines were managed safely and infection control arrangements were in place. Inspectors recommended reviewing staffing levels at night.
- Effective?
- Good
- Staff had relevant training, supervision and induction. People's nutrition and health needs were monitored, and the service was working within the principles of the Mental Capacity Act.
- Caring?
- Good
- Staff were kind, respectful and knew people's needs and preferences. People were supported to make choices, maintain their independence and have their privacy protected.
- Responsive?
- Good
- Care plans were detailed, personal and reviewed when people's needs changed. People were supported with activities and knew how to raise complaints.
- Well-led?
- Good
- The manager and staff used audits, meetings and feedback to monitor care and make improvements. Some staff said they did not feel supported, although people and relatives generally said the home was well run.
What inspectors found, January 2019
Derham House was rated Good; inspectors found safe, kind care and improvements since the previous inspection, but recommended reviewing night staffing.
This was an unannounced inspection on 11 December 2018. Inspectors reviewed care records, medicines records, staff records, rotas and training records. They spoke with people living there, relatives and staff, and observed care.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, received their medicines safely, had suitable food and access to health professionals, and were treated with kindness and respect.
At the previous inspection in August 2017, the home was rated Requires Improvement because care records were not always accurate or up to date. Inspectors found that improvements had been made, including better care planning and regular checks of records.
Improvements since the last inspection
Inspectors found that the earlier problems with care records had been addressed. Care plans were now detailed, personal and regularly reviewed.
“During this inspection the service demonstrated to us that improvements had been made.” from the report
Kind and respectful care
Staff understood people's likes, dislikes and health needs. Inspectors saw staff treating people kindly and respecting their privacy, choices and independence.
“Staff had a good understanding of the needs and preferences of people who lived at the service.” from the report
Safe medicines management
Medicines were stored securely and records showed they were given on time. Daily checks were used to monitor the system.
“This meant that people received their medicines safely and when they needed them.” from the report
Regular quality checks
The management team audited care plans, risk assessments, medicine records, training and other records. Inspectors found that issues identified through checks were acted on.
“There were audits and systems in place to monitor the quality of care people received and to drive improvements.” from the report
Night staffing
needs fixingSome staff felt there were not enough staff on some shifts. Inspectors noted that night staffing should be reviewed to make sure people could be supported safely in an emergency.
“We recommend that the provider review the staffing level at night to ensure people continue to receive care and support safely in an emergency.” from the report
Emergency evacuation plans
needs fixingPeople had emergency evacuation plans, but inspectors said these could contain more detail. The manager agreed to review them.
“However, we noted the PEEP could be further developed to make them more comprehensive.” from the report
Some staff support
minorAlthough staff received supervision and training, some staff told inspectors that they did not feel supported by the management team.
“However, some of staff told us they did not feel supported.” from the report
- 01How many nurses and care staff are normally on duty at night, and what happens if several people need help at the same time?
- 02What changes have been made to the personal emergency evacuation plans since the inspection?
- 03How do you check that care records remain accurate and up to date for each person?
- 04How are staff supported if they raise concerns about staffing or management support?
- 05How are people and their relatives involved when care plans and end-of-life wishes are reviewed?
This was an unannounced inspection of the whole service, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 24 January 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, October 2017
Derham House was rated Requires Improvement; inspectors found safe and caring support, but gaps in care planning, records and management.
This was an unannounced comprehensive inspection on 24 July and 24 August 2017. It followed concerns about end of life care after an inspection in November 2016. Inspectors spoke with people, relatives, staff, managers and a GP, and reviewed care plans, charts, training records, complaints and meeting records.
The home was rated Good for Safe and Caring. People said they felt safe and were treated with dignity and respect. Inspectors found that medicines, safeguarding procedures, staff checks and risk management were generally handled safely.
The home was rated Requires Improvement for Effective, Responsive and Well-led. Some mental capacity, bedrail and DNACPR records were incomplete or out of date. Care plans and records did not always show the care people needed or received, including repositioning, food and fluids. The registered manager was leaving, and there had been several management changes.
People felt safe
People and relatives said they felt safe. Inspectors found that staff understood safeguarding and incident reporting procedures, and risks were assessed and managed.
“People told us they felt safe living at Derham House.” from the report
End of life support
Staff had received additional end of life training and could explain how they worked with other health professionals and supported relatives.
“Staff had recently attended further training on how to support people and their relatives during end of life care.” from the report
Activities and choice
People could choose from activities including gardening, films, knitting, pet therapy, baking and music.
“There is always something going on. I choose what I want to do.” from the report
Incomplete care records
seriousFood and fluid charts did not always show the amounts people needed or received. Turning charts did not always say how often people should be repositioned.
“Records such as capacity assessments, turn charts, fluid balance charts and food diaries were not always completed properly.” from the report
Care plans did not always reflect needs
seriousSome care plans had not been fully reviewed, and care was not always planned in a way that met people's current needs or preferences.
“Care was not always designed in a way that achieved service user'S preferences and did not always ensure their needs were met.” from the report
Mental capacity paperwork
needs fixingSome assessments were more than a year old. A bedrail assessment, two covert medicine authorisations and a DNACPR form were not fully completed.
“However; we found that although capacity assessments were completed for specific decisions, some of them were over a year old and needed to be reviewed.” from the report
Management changes
needs fixingThe registered manager was leaving during the inspection period. There had been three registered managers in two years, which made staff uncertain about how the home was run.
“In addition, this was the third registered manager in a period of two years.” from the report
Unresolved complaints
minorComplaints were generally investigated and resolved, but two complaints were still ongoing when inspectors visited.
“We looked at complaints since our last inspection and found they were investigated and resolved with the exception of two ongoing complaints.” from the report
- 01How are you checking that every person's care plan reflects their current needs and preferences?
- 02How do you record and review people's food and fluid intake, including their individual daily targets?
- 03How do you make sure repositioning instructions are clear and followed for people at risk of pressure sores?
- 04Who is currently managing the home, and what arrangements are in place during management changes?
- 05What action have you taken in response to the Regulation 9 and Regulation 17 breaches?
This was an unannounced comprehensive inspection following concerns about end of life care; inspectors assessed all five key questions and gave ratings for each. This explanation was written from the published report of 3 October 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 Derham House
4 rated inspections over 4 years: the service has held its Good rating throughout.
- January 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
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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