CQC report explained · a residential care home
What the CQC found at Dudbrook House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines systems and suitable infection control, but some recruitment checks and risk assessments needed improvement.
- Effective?
- Good
- This question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective audits, regular staff support and meetings, and good involvement of people, relatives and health professionals.
What inspectors found, December 2023
Dudbrook Hall rated Good; inspectors found safe, caring support and effective management, but asked for improvements to recruitment checks and risk assessments.
This was an unannounced, focused inspection on 22 November 2023. Three inspectors spoke with people living there, relatives, staff and health professionals. They also checked care, medicines, recruitment and management records.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found enough trained staff, safe medicines procedures, good infection control and systems for reporting concerns and learning from incidents.
There were some areas to improve. A few recruitment records were incomplete, one previous-employer DBS check did not have a risk assessment at the time, and some risk assessments had not been updated after changes such as a fall. The provider acted on the recruitment issue during the inspection and was given recommendations.
Enough suitable staff
Inspectors found enough staff and said their numbers and skills matched people's needs. Staff had an induction and shadowing before working independently.
“There are a lot of staff here and they all know exactly what they are doing.” from the report
Medicines managed safely
People received medicines as prescribed. Staff were trained and assessed before supporting people, and medicines were securely stored and regularly audited.
“People were given their medicines safely and as prescribed, and it was recorded on their medicine administration record.” from the report
Good management oversight
Managers used audits, monthly reports, staff meetings and feedback to monitor the service and identify improvements.
“There was an effective quality audit system in place which included a monthly report to analyse themes or trends.” from the report
Open visiting
Relatives were able to visit without restrictions. The report says relatives found the home welcoming and easy to contact.
“There are absolutely no restrictions in place. We can visit whenever we want to.” from the report
Recruitment records
needs fixingSome staff files did not contain proof of address. One DBS check had come from a previous employer without a risk assessment in place at the time. The manager acted during the inspection, but the provider was asked to improve its recruitment checks.
“However, the DBS checks seen on 1 staff file had been issued by a previous employer and the registered manager had not put a risk assessment in place to ensure the member of staff was safe to work.” from the report
Risk assessments not always updated
needs fixingSome risk assessments had not been reviewed after people's needs changed. Inspectors gave the example of a person who had fallen and did not yet have an updated assessment.
“However, some of the risk assessments had not been updated. For example, a person who had recently had a fall did not have an updated risk assessment.” from the report
- 01How do you make sure a person's risk assessment is updated promptly after a fall or other change in their needs?
- 02What checks are now completed and recorded before every new member of staff starts work?
- 03How do you manage DBS checks carried out by a previous employer, and when is a risk assessment required?
- 04How often are medicines records and audits checked, and what happens if an error is found?
- 05How will you keep relatives informed when a person's health or care needs change?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection published on 12 January 2018. This explanation was written from the published report of 14 December 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, January 2018
Dudbrook Hall was rated Good; inspectors found safe, kind and personalised care, with some concerns about meal temperatures and a crowded dining area.
This was an unannounced inspection on 29 November 2017. Two inspectors and an expert by experience visited the home, spoke with people, relatives, visitors, staff and healthcare professionals, and checked care records, staff files, training records and audits.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks and medicines were managed safely, staffing levels were sufficient, and the home was clean.
People were treated with kindness and respect. Staff knew people's routines and preferences, supported independence, arranged activities that reflected people's interests, and responded appropriately to complaints and end of life needs.
Inspectors noted improvements since the previous inspection, including better risk records, medicine checks, infection control and mealtime support. However, some meals served in bedrooms were not covered and people said food was sometimes cold. The small lounge used for some meals was still crowded.
Safe care
Risks were recorded clearly and linked to practical guidance for staff. Inspectors also found that medicines and safety equipment were managed properly.
“Risk assessments were of good quality and tailored to meet individual need.” from the report
Kind and respectful staff
Staff listened to people, gave them time and protected their dignity and privacy. People were encouraged to stay as independent as possible.
“Staff were kind and patient and listened to people.” from the report
Personalised support
Staff knew people's routines, interests and preferences. Care plans were described as accurate and activities were chosen around what people enjoyed.
“The service treated people as individuals and provided care and support that met their needs and wishes.” from the report
Staff training and support
New staff had a six-day classroom induction followed by at least two weeks of shadowing. Existing staff received ongoing training, supervision and appraisals.
“The service provided excellent support to staff to ensure they had the skills and experience to support people effectively.” from the report
Learning from feedback
The management team used complaints, surveys and meetings to make changes. Inspectors found improvements after earlier concerns about records, medicines and cleanliness.
“People, relatives and staff were all included in the running of the service.” from the report
Meals could be cold
needs fixingSome meals taken to people's rooms were not covered, so they could lose heat. People told inspectors that food was sometimes cold, although the manager said lids would be used consistently.
“Feedback from people reported that food was sometimes cold.” from the report
Crowded dining area
minorThe small lounge used by some people with dementia was still crowded. Inspectors saw staff providing good support, but said showing the plates could have helped some people make an informed choice.
“Whilst the environment in the small lounge was still crowded the provider had worked hard to create a nicer atmosphere.” from the report
- 01How do you now make sure meals delivered to bedrooms stay hot?
- 02How do you support people with dementia to choose their meal, including whether you show them the food?
- 03What changes have been made to the small lounge or dining arrangements since this inspection?
- 04How are risk assessments and medicine records checked now?
- 05How do you use feedback from residents and relatives to make improvements?
This was an unannounced inspection covering all five CQC areas and the overall quality of the care home. This explanation was written from the published report of 12 January 2018 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 Dudbrook House
4 rated inspections over 9 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 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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