CQC report explained · a residential care home
What the CQC found at Dukeminster Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found increased risks involving oral health, incident records, risk assessments, environmental safety and some medicines. Infection control, staffing, safeguarding and recruitment were more positive.
- Effective?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Inspectors did observe respectful interactions and staff offering people choices.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. The report noted that people's preferences about the gender of staff supporting them were not always met.
- Well-led?
- Requires improvement
- Quality and safety systems were not always effective. Care plans, complaints records, medicines audits, environmental checks and arrangements for staff gender preferences were not always managed reliably.
What inspectors found, December 2023
Dukeminster Court was rated Requires Improvement after inspectors found risks with care planning, medicines and management systems.
This was an unannounced focused inspection on 17 and 31 October 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicine records, staff files and quality records.
The home was not always safe. Inspectors found increased risks around oral health, incident reporting, out-of-date risk information, environmental safety and some medicines. The provider made some immediate changes, including changing window restrictors, securing furniture and replacing undated medicines.
People generally said they felt safe and staff treated them kindly. The home was clean, infection control was followed, visitors were welcomed and there were enough staff according to most people. However, systems for checking quality and safety were not always effective.
The overall rating changed from Good at the previous inspection to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other key questions were not inspected and their previous ratings were carried forward.
Clean environment
The home was clean and did not have unpleasant smells. Inspectors found regular cleaning and enough housekeeping staff.
“The home was clean and free from malodour. Effective systems were in place to ensure all areas were regularly cleaned” from the report
Kind interactions
Inspectors saw staff speaking respectfully, offering choices and building good relationships with people.
“Our observations of how staff interacted with people were positive. People were spoken to respectfully, and the staff offered them choices.” from the report
Safeguarding
People were protected from abuse and avoidable harm. Staff knew how to report concerns and safeguarding referrals were made when needed.
“People were safeguarded from abuse and avoidable harm.” from the report
Support for choice
The report found that the home was working within the principles of the Mental Capacity Act and that required legal authorisations were in place.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Oral health
needs fixingInspectors found signs that some people were not always supported with brushing teeth or cleaning dentures. Care plans did not always clearly record people's dental needs.
“These findings indicated increased oral health risks to people.” from the report
Medicines
seriousSome as-required calming or sedative medicines were given without a clear record of why. Protocols and records for some medicines were also incomplete.
“This meant the provider could not always review whether the administration of these medicines was justified or appropriate.” from the report
Risk management
seriousCare plans did not always contain current risk information. Inspectors also found unsafe window and balcony arrangements, unsecured furniture and incorrect mattress instructions.
“Systems had not always been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Weak oversight
seriousThe provider's checks did not always identify problems with medicines, care plans or environmental safety. Complaints were not always recorded in line with the home's policy.
“The provider had failed to always operate effective systems to always ensure the quality and safety of the service.” from the report
Staff preferences
needs fixingRecords showed that male staff sometimes provided personal care when people preferred or only wanted female staff.
“Systems were not always effective at ensuring people's staff gender preferences were always met.” from the report
- 01What changes have been made to make sure every person receives the oral care and denture support recorded in their care plan?
- 02How are as-required calming or sedative medicines now recorded, checked and reviewed?
- 03How have care plans been updated so they contain accurate and current information about each person's risks?
- 04What has been done to make windows, balconies, furniture and pressure-relieving mattresses safe?
- 05How will you make sure complaints and people's preferences about the gender of care staff are recorded and acted on?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried forward from the previous inspection. 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 2022
Rated Good; inspectors found safe, kind and responsive care after improvements, with communication sometimes affected by masks.
This was an unannounced, focused inspection on 6 and 16 December 2021. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicines, staff records and management records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were each rated Good. Inspectors found that people felt safe, staff treated them kindly, people's choices were respected and complaints were dealt with quickly.
The home had previously been rated Requires Improvement, with breaches of regulations. Inspectors found that improvements had been made and that the home was no longer in breach. The Effective question was not assessed during this focused inspection, so its previous rating was used.
People felt safe
People told inspectors they felt safe and that staff knew them well. Staff had training to recognise abuse and knew how to report concerns.
“People told us they felt safe living at Dukeminster Court. They liked the staff and told us staff treated them well, were kind and knew them very well.” from the report
Falls prevention improved
The home introduced better risk monitoring and changed where staff were positioned. Inspectors found that the number of falls had decreased.
“This resulted in a change of where staff were positioned in the home to better observe risks and reduce the amount of falls.” from the report
Kind and respectful care
Inspectors saw staff supporting people patiently and respectfully. People were involved in decisions about their care and daily life.
“At this inspection, we observed staff paying attention and speaking to people in ways that supported their dignity and independence.” from the report
Improved management
The new registered manager introduced more detailed checks, regular discussions with staff and a plan for further improvement. Relatives and staff said the atmosphere and communication had improved.
“The registered manager had implemented a robust improvement and development plan, which was regularly reviewed and shared with the CQC and the local council.” from the report
Masks could affect communication
minorInspectors found that masks sometimes made it harder for people to hear and affected their privacy. Staff wrote information down when this happened.
“Wearing masks at times inhibited this due to people's ability to hear and impacted on their privacy.” from the report
- 01How will you make sure my relative can hear and communicate clearly when staff are wearing masks?
- 02What changes have reduced falls, and how do you check that these changes are still working?
- 03How will my relative's care plan be updated quickly if their risks or preferences change?
- 04How are complaints recorded, investigated and shared with families?
- 05What was the previous rating for Effective, and when will this area next be assessed?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was carried forward. This explanation was written from the published report of 1 January 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.
Every inspection of Dukeminster Court
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 16 April 2015.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Central Bedfordshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 83 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.