CQC report explained · a nursing home
What the CQC found at Dundoran Nursing and Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Rated Requires Improvement; the home improved and left special measures, but monitoring of diet and fluids and quality checks were not yet reliable.
This was an unannounced follow-up inspection on 11 and 18 July 2023. Inspectors reviewed care, medicines, staffing, infection control, records and management systems. They spoke with people, relatives and staff, and observed care.
The home had made important improvements since its previous inadequate rating. Medicines, recruitment, infection control, staff training, consent, care planning and activities had improved. Inspectors rated Effective, Caring and Responsive as Good.
Some improvements were recent and needed to last longer. Records did not always accurately show the fluids people were offered or drank, and quality checks had missed nutritional risks. Safe and Well-led were therefore rated Requires Improvement.
The home had been in special measures since 29 June 2023. It was no longer rated inadequate and was no longer in special measures. The provider was no longer in breach of the regulations identified at the previous inspection.
Safer medicines
Medicines management had improved. Staff had relevant training, their competence was checked, and guidance for higher-risk medicines was clearer.
“Medicines management had improved and were managed safely.” from the report
Personalised care
Care plans included people's preferences and wishes and were reviewed with people or their families.
“People's care was now planned in a personalised way.” from the report
Kind staff
Inspectors observed positive relationships and heard that staff were caring, respectful and approachable.
“There was a calm atmosphere at the service and staff provided friendly and compassionate support.” from the report
Improved staff support
Staff had induction, regular supervision and mandatory training. Recruitment records contained the required information.
“Staff received regular support, were fully inducted into their roles and encouraged to enhance their skills, knowledge and experience.” from the report
Activities and relationships
People were encouraged to join activities and maintain relationships. Relatives described efforts to keep people active and involved.
“People were encouraged to get involved in a variety of activities to meet their needs.” from the report
Fluid monitoring records
needs fixingRecords did not always accurately show how much fluid people had been offered or consumed. Inspectors recommended that the provider review how diet and fluids were monitored.
“There were gaps in ongoing monitoring from the previous 3 months throughout care and monitoring records.” from the report
Quality checks missed risks
needs fixingManagers carried out audits, but these checks had not identified the problems with nutritional monitoring before the inspection. The provider took action during the inspection.
“Although a range of audits and checks were carried out at regular intervals across the service to help identify any safety concerns or quality issue the provider had missed issues around nutritional risks.” from the report
Restricted view from one room
minorA shed outside one unoccupied bedroom restricted its view. Inspectors raised this, and the provider planned to address it.
“One unoccupied room had a new shed installed directly outside the window and restricted any views.” from the report
- 01How do you record and check the food and fluids each person is offered and consumes?
- 02What action is taken if a person's fluid intake is lower than expected?
- 03How will you make sure the recent improvements continue over time?
- 04How often are care records and nutritional monitoring audits checked by senior managers?
- 05What has been done about the restricted view from the unoccupied bedroom?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control, after the previous inadequate inspection. This explanation was written from the published report of 5 September 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, June 2023
Dundoran Nursing and Residential Home was rated Inadequate and placed in special measures after inspectors found serious risks to safety, care and management.
This was an unannounced inspection. Inspectors visited on 8 and 10 February 2023, with inspection activity ending on 15 February. They spoke with people living in the home, relatives, staff and professionals, and reviewed care records, medicines, staffing and the building.
Inspectors found serious problems with risk assessments, medicines, staffing, recruitment, training, infection control and record keeping. Care plans were often out of date or contradictory. People living with dementia or mental health needs were not always supported in a calm, personalised way.
The ratings were Inadequate for Safe, Effective, Responsive and Well-led. Caring was rated Requires Improvement. The overall rating changed from Good at the previous inspection, published on 1 July 2022.
Kind staff
Most people said staff were kind and caring. Inspectors observed warm interactions and staff who appeared to know people well.
“Most people told us that staff were kind and caring. Our observations confirmed this.” from the report
Activities
The home had an activities co-ordinator and offered social activities each day. Inspectors saw people enjoying an activity session.
“On the day of our inspection, we saw an activity session in progress, and people enjoying themselves.” from the report
Welcoming families
People said family and friends were made welcome at the home.
“People told us their families and friends were always made to feel welcome.” from the report
Some personalised spaces
Some bedrooms reflected people's personal interests and belongings. Some care plans also included information about what mattered to people.
“People's bedrooms were personalised with the things that were important to them.” from the report
Access to professional advice
People and staff could access advice from an Advanced Nurse Practitioner for day-to-day health needs.
“People and staff had access to the advice of the Advanced Nurse Practitioner from the local GP surgery for any day to day health care needs.” from the report
Unsafe medicines
seriousMedicine records did not show reliably that people received their prescribed medicines. Inspectors also found missing controlled drug doses and unsafe guidance for some high-risk medicines.
“The management of medication was unsafe. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Risks and records
seriousCare records were inaccurate, incomplete or contradictory. Staff did not always have the information needed to manage people's health risks, nutrition, fluids, skin care or personal hygiene safely.
“Records in relation to the care people received were poorly maintained, not always accurate or easy to follow.” from the report
Staffing and training
seriousThere were not always enough staff, and the home relied heavily on agency workers. Many staff had not completed important training or received regular supervision.
“There were not enough staff on duty at all times to meet people's needs. This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Building and infection control
seriousSome areas and equipment were dirty or poorly maintained. Some fire doors did not close properly and some bedrooms and bathrooms had no hot water.
“Parts of the home and its equipment were unclean and unhygenic.” from the report
No effective oversight
seriousThere was no registered manager and quality checks were inconsistent. Problems identified through audits were not always dealt with promptly.
“The management arrangements in place to assess, monitor and improve the safety and quality of the service was inadequate.” from the report
- 01What has changed in medicines management, and how do you now check that every dose, including controlled drugs, is accounted for?
- 02How many permanent and agency staff are normally on each shift, and how do you guarantee one-to-one support when it is needed?
- 03Which staff have now completed training in dementia, person-centred care, food hygiene, restraint and privacy and dignity?
- 04How are care plans checked and updated so that risks, dietary needs, communication needs and medical appointments are accurate?
- 05What action has been taken to fix the fire doors, hot water, cleanliness and other infection control problems?
The inspection began as a focused review of Safe and Well-led after concerns were shared, but significant concerns led CQC to expand it into a comprehensive inspection covering all five key questions. This explanation was written from the published report of 29 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.
Every inspection of Dundoran Nursing and Residential Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Dundoran Nursing and Residential Home →
- June 2023Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
Read what inspectors found at Dundoran Nursing and Residential Home →
- July 2022Goodstayed GoodSafe: GoodWell-led: Good
- November 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- May 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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Most charge £980 to £1,230 a week. 37 can care for a couple. 8 years' experience on average.
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