CQC report explained · a residential care home
What the CQC found at Denecroft Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, appropriate recruitment checks, safe medicines records and risk assessments that were followed. The home was clean, and the previous problem with high temperatures in the conservatory had been addressed.
- Effective?
- Good
- People's needs and choices were assessed, staff were trained, and people were supported with food, healthcare and mobility. Inspectors also found that mental capacity and best-interest decisions were recorded appropriately.
- Caring?
- Good
- Staff were kind, patient and respectful. People were supported to communicate, make choices and do as much as possible for themselves.
- Responsive?
- Good
- Care plans were personalised and people were supported with activities, trips and holidays that matched their interests. The home listened to complaints and used feedback to make changes.
- Well-led?
- Good
- Inspectors found effective quality checks, clear records and an open management approach. People, relatives and staff were involved through meetings and surveys.
What inspectors found, May 2019
Rated Good; inspectors found safe, kind and personalised care, with some end-of-life planning details still being improved.
This was an unannounced comprehensive inspection on 2 April 2019. One inspector spoke with relatives, staff and people where possible, observed care, and reviewed care records, staff files, policies and management records.
The home supported five people with learning and physical disabilities and could accommodate six. Inspectors found enough staff, safe medicines practice, clean surroundings and suitable risk assessments. People were treated kindly, involved in choices and supported to be more independent.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This is the same overall rating as the previous inspection in July 2016. Safe had improved from Requires Improvement after high temperatures in the conservatory were addressed.
Enough staff
Inspectors found there were enough staff to keep people safe, provide company and support daily activities.
“People were cared for by a sufficient number of staff.” from the report
Kind and respectful care
Staff adapted plans and routines to what people wanted. They supported communication, privacy, dignity and independence.
“People were supported by kind and caring staff.” from the report
Personalised support
Care plans helped staff understand each person. People were supported with interests such as music, sports, holidays and trips.
“Care plans were person centred.” from the report
Strong management checks
The management team used audits, meetings and surveys to identify improvements and monitor the quality of care.
“Quality assurance processes were effective at checking quality and driving improvements at the service.” from the report
End-of-life information
needs fixingInspectors found limited end-of-life detail in care plans, although there was enough information to provide care if needed. The manager added new end-of-life details after the inspection.
“Although there was limited end of life details in people's care plans, there was sufficient information to enable staff to provide person-centred end of life care should the need arise.” from the report
Ongoing refurbishment
minorSome bedrooms were still being refurbished when inspectors visited. The report says people had been involved in choosing colours and furniture.
“Some of the bedrooms were still in the process of being refurbished at the time of the inspection.” from the report
- 01What end-of-life information has now been added to each person's care plan?
- 02Which bedrooms have been refurbished since the inspection, and what work remains?
- 03How are you supporting each person to develop or maintain their mobility and independence?
- 04How do you make sure medicines records and guidance remain accurate?
- 05How are people's views gathered and used when planning activities, meals and holidays?
This was an unannounced scheduled comprehensive inspection covering all five key questions and providing new ratings for the service. This explanation was written from the published report of 18 May 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 2016
Rated Good overall, but inspectors found the home was not consistently safe because of excessive heat and medicine record gaps.
This was an unannounced inspection on 5 July 2016. Two inspectors spoke with staff, managers and relatives. They observed care, mealtimes and medicines, and reviewed care records, medicine records, staff files, incident reports and quality checks.
The home was caring, effective, responsive and well-led. Staff were described as kind, respectful and person-centred. People had varied activities, support with health needs, adapted equipment and opportunities to stay connected with family and the community.
Safety required improvement. The conservatory reached 32 degrees Celsius and was uncomfortable. Inspectors also found that some instructions for medicines given when needed had not been agreed by the prescribing doctor, and medicines audits were not regular. Some mental capacity assessments were also missing, although staff generally followed best-interest processes.
Respectful care
Staff knew people well, respected their dignity and took time to communicate in ways people understood.
“People were treated with dignity and respect by staff who knew them well.” from the report
Person-centred support
Care plans reflected people's wishes, goals and preferred ways of receiving support. Relatives were involved in reviews.
“People's care was person centred, care plans were reviewed regularly and involved people and those close to them.” from the report
Activities and independence
People were supported to enjoy varied activities and use equipment adapted to their needs, including visual impairment.
“People were provided with numerous opportunities to take part in a varied range of stimulating activities of their choice inside and outside the service.” from the report
Health support
Staff responded to changes in health and worked with doctors and other health professionals when needed.
“People had access to health and social care professionals, who helped maintain their health and wellbeing.” from the report
Open management
Inspectors found a positive and inclusive culture, with systems to check care and make improvements.
“The service had a positive culture that was person-centred, open, inclusive and empowering.” from the report
Excessive heat
seriousThe conservatory reached 32 degrees Celsius while people were eating and spending time there. The manager had begun looking for a long-term solution and put temporary measures in place.
“The temperature reached 32 degrees Celsius during the afternoon.” from the report
Medicine instructions and audits
needs fixingInstructions for medicines given when needed had not been written or agreed by the prescribing doctor. Regular medicine audits were also missing.
“Further there was no regular audit of medicines.” from the report
Missing capacity assessments
needs fixingDetailed assessments for some specific decisions had not always been completed. The deputy manager said these would be done as soon as possible.
“However detailed assessments of people's mental capacity for specific decisions, such as not being able to go out on their own, had not always been completed.” from the report
- 01What permanent changes have been made to prevent the conservatory becoming excessively hot?
- 02Have all PRN medicine protocols now been agreed by the prescribing doctor and brought in line with Royal Pharmaceutical Society guidance?
- 03How often are medicines audits now completed, and what did the latest audit find?
- 04Have the missing mental capacity assessments for specific decisions been completed and recorded?
- 05How is the new manager's registration process progressing?
This was an unannounced inspection of the overall service, covering all five CQC questions through observations, discussions and records reviewed. This explanation was written from the published report of 4 October 2016 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 Denecroft Residential Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 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.
- December 2010
Registered with the Care Quality Commission on 15 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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