What the CQC found at The Duke's House

Medicines records were well maintained. Staff were trained and checked as competent, and records showed medicines were administered in line with people’s individual guidance.

“We checked a sample of medication administration records; these were correct, showed that stocks were correct, and staff followed individualised guidance when administering PRN medication.” from the report

The home was clean and maintained. Staff had suitable protective equipment and people were supported to visit family safely during the pandemic.

“Managers and staff had responded appropriately to the COVID-19 pandemic.” from the report

People and their families said staff treated people well and that they felt safe with them.

“People and their family members told us they felt safe with staff members, who treated people well.” from the report

A new manager had introduced some changes, including daily briefings and shift handovers. Staff described the manager as approachable, although inspectors said these changes were very recent.

“Staff members described the new manager as approachable and in their initial time at the home had promoted some new ideas that included people.” from the report

The provider had improved its oversight of consent and legal restrictions. The home was no longer in breach of the consent regulation.

“The provider now had oversight of people's care and support being provided in line with their legal rights.” from the report

The provider had not properly considered whether people were suitable to live together. Staff described needing to prevent conflict, and inspectors found that the atmosphere had harmed people’s wellbeing.

“We saw records showing and staff told us there was a reliance of staff physically intervening to prevent actual conflict between people living at The Duke's House.” from the report

The home was described as busy, noisy and sometimes overwhelming. Some people became anxious, upset or spent more time in their rooms because of the environment.

“The service design and environment did not meet all people's needs as outlined in their support plans.” from the report

There had been repeated changes in senior staff and an unstable staff team. The provider had not shown effective learning or continuous improvement.

“There had been a continued period of instability at the home, leadership remained inconsistent; there had been multiple changes of senior staff at the service since our previous inspection.” from the report

Families and professionals reported poor communication, including difficulty contacting the home. Some families said trust needed to be rebuilt.

“Most people's family members told us that the communication by the provider and their representatives had been poor.” from the report

Families, staff and professionals reported very high staff turnover. Staff changes had affected people’s ability to do what they wanted and had made care less consistent.

“People's family members, staff and outside health and social care professionals told us there had been a very high turnover of staff and the staff team had remained unstable since our last inspection.” from the report