Dean Wood Manor

Updated 5 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by an inspector, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Dean Wood Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Dean Wood Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave a short notice period of the inspection due to the COVID -19 pandemic to ensure we had prior information to promote safety. Inspection activity started on 29 June 2022 and finished on 27 July 2022 at which point we had received all the additional information and clarification we had requested from the provider. We visited Dean Wood Manor on 30 June and 1 July 2022.

What we did before the inspection

Prior to the inspection we reviewed information and evidence we already held about the home, which had been collected via our ongoing monitoring of care services. This included notifications sent to us by the home. Notifications are changes, events or incidents that the provider is legally obliged to send to us without delay. We also asked for feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with three people living at the home and seven relatives about their experiences of the care and support provided. Relative feedback was gathered through face to face and telephone interviews. We spoke with 11 staff members, which included the registered manager, nominated individual, head of quality, medicines lead, nursing and care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with a visiting medical professional, who had regular involvement with people in the home.

We reviewed a range of records and other documentation This included six people’s care records, risk assessments, safety records, audit and governance information. We also looked at medicines and associated records for 10 people.

After the inspection

We requested additional evidence from the provider. This included care documentation, monitoring charts, safety records, policy and procedures, audit, quality monitoring and governance i

Updated 5 August 2022

About the service

Dean Wood Manor is a nursing home registered to support younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 49 people were living at the home.

People’s experience of using this service and what we found

People felt safe living at Dean Wood Manor. Relatives told us their loved ones received safe care from staff who knew people well. Enough staff were deployed to keep people safe and meet needs. People told us request for help were met timely. Accidents, incidents and falls had been documented and reviewed to look for trends and help prevent a reoccurrence. We found the home to be clean, with effective cleaning and infection control processes in place. Overall, medicines were managed safely. We identified some recording issues; however, these were addressed promptly during the course of the inspection.

Staff received sufficient training, support and supervision to carry out their roles effectively. People and relatives spoke positively about staff’s competence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People’s healthcare needs were being met. Referrals had been made in a timely manner to professionals when any issues had been noted or concerns raised. Equipment was in place to support people to stay well. People were happy with the food provided, with choices available at each mealtime, along with snacks in between.

People were treated with dignity and respect by staff who were described as kind, caring and friendly. Relatives explained how they had observed staff showing patience and empathy when supporting people.

Care records explained people’s needs and how they wanted to be supported. People and relatives were involved in the care planning process and any subsequent reviews, to ensure care continued to be appropriate. Peoples’ social and recreational needs were met through an activities programme, facilitated by an activity co-ordinator and staff members. The complaints process was displayed around the home and people and relatives we spoke with, felt comfortable raising concerns, although the majority had not needed to.

The home used a range of systems and processes to monitor the quality and effectiveness of the service provided. Actions had been identified and added to the home’s improvement plan, which was regularly reviewed. People and relatives told us the home was well run and spoke positively about the registered manager. Everyone we spoke with said they would recommend the home to others.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This was the first full ratings inspection since the provider had applied to change from a partnership to a limited company. This change, which took place on 19 July 2021, resulted in a new legal entity being created. We carried out a focused inspection of the safe and well-led domains only in August 2021. Following this inspection both domains were rated requires improvement, but as all domains were not inspected, an overall rating was not provided.

Why we inspected

This was a planned inspection based on the date of re-registration in order to provide a rating for the service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.