Deerswood Lodge

Updated 12 October 2021

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 Care Act 2014.

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 undertaken by three inspectors 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.

Deerswood Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

We gave a short period notice of the inspection because we wanted to ensure we had up to date information regarding the COVID-19 status of the home. This would enable us to plan our visit safely.

What we did before the inspection

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 reviewed information we had received about the service since the last inspection and liaised with the local authority for their feedback. We used all of this information to plan our inspection.

During the inspection

We spoke with 14 people who used the service and two relatives about their experience of the care provided. We spoke with 15 members of staff including the managers, team leaders, care workers, housekeeping staff, an activities co-ordinator, a chef and a GP.

We reviewed a range of records. This included 11 people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We are currently improving how we gather people’s experience and views on services when they have limited verbal communication. We have trained some CQC team members to use a symbol-based communication tool. We checked that this was a suitable communication method and that people were happy to use it with us. We did this by reading their care and communication plans, speaking to staff and the person themselves. In this report, we used this communication tool with four people to tell us their experience.

After the inspection

We continued to seek clarification from the managers to validate evidence found and follow up on people’s care. We looked at training data, quality assurance records and audits. We gained feedback from a health professional who has regular contact with the service.

Updated 12 October 2021

About the service

Deerswood Lodge is situated Crawley, West Sussex. It is one of a group of homes owned by a national provider, Shaw Healthcare Limited. It is a residential 'care home' providing care for up to 90 people who may be living with dementia, physical disabilities, older age or frailty. At the time of inspection there were 73 people living at the home.

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

Since our last inspection it was evident the managers of the service and staff had worked hard to make the required improvements and raise the standard of care people received. Most of the providers quality assurance and safety systems for managing risks had been embedded, sustained and had continued to improve the providers oversight of care people received. However, some improvements were still required to ensure that all systems for monitoring people’s health and care were effective in identifying potential risks from which actions to mitigate those risks could be taken. Although processes had been reviewed and updated, more time was required to monitor their overall effectiveness and embed them in everyday practice.

People and their relatives told us they felt safe and were cared for by a consistent team of staff who knew them well. Risks to people’s health were assessed and people were supported to stay safe. Care and support plans were person centred and provided staff with clear guidance on how to support people. Staff were aware of their safeguarding responsibilities and knew how to report and escalate concerns.

Accidents and incidents were appropriately reported by staff, investigated by the managers and action taken to mitigate risks and reduce the risk of reoccurrence. There was a strong emphasis on learning from accidents and incidents to improve people’s experiences of care. Staff worked hard to maintain a safe and homely environment which was clean and well maintained. Infection prevention and control practice was safe and in line with current government guidance.

People told us there were enough staff to meet their needs and staff came quickly when they called. Staff had undertaken training relevant to the needs of the people they were caring for and had the skills and competence to provide safe and effective care. Staff felt supported and engaged in supervision where they received feedback on their practice and had opportunities to develop.

Medicines were managed safely and people received their medicines as prescribed in a safe and respectful way. People prescribed as required medicines (PRN) had care plans to guide staff as to when PRN medicine should be administered and alternative interventions that people could try.

People were supported to develop and maintain relationships which would reduce the risk of isolation and promote their emotional wellbeing. People told us they enjoyed a range of activities and were involved in the running and development of the home. Information and the environment had been adapted to meet the needs of people living with dementia and communication needs. People’s wishes and preferences were understood by staff and people were treated with kindness and respect. We observed people were treated with dignity when receiving care at the end of their lives.

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.

The culture of the service was positive, person centred and promoted good outcomes for people. Feedback from relatives and health professionals was complimentary about the care people received and the management of the service. One relative said, “I think its improved since [registered manager] took over, recently areas have been re painted or refurbished. There is a homely feel as you enter the building.”

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

Rating at last inspection

The last rating for this service was requires improvement (published 21 February 2020).

Why we inspected

We received concerns in relation to people’s care, infection control, the management of people’s medicines and the culture of the service. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Deerswood Lodge on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.