Defoe Court

Updated 17 February 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 27 January 2021 and was announced.

Updated 17 February 2021

This inspection took place on 6 and 10 July 2017. The first day of the inspection was unannounced which meant that the staff and provider did not know that we would be visiting.

At our last inspection of this service we awarded an overall rating of Good.

At this inspection we found the service remained Good.

Defoe Court is a care home for 41 people who require nursing or personal care. Some people who use the service are living with dementia. The home is situated in its own grounds with an enclosed garden area, set over two floors. Defoe Court has a range of communal areas for people and their relatives to use, including a café area. There were 40 people using the service at the time of our inspection.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had a robust recruitment process in place to ensure only appropriate staff were employed to work at the service to support people safely. Staffing levels were appropriate to the needs of the people using the service. The manager used a dependency tool to ascertain staffing levels.

Risks to people and the environment were assessed and plans put in place to mitigate them. The provider had a business continuity plan in place for staff guidance in case of an emergency. People had Personal Emergency Evacuation Plans (PEEPS) in place which were updated regularly. Accidents and incident were recorded and analysed regularly to identify any patterns or themes that may need to be addressed.

There were systems in place to keep people safe. We found staff were aware of safeguarding processes and now to raise concerns if they felt people were at risk of abuse or poor practice.

Medicines were managed safely by staff who were appropriately trained and had their competency to administer medicines checked regularly. This meant the provider had systems in place to ensure the people who lived at Defoe Court were safe.

The provider ensured appropriate health and safety checks were completed. We found up to date certificates were in place which reflected that fire inspections, gas safety checks and portable appliance tests (PAT) had taken place.

Staff received an in-depth induction on commencement of their employment, which included shadowing experienced staff. The manager kept an electronic matrix to monitor staff training. Staff training was either up to date or plans for refresher courses were in place. Staff received regular supervision and an annual appraisal.

People’s nutritional needs were assessed on admission and regularly thereafter. Staff supported people to eat a healthy varied diet. Records to monitor people’s nutritional intake were in place where necessary. Staff ensured people had access to health care professionals to maintain their general health and wellbeing.

Staff were extremely caring in their approach with the people they supported. Staff put people at the heart of everything they did. They also offered kindness and maintained relationships with relatives as part of their caring role. The culture within the service was one which promoted personalised care tailored to each individual’s needs. The service provided outstanding end of life care that had a positive impact on people and their relatives at difficult and upsetting times. Staff provided support for bereaved relatives to return to the home whenever they wished to.

Advocacy services were advertised in the foyer of the service and were accessible to people and visitors. At the time of inspection no one was using an advocate.

Staff knew people's abilities and preferences, and were knowledgeable about how to communicate with people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Care plans were personalised focussing on people's assessed needs. Plans were reviewed and evaluated regularly to ensure planned care was current and up to date. Where appropriate people had emergency health care plans in place. People were supported to attend appointments designed to promote their health and well-being.

The provider had an activity planner with an extensive range of different activities and leisure opportunities available for people.

Processes and systems were in place to manage complaints.

The provider held regular meetings with staff, people and relatives.

The provider had an effective quality assurance process in place to ensure the quality of the care provided was monitored. People and relatives views and opinions were sought and used in the monitoring of the service.

The provider maintained links with and worked in partnership with organisations to ensure best practice was incorporated into the quality of care provided. Community links were maintained with local schools and academies. The home had been nominated for the National Care Awards 2017 and had been recognised as one of the top 20 recommended homes in the North East. Staff had also received recognition for their work, winning Nursing assistant of the Year and nominations for Nurse of the Year.

Further information is in the detailed findings below.