Dene Park House

Dene Park House is a residential care home providing personal and nursing care to up to 51 people. The service provides support to younger and older people, some of whom are living with dementia and/or a physical disability. At the time of our inspection there were 37 people using the service.

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

Medicines were not always managed safely. Some topical medicines such as creams were out of date, handwritten entries had not been counter signed in line with the provider’s policy and national guidance, and guidance for staff lacked detail regarding people’s individual needs.

Pre-employment checks on permanent staff and records relating to the induction of agency staff contained gaps.

There were mostly appropriate infection prevention and control measures in place, although we did advise the provider about PPE compliance.

People told us they felt safe and were happy with the care they received. Staff recognised different types of abuse and how to report it. The manager understood their safeguarding responsibilities and how to protect people

People's care plans included risk assessments about individual care needs and control measures to reduce the identified risk. Staff knew people well and were aware of people's risks and how to keep them safe. There were enough staff on duty to meet people’s needs in a timely way.

We have made a recommendation about staff training and supervisions.

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. However, we did find records were not always in place where decisions had been taken in people’s best interests.

Staff treated people with care and respect. We saw staff interacting with people in a warm and compassionate way. People were supported to make decisions and choices about their care. Relatives were involved in decision making where appropriate.

Some care plans lacked the necessary detail to guide staff how to support a person with a specific need. Not all care plans were person-centred. The provider had already identified care plans needed improving and work was underway to address this.

We have made a recommendation about complaints records.

Systems to monitor and assess the quality of the service were not robust. The provider had not identified all of the issues we found on this inspection. There were gaps and errors in records and people's care records did not always contain the level of detail staff needed to support them safely.

Most relatives we spoke with felt that communication needed improving.

Since the inspection, a new manager had been appointed. They had been the registered manager at one of the provider’s other services.

There was a positive atmosphere at the home and people told us they were happy with the care and support they received.

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 good (published 20 September 2021).

Why we inspected

This inspection was prompted in part due to concerns received about medicines. A decision was made for us to inspect and examine those risks.

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 have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Due to the shortfalls identified during this inspection we asked the provider to take steps to address these issues immediately. The provider gave us assurances these issues would be addressed and we saw evidence of action being taken to mitigate the risks identified during our inspection.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines management and the governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The provider was facilitating visits for people who used the service safely. There was a designated visiting area which was cleaned between each visit. Some people were supported to keep in touch with their families through video calls.

The service was very clean. Additional cleaning was being carried out on frequent touch points such as grab rails and door handles.

People were encouraged to social distance. Lounges and dining rooms had been set out with space between people. Staff worked on specific floors to help minimise the transmission of infection between people.

Staff worked with the local infection prevention team effectively. They acted on advice given by the team such as implementing a new way of disposing of soiled PPE.

Staff wore their PPE correctly. Staff were able to explain the process for putting on and removing PPE in the safest way to minimise the spread of infection. Infection control training was up to date.

Dene Park House is a residential care home providing personal and nursing care to 42 people aged 65 and over at the time of the inspection. The service can support up to 51 people.

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

People we spoke to felt very safe living at the service. The majority of relatives were also happy that people were safe. Comments included, “I know that there is always somebody around to make sure she is ok,” and “They are very safety conscious. It is given a top priority. As far as I am concerned it is absolutely excellent.”

Staffing levels were matched to the overall dependency needs of people living at the home. Staff felt they needed more staff to support people and some relatives agreed with these comments. We discussed this with the management team who were confident that the staffing levels were correct but the deployment of staff needed to be reviewed to enable staff to feel more supported.

Medicines were managed safely. We did find issues with ‘as required’ medicines records but the management team addressed these during the inspection process.

Risks people may face were fully assessed, mitigated and regularly reviewed. Environmental risks were also assessed and checks in place in ensure safety.

The quality and assurance systems in placed allowed for continual monitoring of the service by the manager and provider. Staff felt supported by the new manager in place and were positive about the changes being made within the home.

Infection prevention and control policies were robust and followed by staff. People and relatives were positive about the processes in place for visiting during the pandemic and were happy with the actions taken by staff to keep people safe.

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.

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 good (published 24 July 2018).

Why we inspected

We received concerns in relation to staffing levels and management oversight. As a result, we undertook a focused inspection to review the key questions of safe 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 not changed. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dene Park House 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.

We found the following examples of good practice:

• Appropriate measures were in place to reduce the risk of infection. The environment was very clean, with enhanced cleaning taking place of frequently touched surfaces.

• Clear signage was in place at the entrance, personal protective equipment (PPE) was available and temperature checks were carried out of all visitors.

• Social distancing rules were being complied with. Some minor changes had been made to the layout of furniture to encourage and support social distancing.

• The provider was following national guidance for anyone moving into the home and admissions were carried out safely.

• People were supported to keep in touch with their family members via video or telephone calls. The provider had developed ways to safely support visits in line with the latest guidance.

• PPE was appropriately stored, used and disposed of. Staff had undertaken additional training in infection prevention and control and regular audits were carried out.

• Staffing levels had been maintained during the recent outbreak with the support of agency staff.

At the last comprehensive inspection of the service on 15, 16 and 20 June 2017 we identified breaches of regulation 12, safe care and treatment, and regulation 17, good governance. The provider had not fully assessed and mitigated the risks to people who used the service and infection control procedures where not always followed by staff. The provider failed to ensure that there was an effective system in place to monitor the quality and safety of the service and care records were not always accessible or complete. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

At this inspection the service had made the required improvements. We found no breaches of regulation and the service was meeting the legal requirements. Risks to people were clearly identified, assessed and mitigated, infection control procedures were being followed by staff and there was a new robust governance framework in place. People's care plans reflected their individual needs and risks were assessed.

Dene Park House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home accommodates people in one adapted building over three floors and on the date of this inspection there were 43 people living at the home, some who were receiving personal care, nursing care and some people who had a diagnosis of dementia.

The service had a registered manager in post who had been registered with the Commission since December 2017. A registered manager is a person who has registered with the CQC 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.

People at the home felt safe living there and relatives agreed with these comments. There were safeguarding policies and procedures in place to keep people safe. Staff had received training and attended supervisions around safeguarding. The registered manager appropriately escalated all safeguarding concerns to the local authority.

Staff were safely recruited and were provided with all the necessary induction training required for their role. The registered manager continued to provide on-going development for staff through refresher training and accessing courses to increase staff knowledge and skill. Accidents and incidents were recorded correctly and if any actions were required, they were acted upon and documented. There were enough staff to meet people’s needs. We saw documentation to show staff received regular supervisions and appraisals.

The premises were safe. Regular checks of the premises, equipment and utilities were carried out and documented. These were also audited regularly by the registered manager and any issues identified were acted upon. On the first day of inspection we found three clinical waste bins which were not secure. The registered manager took immediate action with this and requested the maintenance person to secure the clinical waste bins. Infection control measures were in place and the home was clean. We saw domestic staff cleaning the home regularly during the inspection.

The premises were ‘dementia friendly’ and people had personalised bedrooms. There was pictorial signage throughout the home to help people to orientate themselves. The registered manager was working in partnership with Silverline Memories to create a dementia friendly café in the home.

On both days of inspection, we observed a positive dining experience. There were pictorial menus available in dining rooms to help people make their own choices for food. People were supported to maintain a balanced diet. People told us that they were always offered drinks and food throughout the day.

The home provided safe medicines management. Procedures were in place to ensure the safe receipt, storage, administration and disposal of medicines. There were records detailing other professional’s involvement in people's care, for example GPs and dietitians.

The home had records detailing activities people had attended and there were photographs of events around the home. People were positive about the activities offered and this was discussed and documented at the resident and relatives meeting.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Staff demonstrated their understanding of the MCA and worked in accordance with this. The registered manager had made applications on behalf of people living at the service to restrict their freedom for their own safety in line with the MCA. We saw staff asking people for consent when supporting people with personal care.

Staff and people enjoyed a positive relationship and we observed kind and caring interactions. Staff knew people well and knew people’s likes and dislikes. People were treated with dignity and respect.

There were initial assessments for people which detailed all of their assessed needs. People had person-centred care plans and risk assessments to keep them safe, these were regularly reviewed for any changes in people’s needs. We saw involvement from other professionals and family for best interest decisions and mental capacity assessments. All of the care records we reviewed were accurate and up-to-date.

People had access to Independent Mental Capacity Advocates (IMCAs) and independent advocacy services if they wished to receive support. Information related to services was on display in the home.

The registered manager and provider had a clear vision to improve the quality of personalised care at the home. Staff and relatives were positive about the registered manager. There was a robust governance framework in place to ensure the quality and safety of the service provided. The provider carried out feedback surveys. The information from these was analysed and used to improve the home for people.

Dene Park House is situated in Gosforth and close to the town centre and local amenities. Residential and nursing care is provided for up to 52 people. There were 42 people using the service at the time of our inspection. Accommodation is provided over three floors.

There was no registered manager in post at the time of the inspection, as they had left the service in March 2017. A new manager had been appointed and the service was being supported by a regional manager and an experienced home manager from another Akari service.

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.

Not all aspects of the service were safe. Staff did not always maintain a safe environment. Doors which should have been locked were found to be left unlocked during our inspection and hazardous substances were not always stored correctly. Boxes of archived care records were stored unsafely, however these were removed before we completed our inspection. Infection control procedures were not always followed. A small number of wardrobes were not secured to the wall which posed a potential risk of tipping. These were secured before we completed our inspection.

Medicines were found to be managed safely, and records were satisfactorily maintained. New improved records of the administration of medicines prescribed ‘as and when required’ had been developed but were not in use on each floor on the first day of our inspection. These were introduced to all floors before we completed our inspection, but this procedure was not fully embedded. We have made a recommendation to monitor compliance with the new procedure.

There were suitable numbers of staff on duty during our inspection. There had been some concerns raised about staffing levels prior to our inspection, and we found there had been an increase in staffing on each shift including at night. There was a shortage of permanent nursing staff, and the service was relying heavily on agency nurses. Four new nurses had been appointed, and were awaiting checks prior to starting employment. Recruitment of additional care staff and a deputy manager was underway. Experienced staff from other services including a manager and senior care staff, had been brought in to the service to help support and stabilise the home. Although some people and their relatives told us they had noticed an improvement in staffing levels, some people remained concerned. We have made a recommendation to continue to monitor staffing levels closely.

We found that there had been an increase in the amount of equipment in use for the safe moving and handling of people, and occupational therapists were involved in assessing risks and ensuring correct handling plans were in place.

We observed people being supported at mealtimes, and found that where people were found to be losing weight that advice had been sought from a GP and dietician. Records of people's weights on each floor contained gaps, and did not always record people’s full details. Weights were recorded in people’s individual care files. The regional manager had recognised a lack of oversight of people’s weights and was collecting this information to monitor people's dietary needs more closely. Despite recognising weight loss and addressing this through specialist support, the kitchen had not been made aware of the changes in dietary requirements and people requiring fortified meals with added calories, were still recorded in the kitchen as receiving a normal diet. We found that in practice, however, that staff were giving people supplements and additional snacks.

There was evidence of health checks being carried out and a GP told us that timely advice was sought, however poor communication particularly between nursing staff could cause some difficulty. Important health related records including Do Not Attempt Cardiopulmonary Resuscitation orders had not always been reviewed and updated. We spoke with the regional manager about this who told us they would be reviewed as a matter of urgency. We were given assurances that this had been carried out.

The service was operating within the principles of the Mental Capacity Act 2005. Records of applications to the local authority to deprive people of their liberty were held including those granted. Care records contained information about the level of support people needed to make decisions, although this could be more detailed. Records did not always clearly record where other people had been granted legal authority to support with their relative’s financial and care decisions, such as power of attorney.

Staff told us, and records confirmed they had received regular training. A system of supervision and appraisal was also in place to support staff and identify development needs.

People and their relatives told us, and we observed, that most staff were kind, caring and attentive. We observed a small number of interactions with people that were well intended but ‘bossy’ in tone. We also heard some staff referring to clothing protectors as ‘bibs’ which could compromise people’s dignity.

Care plans were in place which had been evaluated monthly. We found, and the regional manager had recognised, that these could be more detailed. They had introduced a new format and also a ‘personal profile’ for each person, which outlined their previous experiences, interests, likes and dislikes in more detail. There were gaps in some care records and where paperwork had run put, some staff had written on scraps of paper or the back of other documents despite master copies being available.

An activities coordinator was in post, but had been absent from work during which time there had been a reduction in the number of activities available to people. Some people and their relatives told us there were insufficient opportunities to take part in activities or to meet people with similar interests. Additional activities coordinator hours were being made available for recruitment. We observed people enjoying activities during our inspection.

People and their relatives recognised there had been a period of deterioration and instability in the service, but there was general consensus that things were improving. Staff also confirmed that morale was improving. The senior management team and manager were aware of shortfalls and were addressing issues in order of safety and urgency. They recognised that communication and record keeping was poor. Several improvements had already been made or were being introduced to address these issues. Experienced staff, including an assistant nurse practitioner had been appointed to support with the oversight of clinical care. A practice development nurse was also due to be based at the service to support with improvements.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance.

You can see what action we told the provider to take at the back of the report.

Dene Park House is a care home which provides nursing and residential care for older people, including people living with dementia. The home has 50 bedrooms over three separate floors. There were 38 people living in the home at the time of this inspection. The ground and the first floor were both fully occupied and we were informed the top floor had been re-opened a few weeks prior to the inspection following a number of emergency admissions.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems were in place to keep people safe from harm. Staff were aware of the different types of abuse people might experience and of their responsibility for recognising and reporting any potential signs of abuse.

Possible risks to the health and safety of people using the service were assessed and appropriate actions were taken to minimise any risks identified.

A new electronic system had recently been introduced for the management of medication. Although staff had been trained in the use of this system and daily reports were available to the registered manager to check people were receiving their medication as prescribed we found these were not always effective.

Staff were provided with the training and support in terms of both supervisions and appraisals required to assist them in performing their roles effectively.

People using the service told us they felt staffing levels were not sufficient. However we found staffing levels were appropriate based on people’s dependency levels and expected staffing ratios for the completion of care tasks. Staff felt staffing levels were appropriate and our observations during the inspection were that there were sufficient staff to safely meet people’s needs.

Care plans we viewed were evaluated by staff on a regular basis but people and their family members had not been involved in this process. Regular reviews had also not been taking place and formal consent to care and treatment had not been captured. The registered manager had already recognised that people and their relatives had not been provided with the opportunity to be involved in their care planning and we saw evidence reviews had now started to take place. The registered manager also accepted consent to care and treatment had not been formally captured but gave assurances this would be addressed as part of the on-going work being undertaken to update people’s care records.

People were supported to meet their health needs and access external healthcare services and we received positive feedback from an external healthcare professional about the staff team’s response to advice and guidance.

Staff were described as kind and caring and we found they were knowledgeable about people’s needs and preferences. Staff treated people as individuals and were aware of the importance of respecting people’s privacy and dignity.

Systems were in place to obtain feedback from people using the service, their friends and family members and staff. The service had a complaints policy and procedure and information was on display throughout the service informing people how to complain. However records held in relation to complaints were variable and did not always provide details of whether the complaint had been resolved to the complainant’s satisfaction. People and relatives we spoke with felt although complaints were accepted these were not always resolved to their satisfaction.

The service had a registered manager in post. People, relatives and staff knew who the registered manager was and told us they felt they were approachable.

The provider had a range of systems in place for monitoring and reviewing the quality of the service, however, we found these were not always fully effective. Record keeping around areas such as complaints and actions taken to resolve areas for improvement was poor.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to complaints and governance. You can see what action we told the provider to take at the back of the full version of the report.

We asked for, and received from the provider a written plan of the actions that were to be taken to become compliant with this outcome.

In this desk-based review we have reviewed documentation submitted by the provider to demonstrate compliance.

We found the provider had taken appropriate steps to ensure effective recruitment and selection procedures were in place and carried out relevant checks when they employed workers.

We looked at a sample of staff recruitment and selection files and spoke with the manager.

We found a number of deficits in recruitment practices, including a failure to check proof of identity and employment histories properly; a failure to ensure appropriate references were obtained; and a failure to fully check the reasons for the ending of previous employment. This meant we could not be confident that only suitable persons were being employed to work with vulnerable people.

We found there had been improvements in the provision of training, supervision and appraisal of the staff team, and that systems were now in place to maintain these improvements. This meant staff were better able to deliver people's care and treatment safely and to an appropriate standard.

We found improvements had been made in the quality of the records kept of people's care, and the frequency with which those records were updated. This meant an accurate record of people's care and treatment was now being kept by the home.

People told us they were well cared for in the home, and were treated with respect at all times. Visiting relatives confirmed they were very happy with the care given, and spoke highly of the manager and her staff.

People's medicines were supplied when they needed them, and were safely stored and administered.

Systems were in place to make sure that no unsuitable people were employed to give people care in the home.

Staff were not receiving the necessary support in terms of supervision, appraisal and training, to make sure they provided safe and effective care to people at all times.

Appropriate systems were in place for responding to any complaints about the home or the care provided.

Written records in the home did not fully reflect the quality of the care provided, and were not always kept up to date.

People were very happy with the quality of their care, and told us they felt relaxed and content in the home. People's comments included, 'I like everything about the home'; 'I'm treated very well, and the staff give me care in the way I want it'; and, 'I'm well settled and I like it here. Everyone is so accepting of everyone, and there's a nice atmosphere'.

Visiting relatives were also very positive about the home and the staff. One person told us, 'Mum has thrived here'. Another relative said, 'The quality of the care is fine. There's some very caring people on the staff'

People in the home were protected from abuse. Staff were very aware of their responsibilities to keep people safe, and told us they would report any bad practice. People told us they felt safe and protected by the staff who, they said, were kind and caring.

Staff had not been fully supported in meeting people's needs because they did not all receive regular supervision or appraisal, and because not all training was up to date.

The home had systems in place to regularly check the quality of the care and other services such as catering, the environment and fire safety. Actions had been taken where problems had been identified.