Dormy House

Updated 30 January 2024

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.

Inspection team

Our inspection was completed by 4 inspectors.

Service and service type

Dormy House 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. Dormy House 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post however, they were absent at the inspection. Instead, we were supported by members of the providers management team.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people and 11 relatives of people who lived at the service about their experience of the care provided. We spoke with 14 members of staff including the Chief Executive Officer, regional director, managers from sister care homes, care staff, nurses and ancillary staff. We received feedback from 3 external professionals.

We reviewed a range of records including 12 people's care records including daily care notes, multiple medication records, incident records and complaints. We reviewed a variety of records relating to the management of the service including 4 staff recruitment files, spot checks, policies and quality assurance records.

Updated 30 January 2024

About the service

Dormy House is a care home providing personal and nursing care for up to 88 people. The service provides support to people who have care needs, such as, diabetes and Parkinson’s disease. Some people were living with dementia or had deteriorating mobility. At the time of our inspection there were 60 people using the service.

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

Risks associated with people’s care were not always managed in a safe way. Incidents and accidents were not always recorded in detail or investigated to reduce further risks. Medicines were not being managed safely and there were times people received as and when medicines with no detail as to why this was given.

People were not always protected from the risk of abuse or neglect as staff were not always reporting or investigating allegations. There were some areas of the service that were not clean or well-maintained, however, we saw in other areas staff practiced good infection control. There were not sufficient staff deployed to ensure people received their care when needed.

Staff were not always supervised in relation to their role and training was not always effective in ensuring good practice. The environment was not always suitable to meet the needs of people.

There were mixed response from people about the quality of the meals. The mealtime experience was chaotic, people at times were served with food that had gone cold.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. The provider has taken action to address this.

There were times when people were not treated in a kind and dignified way. However, we did see examples of staff being caring and considerate. Care plans required more detail around people’s life histories and preferences and there was some guidance missing that related to people’s needs. Activities for people were lacking.

Complaints were not always investigated, and actions taken to address the concerns. People and relatives were not always confident in the leadership at the service. There was a lack of robust oversight to ensure the quality of care. There were staff that felt they were not always listened to however, other staff said they were starting to feel more supported. The provider has increased the management presence in the service and were working on making and embedding improvements.

The provider operated effective and safe recruitment practices when employing new staff. People had access to health care when needed and assessments of people’s care were undertaken before they moved in.

Rating at last inspection and update

The last rating for this service was good (published 13 May 2021.)

Why we inspected

The inspection was prompted in part due to concerns received about the safe care and treatment of people, and staff levels. A decision was made for us to inspect and examine those risks.

The inspection was also prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of choking. This inspection examined those risks.

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

Enforcement and Recommendations

At this inspection we have identified breaches in relation to the safe management of risks, the deployment and supervision of staff, the management of medicines and people not being protected from abuse. We also identified breaches in relation to complaints not always being responded to, the lack of person-centred care planning and lack of meaningful activities. We identified concerns about people not always being treated in a caring and dignified way and the lack of robust oversight.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

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.

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