Deepdene Care Centre

Updated 21 October 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 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.

Service and service type

Deepdene Care Centre 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. Deepdene Care Centre 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We referred to the action plan sent to us by the provider following our last inspection. This told us what they planned to do to improve the service. We reviewed all of the information we held about the service, which included statutory notifications or safeguarding concerns. We used all of this information to support us with this inspection.

During the inspection

During our inspection, we spoke with six people who lived at the service and four relatives. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also spoke with the registered director, deputy manager and regional manager as well as six staff, which included the chef and activity staff.

We reviewed documentation in relation to the care of people, as well as the running of the service. This included nine care plans in varying detail, medicines records, audits and policies. We also looked at four recruitment files for staff.

Following our inspection, the registered manager sent us further information we had requested which included details of training, supervision and surveys.

Updated 21 October 2022

About the service

Deepdene Care Centre is a care home providing personal and nursing care for up to 66 people. The care home accommodates people over three floors, each having their own lounge and dining areas. Some people were living with dementia, others had long term health conditions. At the time of our inspection, only two floors of the service were being used as the top floor had been closed for refurbishment. There were 42 people receiving care at Deepdene Care Centre on the day of our inspection.

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

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. We have made a recommendation to the registered provider in relation to some detail in people’s capacity assessments.

Staff felt very supported by their peers, line managers and senior management. However, staff did not routinely receive supervisions to give them the opportunity to discuss their role, performance or training needs. We have made a recommendation to the registered provider in relation to this.

People said they were happy living at Deepdene Care Centre. They told us they felt safe at the service and staff treated them with respect and kindness. Risks to people had been identified and action taken when incidents and accidents occurred.

People received care from a sufficient number of staff who were suitably deployed around the service and people told us staff knew them well. People received the medicines they required and were referred to, or were involved with health care professionals when needed. People received sufficient food and drink and modified diets were prepared appropriately for those who needed them.

People lived in an environment that was clean and hygienic, checked for its safety and suitable for their needs. The quality of the service people received was monitored and audited to help ensure it was consistently good. Improvements had been made to the activities staff provided for people both in their rooms and communal areas.

People said staff were considerate of them and focused on their needs. People were comfortable speaking with staff or management should they have any concerns or complaints.

The service worked closely with external agencies and staff told us they had seen improvements at Deepdene Care Centre since the registered manager had started. The registered manager had a clear vision of where they wished to take the service, telling us, “I want people to have a normal life.”

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

The last rating for this service was Requires Improvement (report published 28 July 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the registered provider checked people’s care plans for their accuracy and review staff deployment. At this inspection we found the registered provider had acted on these recommendations and improvements had been made.

Why we inspected

This inspection was prompted by a review of the information we held about this service and to follow up on the breaches of regulation found at our last inspection.

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.