Dashwood Manor

Updated 4 May 2023

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 2 inspectors, 1 medicines inspector and 2 Experts 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

Dashwood Manor 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. Dashwood Manor 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.

Inspection activity started on 13 March 2023 and ended on 29 March 2023. We visited the service on 13 and 14 March 2023.

What we did before the inspection

We sought feedback from the local authority and professionals who work with the service. 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 used all this information to plan our inspection.

During the inspection

We reviewed the home environment, made observations of mealtimes, medicines administration and staff interactions with people.

We spoke with the registered manager and 9 members of staff, including the deputy manager, care staff, activities staff, housekeeper and maintenance staff. We spoke with 6 people using the service, and 15 people's relatives. We spoke with 1 visiting professional.

We reviewed a range of documents, these included 12 people's medicines records, care plans and risk assessments. We reviewed policies and procedures, training records, audits, recruitment files and other records in relation to the running of the service.

Updated 4 May 2023

About the service

Dashwood Manor is a residential care home providing nursing and personal care to up to 70 people. The service provides support to older people, some requiring nursing needs and some of whom were living with dementia. At the time of our inspection, they were providing care to 62 people.

The service accommodates people in one adapted building over three floors. The ground floor supports people with residential care needs, the first floor comprises of 2 units which both support people living with dementia and the second floor supports people requiring nursing care.

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

We found medicines, including controlled drugs were not always managed according to guidance and legislation, and a failure to ensure the proper and safe management of medicines. Some people's risk assessments and care plans were not always accurate and contained inconsistencies.

Quality assurance measures were in place but these were not always robust, some issues identified on inspection were not appropriately identified through the providers audit processes. The registered manager has acted upon feedback from this inspection and was putting plans in place to address the issues identified.

We found the principles of the Mental Capacity Act 2005 (MCA) were not always followed, for example in relation to care and treatment, medicines, and hourly welfare checks. People were not 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.

Peoples care plans were personalised and contained information about people's history, and personal preferences. However, some areas of the care plans contained inconsistent information or it was missing which was not always identified during the audit process.

People were supported by kind and caring staff who treated people as individuals and with dignity and respect. The provider had robust recruitment systems to ensure staff were safely recruited.

People and their relatives said staff were lovely. We observed staff were patient and compassionate towards people.

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

Rating at last inspection

This service was registered with us on 8 September 2021 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement

We have identified breaches in relation to need for consent, safe care and treatment and good governance at this inspection.

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.