Dorandene - Care Home Learning Disabilities

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Whilst there have been improvements made since the last inspection using our previous methodology, there were still areas that required further work in relation to medicines management. Medicines were not always stored in line with manufacturers’ instructions and MARs did not always include the necessary information. When we made the management team aware, they addressed this immediately. We found the management team to be responsive to the issues we identified and willing to learn. Other areas of medicines management had improved significantly since the last inspection such as ‘when required’ medicines (PRN) protocol. These explained what a medicine was to be used for and what the outcome should be. Staff received training in the medicines management annually which included competency assessments. Topical preparations (those applied to the skin) included body maps which helped staff to apply these in the correct areas. The provider assured us that the service was being overseen by them to ensure improvements were being embedded. On our first site visit day, there was malodour present in the service and damaged chairs in the lounge which meant these could not be cleaned effectively. By the second day, the furniture had been disposed of and the service had been deep cleaned. This significantly improved the environment although there was further work required which we saw the management team had started addressing. The service was free from clutter and trip hazards, and emergency exits were signposted. Risks associated with people’s care were generally managed safely by staff. Where staff needed to gain further confidence, the management team was proactive and we observed them coaching staff on how to support people appropriately. At our last inspection, we identified that several people required the front door to remain locked. We saw that this had now been completed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt safe living at the service. Whilst they had felt unsafe under the previous management, they generally felt that the new management team listened to their concerns and that there had been some improvements. As other areas of this report highlight, we identified areas of improvement during this assessment which the management team had already identified. We observed staff being coached by the interim manager to appropriately support people. We saw people’s experience had improved since the last inspection and the management team addressed areas for improvement that we identified on the first day by the second day of our assessment. Where areas required further work, we were provided with assurances by the provider with a timeline of completion.

Staff we spoke with told us they discussed incidents and accidents to look at what lessons could be learnt. Staff understood the importance of reporting concerns to the relevant authorities, in order for information to be shared appropriately. Staff understood the principles of duty of candour and they felt supported by the management team.

We found that the service had records of investigating incidents and accidents which had actions taken to mitigate future risks. For example, in response to an injury the whole staff team had been gathered to reinforce the importance of prompt reporting. Additional training had been provided to staff in response to another incident, and external professionals were contacted in response to another. Where records showed that risks were not always proactively managed, the provider had a service improvement plan in place which addressed this. The provider had notified CQC of reportable incidents. The provider carried out surveys with people and relatives which had a section focussed on safety with the aim to gather concerns and address these.

People and their relatives told us they had access to services when they needed these and that their healthcare needs were understood by staff. They told us that this had improved recently under the current management team.

Whilst there were areas for improvement, such as ensuring that staff always followed instructions when management were not present, the new management team worked together with people and coached staff to ensure that care was delivered in a way that encouraged partnership working. The new management team had already identified several areas prior to the inspection and we saw that they were working to address each point.

We received mixed feedback from partners with some commenting on the previous management team and the reluctance to consistently follow up referrals. Others told us of the improvements that have been made by the current management team and the positive impact this has had on people’s lives.

We saw that people had hospital passports in their care plans which allowed the safe transfer of key information in a single document should a person be taken to hospital. This included information such as how a person communicates and any allergies. People also had a one-page profile to help introduce themselves to people who may not know them well, enabling transitions to be person-centred. Shift lead roles and responsibilities were clearly identified and included a walk around with the previous shift leader and thorough handover highlighting any changes to people’s needs.

People and their relatives told us they felt safe living at the service. Relatives highlighted that there had been improvements since the last inspection and told us they could approach the new management team.

Whilst staff were able to tell us about their roles and responsibilities in relation to safeguarding, we observed instances of staff assisting people without their prior consent. For example, when assisting people to clean their face following a meal. We also observed the manager immediately speaking to staff before we highlighted this to them. The management team undertook a coaching session to discuss this with staff and ensure they were consistently following national guidelines, such as Right Care, Right Support, Right Culture. There was further time required to embed the values of the management team within the service.

We observed people generally being treated in a kind and respectful way. However, there were also instances where staff did not demonstrate a full understanding of how to respect people’s right to choose what they would like to do. Following a meal, staff wiped a person’s mouth without a prior conversation. This meant that the person was not able to choose whether they would like to, particularly as we also observed the person being able to undertake the task independently on another occasion.

The service improvement plan had identified that staff were not always aware of the protocol to follow when it was felt someone needed to be safeguarded. The plan evidenced an action to highlight and discuss in staff meetings that all staff learning and development would be discussed in their individual supervisions and group supervisions. Training for safeguarding had been completed by most staff, however there was an instance where a staff member who was regularly rostered had not received safeguarding training. We received assurances that this had been addressed.

Relatives told us they felt risks in relation to people’s care were generally managed by staff and that they were generally contacted following changes or incidents. We saw people’s risks were generally managed but there were still areas of improvement in relation to staff confidence of moving and handling risks. The management team was aware of this prior to our assessment and we observed them coaching people on the appropriate use of aids during our assessment.

Staff told us they knew how to manage risks in relation to people’s care. Staff told us about people’s varying needs, such as managing the risk of choking, moving and handling, expressing feelings with an emotional reaction, the risk of constipation and the risk of falling. Staff told us they knew the steps they should take to reduce these, which healthcare professionals they should involve and staff knew where to find the information in people’s risk assessments.

Whilst staff were confident explaining the measures they should take when supporting people to reduce risks in relation to care, we observed instances where staff appeared unsure how to support people in line with their risk assessments. We observed an instance when a member of staff struggled to assist a person to stand and another instance where a staff member was unsure how to assist a person who appeared anxious. The management team was present and we saw that measures had been taken to address these, such as further training. However, there was further time required to embed the training and supervision. We observed people being offered the appropriate consistency of meals and drinks, pressure-relieving mattresses were set to the appropriate setting and in other instances people were assisted appropriately to reduce the risk of falling and to manage their anxieties.

People’s care records included relevant information around their individual risks and what staff should do to support people to remain safe and well. Care records contained details of people’s healthcare needs and the professionals involved. Care records and instructions from healthcare professionals were generally being followed by staff. Instructions from healthcare professionals included which consistency meals and drinks should be to reduce the risk of choking and how to support people in managing their anxieties. We also saw in people’s records that they were supported by staff to see the dentist and guidance from professionals in relation to maintaining good oral hygiene.

On our first day visiting the service, we found several damaged sofas and malodour present in the communal areas. The following day, when we visited the service again, the furniture had been disposed of and the service had been deep-cleaned, which significantly improved the quality of the environment. The service was undergoing a deep clean when we attended on the first day. The environment was free from clutter and trip hazards and there were instructions and equipment for emergencies, such as fire extinguishers.

Staff told us they understood their responsibilities in relation to maintaining a safe environment. Whilst staff were able to tell us about their role in relation to emergency evacuations and maintenance checks of the environment, they had not taken appropriate action by removing damaged furniture. The new management team had already identified that the service required a deep-clean and addressed this but other areas were not addressed as a priority until we visited the service.

We observed an environment which was free from clutter and emergency exits were signposted and accessible. Whilst we identified areas for improvement in relation to infection prevention and control which would impact on the general safety of the environment, bedrooms and communal areas were accessible to people and we saw people using the spaces independently. Equipment and cleaning products were kept stored safely and away were not accessible to people.

The provider had undertaken an audit and fire risk assessment to assess the environment and had identified that all areas had not been kept safe. For example, the frequency of fire evacuation practices, checks of equipment, access to sharps drawers, anti-smoke seals and the emergency lighting. The management team provided assurances that these areas had been addressed. Where shortfalls required further work, there was a timeline of completion. The majority of staff had completed fire training and there was at least one person present who had completed fire training on each shift. There were emergency personal emergency evacuation plans (PEEPs) in place for all people living at the service. However, two people’s PEEPs did not accurately reflect their current ability in relation to recognising the dangers and ability to self-evacuate. For example, one person’s PEEP stated that they were independent but then stated later on in the document that they required support from carers. When we discussed this with the management team, they acknowledged that these records required to be updated and addressed this so that the PEEPs now reflected people’s current needs.

People did not have to wait for support and there were sufficient staff on duty. However, at night time, there were less staff available to support people and this meant that people may have to wait for support. There were 2 members of staff deployed at night time and there were 3 people who required the assistance of 2 staff. The management team was already aware of this and was in the process of recruiting further staff.

Staff told us there were generally sufficient staff to meet people’s needs. Where sickness meant that staff were unable to work at short notice, the management team covered these shifts with staff from an agency.

There were sufficient staff available to support people on the days of the site visits, however staff were not always deployed effectively as we saw people were sitting in the communal areas whilst staff were cleaning other areas of the service. This meant that only one member of staff was sitting in the communal area and supervising people whilst music was playing. When staff required help, we observed them calling loudly for help. For example, we observed one instance when a person required assistance with personal care and staff loudly discussed this in the presence of people until a manager intervened. Staff regularly checked on people’s welfare to ensure they were safe.

The provider used a dependency tool to establish the level of staff required for people. The rosters had not always been kept updated. For example, they did not always reflect the number of agency staff or managers on shift which meant that there was not always an accurate picture of the number of staff on duty. At night time, the staffing levels were not always sufficient to ensure people’s safety as 3 people required 2 staff to assist with personal care needs. The management team was already aware of this and was recruiting staff to this role. Training records did not show that all staff had completed training for learning disabilities and autism. There was a timeline in place by which staff were due to complete the training and we saw that this was being prioritised by the management team. Staff had been recruited safely. Where staff were unable to provide two employment references, additional character references were sought. All staff had completed Disclosure and Barring Checks (DBS) prior to commencing employment. All staff records we reviewed had previous relevant experience.

On the first day of our site visits, people were exposed to some poorly maintained furniture and equipment and there was a malodour present throughout the premises. When we returned the following day, the service had been deep-cleaned and the damaged sofas had been removed with new furniture having been requested by the management team. The deep-clean had been scheduled by the provider previously, but the furniture was removed as a result of our first day visit.

Staff told us that they had raised the malodour in the premises with the management team and as a result the deep-clean was arranged. Staff told us that they had sufficient time to clean the premises but that the some areas, such as the communal areas, required a regular deeper clean.

There was a malodour present throughout the premises on the first day and several sofas and a toilet seat were damaged which meant they could not be cleaned properly. By the second day of our on-site assessment, the service had been deep-cleaned, the damaged sofas had been removed and the management team had submitted a request to replace the toilet seat.

There were processes in place to clean the premises and staff had displayed cleaning schedules outside people’s bedrooms and in the communal areas which were generally completed. Where staff mentioned cleanliness as an issue during their supervision, the management team took action to request a deep-clean of the service. Staff had completed relevant training in relation to infection prevention and control.

We observed people receiving their medicines in line with their electronic medicines administration records (MARs). This included supplementary medicines used to modify the texture of drinks. We saw staff using this appropriately when offering people drinks and ensuring that people were supported to take their medicines in a way that they preferred.

Staff told us there was no record kept of incidents and there was no evidence that learning was shared from mistakes and incidents. Staff told us there were no audits of medicines taking place. Staff were not aware of medicines with additional risks and people’s MARs did not include appropriate information to inform staff of these risks. Staff did not always know which ‘when required’ medicines were still used or discontinued. Whilst the management team kept a log of clinical safety alerts, staff were not always aware of this. We made the management team aware of this and they planned service audits of medicines and sought advice from the GP in relation to MARs.

The service did not always safely store and administer medicines. The service did not always follow the process for ensuring that administration records accurately showed how medicines were prescribed and administered. Medicines were not always stored safely as storage temperatures were not always recorded. Governance requirements were not in place for processes such as monthly medicines audits since January 2024, medicines risk assessments and learning from incidents. When we discussed this with the management team, they showed us the systems they were due to implement in order to ensure medicines were managed safely. Following the site visit, the management team addressed the issues in relation to how medicines and temperatures are recorded and implemented a medicines incident log. The management team and provider were responsive when we highlighted areas for improvement we had identified. Other areas of medicines management were completed appropriately. This included a weekly telephone call with the GP surgery to discuss changes in people’s needs and arrange for people to be seen by their GP and ensuring people’s medicines were still appropriate for their needs. ‘When required’ medicines (PRN) protocols were in place for prescribed medicines. These explained what a medicine was to be used for and what the outcome should be. Staff received training in the medicines management annually which included competency assessments. Topical preparations (those applied to the skin) included body maps which helped staff to apply these in the correct areas.