Deer Park Care Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed one quality statement in the well led question and found some good practice but also some improvement required. The score for this area has been combined with scores based on the rating from the last inspection which was inadequate. Though this assessment of this area indicated some good practice, our rating for the key question remains inadequate. The management team completed checks and audits on all areas of the service. People, staff, and relatives had been asked to complete quality assurance surveys. The results had been analysed and suggestions were recorded. There were no action plans in place to show what action had been taken to make improvements and when these had been completed.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they asked people, relatives, staff and professionals to complete quality assurance surveys regularly, the last one was sent out shortly before our assessment and some positive feedback had already been received. Systems were in place to share the outcomes of the surveys with people once they had been analysed. Any negative feedback or concerns were addressed and feedback was provided to the person raising the concerns. All feedback was discussed at meeting with people and their relatives. The registered manager also had a ‘You said, we did’ process in place to share how they had acted on feedback received. The management team completed a number of audits each month including on the environment and on people’s records to ensure they were complete. The registered manager told us the provider completed their own checks each month when they visited. They told us people were able to share their feedback at monthly resident’s meetings or individually when they wanted. The registered manager did not attend the meetings to allow people the freedom to raise any concerns they had about the management of the service. They told us people discussed, activities, trips out, food, staff and “anything they wish to discuss”. The management team understood when they were required to notify CQC of important events at the service. The head of care told us they were confident to complete notifications in the registered manager’s absence.

There were processes in place to monitor the quality of the service including monthly audits. The management team met with the provider each month to discuss the service. The results of the quality assurance surveys had been analysed. A document including an action plan and timescales had been developed, however, not all the actions had detail or a timescale. The plan did not have details of who was responsible to complete the action and a section to sign off when completed to show improvements that have been made.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.