Deepdene Court

On this page

• 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

At the last inspection, we found the provider in breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to failure to manage risks associated with the environment, including fire safety. At this assessment, improvements had been made to the cleanliness of the environment and fire safety risks were being managed. However, we found concerns around management of risks to people which resulted in a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were not enough suitable staff with the skills to support people’s needs, and some staff told us they did not always feel safe on duty. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People said they felt safe at Deepdene Court and would tell staff if they were worried. We observed how staff had developed positive relationships with people who they knew well. Staff had been trained in safeguarding and demonstrated a good understanding of their responsibilities, including for protection people’s rights in line with the Mental Capacity Act. Some people were subject to DOLS and conditions attached to DOLS authorisations were met. Staff had a good understanding of how to support people to be involved in managing risks. One staff member said, “We involve them by talking things through, working out the risks and deciding how to proceed. It depends what they want to do.” We observed staff were knowledgeable about people’s individual needs and preferences.

This service scored 56 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at Deepdene Court and said they knew how to raise any concerns and would feel comfortable to talk to staff. People described how staff supported them to remain safe when out in the community. One person said, “Inside here I feel safe, not outside on my own. Staff come with me, and I am ok.” People said they could talk to staff about any concerns they had. One person told us, “I feel safe here, better that the last place I was at. If I saw something naughty, I would tell a member of staff. Probably the manager. Staff are great here. We have a laugh and they are kind.” Another person said, “ Yes I would say I feel safe, I feel like the staff have your back if you know what I mean.”

We observed how staff had developed positive relationships with people who they knew well. People appeared happy and relaxed in the presence of staff. For example, we observed the nurse on duty talking to a person about their emotions and how they were feeling. They demonstrated good insight into the person’s needs and gave them reassurance in a kind and caring way. We noted people were laughing and joking with staff who were supporting them, for example at meal time. We saw people coming to the deputy manager to talk or ask for things. She was responsive and good humoured and gave clear explanations of what she was doing.

Staff had been trained in safeguarding and demonstrated a good understanding of their responsibilities. Staff were consistently able to describe how they would recognise signs of abuse and described being vigilant and aware of people’s vulnerabilities. One staff member said, “It’s part of our job to make sure people feel safe, here and out in the community. They know they can tell staff anything if they are worried.” Staff were aware of how to report abuse and gave examples of when actions had been taken to ensure people were safeguarded . This had included a person who was being bullied by another person at the home. Staff described recognising situations where people were vulnerable to abuse and supporting them to make safe decisions. For example, a person had been exposed to possible financial abuse and staff supported them by putting arrangements in place to prevent this happening. They described continuing to support the person to have control of their money in a safe way. Staff spoke about people in a positive way, including the emotions they expressed. One staff member expressed their pride in one person’s achievements, saying, “They have worked so hard to turn their life around.” Staff demonstrated a good understanding of the Mental Capacity Act and knew two people were subject to DoLS and the reasons for this. A staff member described how one person’s cigarettes were kept in the office to ensure they did not smoke in their bedroom and this restriction was included within the DoLS agreement. Staff said they did not restrain people and used verbal techniques only to de-escalate situations when needed. One staff member said, “We know people well so we can usually talk them round if we need to.”

Processes did not support consistency in identifying safeguarding matters. A partner agency had raised a safeguarding alert as a result of concerns about people not receiving antipsychotic medicines in line with their prescriptions. These incidents were not recorded within the provider’s system for monitoring incidents and had not been identified by the provider as a potential safeguarding issue. Other safeguarding incidents had been identified and reported appropriately. For example, altercations between people had been identified and reported appropriately and actions were taken including reviewing care plans, to ensure people’s safety. People’s care records showed the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met.

Processes were not robust to ensure risks to people were always assessed, monitored and managed safely. Administration of slow release medication by injection, (Depot injections) had been inconsistent because there was not always a registered nurse on duty to give the depot injection when it was due. Risks to people from not receiving their medicine as prescribed had not been assessed and managed. A lack of systems for monitoring depot injections, MAR charts, prescriptions and for oversight of people’s health needs, meant that shortfalls had not been identified and reported and risks were not always managed safely. Some people were subject to Community Treatment Orders which required them to remain compliant with their prescribed medicines. Conditions relating to CTO’s were not included in people’s care plans to ensure risks associated with meeting the conditions of the CTO were assessed, monitored and managed. The increased risks from inconsistent administration of Depot injections had not been identified and assessed. A person needed support with insulin injections including a variable dose depending on the person’s blood sugar levels which were measured three times a day. This required a clinical judgement about the dose of insulin to be administered. Some care staff had received additional training so this task could be delegated to them. However, there was no nurse employed to provide clinical oversight and to be responsible for this delegated task. This meant risks associated with administration of insulin were not being effectively monitored and managed. The provider’s monitoring systems had failed to identify that MAR charts were not always clear and errors and inconsistencies had not always been identified and reported.

There was a calm atmosphere and people appeared relaxed in the company of staff. We observed staff supporting people in line with their care plans, using techniques to engage people with activities and supporting them to talk about their mood and feelings. We saw the nurse on duty supporting and encouraging people to take their medicines, they had a good rapport with people and treated them with kindness and understanding. We observed a staff member quietly praising a person for their kindness to another person and this was well received, the person was observed to be very happy with the remarks.

People told us they were involved in developing their care plans and in managing risks. One person explained she had a keyworker and they talked about what she needed and wanted. Another person told us staff supported her with managing health appointments, her medicines and money. People described being included in discussion about risks. One person explained how staff had talked with them about risks associated with smoking, including fire risks. They said they smoked outside now. Another person said, “They don’t force you to do anything here, I do my own room and laundry they encourage you to be independent.” Another person described being supported to be as independent as possible, they told us, "I can do what I want really, its good."

Staff raised concerns about clinical risks not being effectively managed at the service. Staff explained how nurses were not always available when people were due to have their injections. This meant medicines were not administered consistently and in line with their prescription. This increased risks of a deterioration in people's mental health and increased the risk of breaching Community Treatment Orders for some people. Staff told us a person needed regular insulin administered to manage their diabetes. Due to the lack of nurses on duty, staff said there was no oversight or checks to ensure the safe administration of the insulin, including the correct dose. Leaders told us no risk assessment had been completed to assess the risk and impact for people from not always having support from a nurse on duty. Other risks to people were being assessed and managed by staff who knew people well and understood their needs. Staff described how people were supported to be involved in managing risks. One staff member said,” We involve them by talking things through, working out the risks and deciding how to proceed. It depends what they want to do.” The chef (who was new in post) was aware of people who required modified diets. They told us they were keen to include people in cooking activities to improve their skills and build confidence and would undertake risk assessments to support people with this activity.

Systems in place to record when cleaning tasks were undertaken. Infection prevention and control measures in place and records kept. Health and safety records including fire drills, legionella checks maintained. A log book which identified faults and repairs showed these had been fixed and signed off. Staff said this system seemed to be working well for general repairs.

We saw people were supported to smoke outside and were compliant with fire safety requirements. Places outside including a shelter for people to smoke. Do not smoke signs everywhere, including in some people’s rooms. We observed staff encouraging people to remember to only smoke outside. The general cleanliness of the buildings was reasonable and there were no unpleasant odours. 6 people gave us access to their rooms. All in reasonable state of cleanliness, people were supported to maintain a basic standard.

People told us the cleanliness and homeliness of the environment had improved. People were happy to show us their rooms and said the staff helped them with cleaning and laundry. One person told us, “I am very satisfied with my room.” People described having been supported to understand fire safety risks that were identified at the home and knew they should only smoke outside the building. One person said, “We had the fire person come and talk to us about the dangers of fire.” There was access to kitchen facilities and one person described how they used this areas to prepare their own food when they wanted to.

Staff told us there had been improvements in managing the environment since the last inspection. One staff member said, “It’s improved a lot they have hired more cleaners and that has made a huge difference and staff support with deep cleans when needed.” A staff member was responsible for managing maintenance at the home and described the progress they had made since taking on the role. Staff described improvements in managing risks of smoking in the home. One staff member told us, "We have done a lot of work on this, people are getting it now and there is a much better understanding of the risks."

The rota showed adequate staffing levels were not consistently maintained. Rota shows vacant posts: x 3 for day support workers, and x2 RN vacancies. Also 1x vacancy for senior night worker and x1 for night support worker. The vacant posts were not being covered consistently. For the period 1-12-2023 to 17-1-2024 (48 days) there was no nurse on duty on 23 days and a nurse for a shorter then usual shift on 13 days. This meant people were not always receiving the care they needed, including some people who required injections for medicines as part of their community treatment order. There was no process in place to determine the level of risk to people from not having suitably trained staff on duty. The provider had a supervision policy, but this did not include how registered nurses should receive clinical supervision.

Staff described shortfalls in staffing levels. Deputy manager said there should be 6 staff (including 2 seniors) and one nurse on duty during the day and 6 staff including 2 seniors at night. Staff described how previously (before October 2023) there were two nurses employed at the service. However, they now work as bank staff and there is a heavy reliance on agency nursing staff to cover all the shifts. Staff described prioritising days when service users needed to have a depot injection to try and find agency nurses to cover, as the injections could only be administered by a nurse. However, there were not always nurses available for these shifts. The consistent lack of trained nurses on duty meant there was a failure to ensure there were enough staff with suitable skills to meet people’s needs. Staff consistently described not always feeling safe at work due to lack of staff on duty. One staff member said, "At weekends there's not always enough staff, managers and nurses, and then I don’t feel safe." Another staff member said, "At weekends there is no manager, it makes a big difference if there is no nurse too.” Staff described how the shortage of kitchen staff as well as lack of nurses and heavy reliance on agency staff had an impact on safety. They explained care staff were covering in the clinical rooms and the kitchen which left fewer staff supporting people. Staff described how some people had complex mental health needs and needed a consistent approach from staff who knew them well. Staff said having new or unfamiliar agency staff meant people were not always receiving the consistent approach they needed. One staff member said, “It means the residents don’t get people who know them well, agency staff don’t know people well- its inconsistent, we don’t know who is coming, it adds pressure to staff. “ Not all staff were receiving the supervision and support they needed, for example, there were no arrangements for clinical supervision for nurses.

We saw staff were busy throughout the assessment and were responsive to people’s needs. Staff were spending time talking with people and there was a calm atmosphere. People appeared to be comfortable in the company of staff. We observed bank nurse on duty administering medicines to people during the day. Clearly they knew people well and had a good rapport. We observed the person in charge had a good rapport with people, saw people coming to her to talk or ask for things. They were responsive and good humoured. Gave clear explanations about what she was doing and offered other staff or a short wait to a person as they wanted to chat and they were supporting someone else. Observations showed staff supporting one person well, in a kind and considered way, the person responded positively and appeared calm and happy.

People told us there were usually enough care staff on duty to meet their needs. Some people felt there were not always enough staff around including at weekends, their comments included, “Could do with more (staff) at weekends” and "Could do with more, and staff keep changing ( agency staff)," and, " It's ok but could be more people at weekends though. " People spoke highly of the staff and said they had developed positive relationships with staff who they knew well. Some people told us there was a high turnover of staff and described the impact this had. One person said, "The staff change a bit too, I like these ones. I would rather they didn’t keep changing my keyworker."

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.