Archived: Dean Wood Manor

Updated 12 January 2021

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 Care Act 2014.

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 an inspector and a medicines inspector.

Service and service type

Dean Wood Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. A registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The previous registered manager had left and their replacement had transferred to Dean Wood Manor from another of the provider's homes. They were in the process of having their registration amended to reflect this change.

Notice of inspection

We gave a short period notice of the inspection due to the Covid-19 pandemic to ensure we had prior information to promote safety. Inspection activity started on 17 November 2020 and finished on 2 December 2020, at which point we had received all the additional information and clarification we had requested from the provider. We visited Dean Wood Manor on 18 November 2020.

What we did before the inspection

Prior to the inspection we reviewed information and evidence we already held about the home, which had been collected via our ongoing monitoring of care services. This included notifications sent to us by the home. Notifications are changes, events or incidents that the provider is legally obliged to send to us without delay. We also asked for feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with five people living at the home about their experiences of the care and support provided. We also spoke with five care staff, the manager, regional manager, provider’s head of compliance, the provider's pharmacy technician and the managing director. Following the inspection we contacted six relatives to ask for their views and opinions on the home and care provided.

We reviewed a range of records relating to the safe and well-led key questions. This included 11 people’s care records, risk assessments, safety records, audit and governance information.

After the inspection

We requested additional evidence from the provider. This included further medication documentation, monitoring charts, audit, quality monitoring and governance information.

Updated 12 January 2021

About the service

Dean Wood Manor is a nursing home registered to support younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 47 people were living at the home.

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

We found improvements were required with the management of pressure care; particularly the recording of pressure relief, and with medicines. This included medicine administration practices, stock control and record keeping. The medicines audit process also required strengthening, to ensure where issues had been identified, clear action plans had been documented.

We have made a recommendation about the management of pressure care.

People felt safe living at the home and told us they received a good standard of care. Staff had received regular training in safeguarding and knew how to report any concerns. Staffing had been challenging throughout the pandemic due to absences and shielding, with the home reliant on agency staff to ensure enough staff were deployed to keep people safe. Recruitment was ongoing, with the required safety checks being completed for each new staff member. Accidents and incidents had been documented and reviewed to identify trends to prevent reoccurrence and keep people safe.

The home had a detailed audit and quality monitoring schedule in place, to ensure all aspects of care, support and safety were regularly assessed and actions taken to address any concerns. People, relatives and staff spoke positively about how the home was currently being run. The current manager was reported to be open, approachable and supportive.

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 good (published October 2019).

Why we inspected

We received concerns in relation to staffing levels and the management of medicines, dietary management and people’s pressure care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dean Wood Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines management and the home’s governance process.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.