Dukeminster Court

Updated 14 December 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.

Inspection team

This inspection was carried out by 3 inspectors and 3 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

Dukeminster Court 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. Dukeminster Court is a care home without 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.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority 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 spoke with 22 people who used the service and 25 relatives about their experience of the care provided. We spent time observing care and support in the communal areas. We observed how staff interacted with people who used the service.

We spoke with 18 staff including housekeeping staff, kitchen staff, care workers, senior care assistants, the deputy manager, the registered manager, the regional manager and the quality and compliance manager.

We reviewed 11 people’s care records. We looked at 3 staff files in relation to recruitment practices. We reviewed various records relating to the management of the service including training records, quality assurance reports and accidents and incidents.

Updated 14 December 2023

About the service

Dukeminster Court is a residential care home providing personal care for to up to 75 people. The home is purpose built and consists of 5 units, each with separate adapted facilities. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 67 people using the service.

There was an increased risk of people's oral health needs not being met. Incident reports had not always been completed by staff. People's care plans did not always contain current information on managing risks. Environmental risks were not always identified and managed in line with guidance. People did not always receive their medicines safely. However, infection control measures were robustly followed, and staff had access to sufficient PPE. People told us they felt safe and there were enough staff. Relatives told us they felt free to visit without restrictions.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Systems and processes were not always operated effectively to ensure safety and quality risks were well managed. There was evidence that people's preferences around who supported them were not always met. The provider was working through action plans to improve quality concerns they had identified and took action in response to the concerns we found during this inspection. People and their relatives informed us there was a positive culture in the service, and our observations of how staff interacted with people confirmed this.

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

Rating at last inspection

The last rating for this service was good (published 5 January 2022).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service sustained an injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of people's individual risks. This inspection examined those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

Enforcement

We have identified breaches in relation to safety and good governance. 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.