Archived: Dearne Hall

Updated 5 September 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection took place on 16 August 2018 and was unannounced. The inspection team consisted of two adult social care inspectors and an expert 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.

Before our inspection, we reviewed the information we held about the service. This included correspondence we had received, and notifications submitted by the service. A notification must be sent to the Care Quality Commission every time a significant incident has taken place, for example, where a person who uses the service experiences a serious injury.

The provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We gathered information from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. This information was reviewed and used to assist with our inspection.

At the time of our inspection there were 44 people using the service. We spoke with nine people living at the home, six relatives or friends of people and a visiting health professional.

We spoke with 14 members of staff, which included the registered and deputy managers, team leaders, the registered providers head of care and care and dementia advisor, support workers, maintenance, domestic and catering staff.

We spent time observing care in the communal areas and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked around different areas of the service; the communal areas, bathrooms, toilets and with their permission, some people’s rooms.

We spent time looking at records, which included three people's care records, four people’s Medicine Administration Records (MAR), three staff records and other records relating to the management of the home, such as training records and quality assurance audits and reports.

Updated 5 September 2018

We carried out this inspection on 16 August 2018. The inspection was unannounced. This meant no-one at the service knew we would be visiting.

Dearne Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Dearne Hall is registered to accommodate 48 older people. At the time of the inspection 44 people were living at the home. The home has three floors. The middle floor is for people living with dementia, the ground and top floor is for people who require personal care, some of whom are living with dementia.

Our last inspection at Dearne Hall took place on 5 and 15 June 2017. The service was rated Requires Improvement overall. We found the service was in breach of three of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. Regulation 12, Safe care and treatment, Regulation 19, Fit and proper persons employed and Regulation 17, Good governance.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions asking if the service was safe, effective, responsive and well led, to at least good. The registered provider sent us an action plan detailing how they were going to make improvements. At this inspection we checked the improvements the registered provider had made. We found sufficient improvements had been made to meet the requirements of the Regulations.

There was a manager at the service who was registered with the CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People living at Dearne Hall told us they felt safe and they liked the staff. Relatives we spoke with felt their family member was in a safe place and did not have any concerns about their family member’s safety.

Regular checks of the building were carried out to keep people safe and the service well maintained.

Staff confirmed they had been provided with safeguarding vulnerable adults training, so they understood their responsibilities to protect people from harm.

There were sufficient staff to meet people’s needs safely and effectively.

The service used effective recruitment procedures which helped to keep people safe.

We found systems were in place to make sure people received their medicines safely.

Staff were provided with relevant training and supervision to make sure they had the right skills and knowledge to support people.

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

People enjoyed the food provided and were supported to receive adequate food and drink to remain healthy.

We found the home was clean, bright and well maintained.

People had access to a range of health care professionals to help maintain their health.

People were treated with dignity and respect and their privacy was protected. People, their relatives and health professionals we spoke with made positive comments about the care provided by staff.

A range of activities were available both inside and outside the home to provide people with leisure opportunities.

People living at the home and their relatives said they could speak with the registered manager or staff if they had any worries or concerns and they would be listened to.

There were effective systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to.

Staff told us they felt they had a very good team. Staff, people and relatives said the registered manager was approachable and communication was good within the service.