Denison House Care Home

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• 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

The previous rating for this key question under the old provider was good. At this inspection we found the rating had decreased to requires improvement. The service was in breach of Regulation 15 Premises and Equipment. Some areas of the home needed maintenance work to meet safety and hygiene standards. The lift was found to be out of service as well as the upstairs shower room. Areas of flooring required replacing and there were noticeable lingering and unpleasant odours. Whilst people were to access the smaller garden areas, due to a lack of planned maintenance people were unable to safely access the large outside garden area. There were no planned dates to have this work completed. People told us they felt safe. However, risks associated with people’s care had not always been managed to keep them safe from otherwise avoidable harm. For example, people requiring pressure relief, did not always receive this consistently and information to guide staff was not always in place. Some care records lacked detail to support people with nutritional intake and hydration. Where people required support to take their medicines they did not always receive them as prescribed. We observed poor infection, prevention and control practices which meant people were not always protected from the risks of cross infection. Processes in place to learn from accidents and incidents required improvement to help prevent re-occurrence. There were enough suitably trained staff at the service, although they were not always deployed effectively to meet people’s need

This service scored 59 (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 felt safe. People told us, “I feel safe here and happy to be honest. I wouldn’t stay if I didn’t feel safe and happy” and “I am safe here, yes. I am happy too. The staff are all good. The girls are lovely”.

Staff and the manager spoken with were all open and welcoming during the assessment. Staff told us they completed safeguarding training and had access to the safeguarding policy to raise their concerns.

People were not always safe from the risks of abuse. The provider had shared safeguarding information of concern with the CQC concerning altercations between people residing at the home. Whilst the provider had submitted the required safeguards for further review no internal analysis of these incidents had been recorded to keep people safe and prevent re-occurrence. During our assessment visit we observed additional ongoing risks to people. Some people were observed walking with purpose and entering other people’s bedrooms which frustrated the occupants. The manager told us they were updating care records and reviewing risk assessments to ensure information was available to help keep people safe. People were generally observed to be comfortable living at the home and engaging on first name terms with staff supporting them.

We were not assured people were protected from avoidable harm as not all staff had completed required safeguarding training. The manager used a safeguarding tracker to record safeguarding incidents but this was not up to date. We found 9 safeguarding concerns for June 2024, 5 of which were medication errors. However, these were not included on the tracker to support effective evaluation and learning. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found DoLS applications had been made where required. However, these did not always reflect people’s recorded assessment under the MCA. For example, some people were assessed as having capacity under the MCA but were subject to restrictive practice under a DoLS. Where people had been assessed as not having capacity and had restrictive practices in place correct process under the Act had not always been followed to determine the decisions were decided by individual(s) best placed to make that decision, to ensure the decision was in the person's best interest, or to ensure it was the least restrictive option. One example, included the implementation of a lowered bed, The manager was working to improve these records.

People and their relatives were involved with their care and support, but we received mixed feedback about communication and active response with people and their relatives to manage everyday risks. One person told us, " Staff bend over backwards to help. Staff are really good. I can’t think of anything bad to say.” However, a relative said, “[Person’s name] is a bit of a wanderer and I get lots of calls saying that [they] have fallen. They do not know how long [they] may have been laying there, waiting to be found either. They have pressure mats, but I don’t think that they are effective.” The manager acknowledged the need to improve and expand the scope of people’s involvement in their care planning, to evaluate feedback and provide outcomes with actions to maximise the effectiveness of people’s care and support.

Staff told us they were attentive and used equipment as intended to manage risks. Staff spoke with people before, during and after any task. They did this checking about their safety in a respectful, gentle way. The manager was aware of short falls in care plan records used as a point of reference for staff to use to manage risks. Actions were in place to update those records to support safe practice care and support.

Staff were not always aware of risks posed to people due to lack of direction and guidance within care plans. For example, 1 person had a diagnosis of polycystic kidney disease which should avoid high potassium and phosphorus in their diet. This person was at stage 5 (includes signs of severe kidney disease and kidney failure) for which the amount of fluid they consume may need to be limited to preserve kidney function, there was no guidance for staff to support this.

We could not be fully assured of the team's knowledge in relation to risk management because there were some gaps in care plan and risk assessment documentation. Risks to people were not always assessed or managed safely. Care records were not always accurate, complete or sufficiently detailed to provide the required direction in support of safe care. This included care plans and risk assessments relating to health conditions such as epilepsy, diabetes, and chronic conditions. They did not always provide sufficient guidance for staff to manage risks to people. There was little evidence people, or their families had been engaged with when assessing and managing risk.

Feedback from people was generally positive about their personal room environment but raised concerns about the wider public areas of the home. One person said, “My bedroom is okay. It is kept clean by the staff. Things do have a habit of going missing though.” and, “There isn’t a lot to do. I would like to get out and sort the garden. I have not really been outside, other than the front. I would need some tools and equipment but I am still waiting. I would like to do things. I feel active and like to use my hands." Another person said, “My TV has not worked for 2 weeks and I'm not aware of anyone trying to sort it”. Another person said, “I don’t like the stair chair [lift], I would much prefer the [passenger] lift."

The manager told us they were aware of the concerns we found and told us they were working hard to implement the required improvements.

We observed areas of the home which required urgent maintenance work to meet safety and hygiene standards. Some areas of the home were not clean. This included outstanding deep cleaning of bathroom areas, strong unpleasant odours and dirty walls. There were areas of the home that were under refurbishment, including ripped and stained flooring. The passenger lift was observed to be out of service as well as an upstairs shower room. There were no dates secured to have these areas fixed. There was a large outdoor area to the rear of the property. However, this was overgrown and inaccessible requiring maintenance and tidying for people to enjoy.

Systems and process were not effectively established and managed to detect and control potential risks in the care environment. Processes had failed to ensure the passenger lift and upstairs bathroom, (both of which had been out of use for a considerable time) had been repaired within reasonable timescales. Other checks to ensure the environment remained safe had failed to ensure they were completed at identified intervals. For example, the electrical safety certificate was out of date with no date confirmed for testing at the time of our assessment. We did not see any processes in place to ensure equipment safety checks were completed where required. For example, to ensure bedrail checks, profile bed checks, or wheelchair checks ensured their safe use and operation. Processes to ensure records for people and staff remained current and relevant, providing points of reference for management control, and information to support safe care was under review due to omissions of accuracy, and a failure to provide required prompts to keep everybody safe. Time simulated emergency evacuations were completed. However these did not always include the time taken to evacuate. We could not be assured evacuation of all areas of the home was in line with guidance. There was nothing recorded within the fire risk assessment to suggest additional measures were needed when the time to evacuate could not be achieved.

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

People we spoke with did not raise concerns with the cleanliness of the home. People told us, “My room is comfortable and clean. Staff keep it very clean” and “Staff keep my room clean. It isn’t like home but its comfortable enough”.

Whilst staff had an understanding about the importance of Infection Prevention and Control (IPC), further improvement was required to keep people safe from the known risks. The manger told us further training was planned. Staff told us they had access to an IPC policy and had received some training in IPC with more planned. A staff member said, "I have read the policies, I have shadowed others, and I am attending the training this week. Another staff member told us, "There is an on-line course through Elfi. However, the Council are attending some IPC sessions with staff members this week."

We observed some significant concerns around the home environment with reference to required infection control. Parts of the home were under refurbishment, other areas required work but there was no clear plan for this. Laundry was processed on site, but the processes did not always follow best practice. We observed the transportation of meals from kitchen to the servery did not support best practice to maintain IPC. Storage of personal protective equipment (PPE) was not safely organised; boxes were stacked on floors in cupboards mixed with non PPE products including disposable urine bottles putting the equipment at risk of contamination.

Processes in place were not effective and without good oversight to ensure the home remained clean and maintained free from the risks of infection.

When asked about medication, people who required this support told us that staff controlled this and they all knew why they took their medication. People said, “Staff look after all my medication. They bring it when I need it and I know what I take and why." and, “Staff look after all my medication, they are very good.”

Staff told us that they were trained appropriately in medicines and this was regularly assessed. One staff member said, "I was trained in house on medicines, I shadowed a former deputy manager in delivering medicines, they then needed to assess my competence. I was happy with the training that was provided and what was expected of me."

Guidance to support people to take their medicines as prescribed was not always up to date for staff to use as a point of reference and were not person-centred, which could lead to a risk of people not receiving their medicines efficiently and effectively. People who were prescribed ‘when needed’ (PRN) medicines did not always have a clear plan to direct when, how, or why these should be safely administered. Where a medicine was prescribed with a variable dose for example, to take one or two, no plans were in place to guide staff in deciding which dose to administer. Cream charts were not consistently filled out by staff to show if a person had received their creams applied as prescribed. The clinic room where medicines were stored was not fit for purpose, however the manager acknowledged this, and we were informed new cupboards were being ordered to ensure medicines would be stored safely. We found that when people were given medicines ‘covertly’ (hidden in food or drink) there was a clear plan in place for this and good documentation on how to give the medicines safely. We found staff competencies to administer people's medicines were completed and reviewed regularly. Medicines audits were not always completed each month, but the manager was already aware of this and was taking measures to ensure this would be done in the future. While we were told by staff that they had a good relationship with the pharmacy, we found a more robust ordering system could be put in place to avoid over ordering and waste of medicines.