Denison House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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 17 Good Governance. A range of service checks including audits were available but failed to record with outcomes and actions the concerns we identified during our inspection. Process in place failed to ensure feedback was captured from a full range of people receiving a service and other stakeholders. Where feedback was obtained information was not routinely analysed or shared with outcomes and actions to help improve the service. Analysis of information to identify themes and trends for the benefit of people required improvement. Where concerns, incidents, and accidents were recorded there was minimum evidence of lessons learnt or sharing of required actions with staff to prevent re-occurrence keeping people safe. Checks to safely maintain and improve the health and safety of people and the environment required improvement with the addition of timescales, actions and outcomes commensurate with the level of risk.

This service scored 62 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had a new manager in post who was in the process of applying to register with the Care quality Commission. Everybody spoke positively about the new manager and their commitment to improve the service. A staff member said, "Now there is a new manager in-place who is excellent, and we have her here permanently then yes, the communication is good. I have thought many a time in recent months, about getting another job, with [new manager] we have the stability that we need, we are a fab team, and we all help each other."

A range of checks including audits were in place. However, these internal processes did not identify the concerns found during our assessment. Some recent audits lacked a consistent approach. Information checked was not effectively evaluated for themes and trends which meant required actions to mitigate risks were not always identified and responded to. A lack of robust checks lead on to minimal evidence of lessons learnt and shared with the wider staff team after serious incidents and concerns. There have been occasions lessons could have been learnt for the benefit of people receiving the service. Examples included a lack of investigation and action associated with medication errors, falls, and the home environment. There was limited analysis following feedback to support service improvement. Some surveys had been completed and these required further evaluation and response to evidence the importance of capturing the voice of people both involved with and receiving a service. Records showed when the regional manager had visited. However, the manager did not have any recorded appraisals or development plans to work towards. There was no evidence of recorded provider oversight to ensure reporting mechanisms, systems, and processes remained fit for their purpose to evaluate the service, maintain standards and identify areas requiring improvement. The service had a business continuity plan, but this was associated with a previous manager and required updating to reflect the required changes. The service had received support from the local authority (LA) who had implemented an improvement plan to help the service achieve full regulatory compliance. Visits had commenced in March 2024. However, at the time of our assessment, the LA had not received a required action plan to determine, within appropriate timescales how, when and by whom the identified improvements would be made.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.