• Care Home
  • Care home

Archived: Deanwood Lodge

Overall: Requires improvement read more about inspection ratings

Church Road, Maisemore, Gloucestershire, GL2 8HB (01452) 415057

Provided and run by:
Casterbridge Homes Limited

Important: The provider of this service changed. See old profile

All Inspections

21 February 2017

During a routine inspection

We inspected Deanwood Lodge on the 21 and 23 February 2017. Deanwood Lodge is a residential and nursing home for up to 47 older people. 42 people were living at the home at the time of our inspection. The majority of these people were living with dementia. This was an unannounced inspection.

There was a registered manager in position. 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 2008 and associated Regulations about how the service is run.

We last inspected in July 2016 and found that the provider was not meeting all of the regulations. We found that people were not always supported by staff who had the training and support they required to carry out their roles. Following our inspection in July 2016, the provider issued us a plan of the actions they would make. At this inspection we found appropriate action had been taken to address our concerns.

The provider had systems to monitor and improve the quality of service people received, however these systems were not always effective and did not always identify concerns, or ensure action was taken when concerns had been identified.

People’s care and risk assessments were often reflective of their needs; however some people’s care and risk assessments did not reflect their need. The registered manager and clinical lead were taking action to address this concern.

People and their relatives were positive about the home. They felt safe and well looked after. People enjoyed the food they received in the home and had access to food and drink. People benefitted from the activities provided to them.

People benefitted from positive caring interactions with care staff. Care staff supported people to make choices and respected their wishes. Care staff took time to engage with people in a positive and meaningful way and ensured that personal care was a positive activity.

People and their relative’s views were sought and acted upon by the registered manager and provider. People’s relatives were confident their concerns would be responded to and resolved.

Staff were deployed effectively to ensure people’s basic needs were met and kept safe. All staff had received training to meet people’s healthcare needs. Staff felt supported and had access to a structured supervision (one to one meeting) and appraisal process. Staff spoke positively about the support they received.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

21 July 2016

During a routine inspection

We inspected Deanwood on the 21 and 27 July 2016. Deanwood Lodge provides residential and nursing care for older people; many of the people living at the home had a diagnosis of dementia. The home offers a service for up to 47 people. At the time of our visit 28 people were using the service. This was an unannounced inspection.

We last inspected in January 2016 and found that the provider was not always meeting the regulations. We found that people did not always receive safe care and treatment as they were not always protected from the risk of choking. People were cared for in an environment which was not always safe. Additionally people did not always benefit from person centred care and did not have access to activities and meaningful stimulation. The provider did not have effective systems to monitor and improve the quality of service people received. Following our inspection in January 2016, the provider issued us a plan of the actions they would make. At this inspection we found appropriate action had been taken.

There was a registered manager in post on the day of our inspection. 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 2008 and associated Regulations about how the service is run.

People were cared for by staff who had not yet all completed their formal training in all the topics they needed. A number of people living at the service had a diagnosis of dementia, however not all staff had effective training around dementia. All staff felt supported by the registered manager and provider. The registered manager had a clear plan in relation to staff training.

People and their relatives were positive about the home, the staff and management. People told us they were safe and looked after well in the home. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm. People had the assistance they required with their prescribed medicines.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured their on-going healthcare needs were met.

People benefitted from activities and person centred care. There was a friendly, pleasant and lively atmosphere within the home. People also enjoyed the time they spent with each other and staff and carrying out activities. People were offered choices about their day. People and relatives told us they felt listened to and able to raise concerns or suggestions.

Staff were supported by a committed registered manager. There were enough staff with appropriate skills deployed to meet the needs of people living at the service and support them with activities. Staff spoke positively about the home and the registered manager.

People and their relatives spoke positively about the management and the service. The registered manager ensured people, their relatives and external healthcare professional’s views were listened to and acted upon. The registered manager and provider had systems to assess, monitor and improve the quality of service people received at Deanwood Lodge.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

6 January 2016

During a routine inspection

We inspected Deanwood on the 6 January 2016. Deanwood Lodge provides residential and nursing care for older people; many of the people living at the home had a diagnosis of dementia. The home offers a service for up to 47 people. At the time of our visit 34 people were using the service. This was an unannounced inspection.

We last inspected in March 2015 and found the provider was meeting all of the requirements of the regulations at that time.

There was not a registered manager in post on the day of our inspection. The previous registered manager had left in November 2015. A new manager had been appointed and they were in the process of applying to become the registered manager. 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 2008 and associated Regulations about how the service is run.

People told us there were not always things to do and that life in the home could be boring. Some people went periods of time without any contact with care staff. There was an activity co-ordinator in post who was due to leave the service, however another two activity co-ordinator was due to start at the home shortly.

People were not always protected from the risks associated with their care. One person had a choking incident as they had been given food which was not in accordance with their assessed needs.

The provider had not ensured that systems were in place and regularly undertaken to sufficiently assess, monitor and continually improve the quality and safety of the services provided, including the quality of the experience of service users in receiving those services.

People were not always protected from the risks of environment or in the event of a fire. Fire safety and maintenance checks were not being carried out in accordance with the provider’s policies. Some rooms which contained items that could put people at risk were not always secured.

Care staff treated people with dignity and respect when they assisted them with personal care and mobility. However, they did not always ensure people’s drinks were left close to them to enable them to assist themselves independently. Care staff sometimes made choices for people over what they would like to eat or drink, without giving them choice.

People received their medicines as prescribed. Care staff did not always keep an accurate record of the support they have given people with their medicines. Where people needed their medicines covertly, care staff followed clear guidance to ensure their needs were met.

Care staff ensured where people needed assistance with their personal hygiene that they were kept clean and comfortable. Staff showed genuine care for people if they were anxious or unhappy.

People were supported by kind, caring and compassionate care staff. Staff spoke positively about people in the home and knew what was important to them.

People told us they felt safe in the home. Staff had a good understanding of safeguarding and the service took appropriate action to deal with any concerns or allegations of abuse.

People's needs were assessed. Where any risks were identified, management plans were in place. People’s care plans were being updated by staff at the home.

People’s relatives spoke positively about the manager. The manager had clear aims to improve the quality of service people received in the home. A new clinical lead had been appointed and the provider had implemented an action plan with an aim to ensure people received a good service.

Care staff had access to development opportunities to improve their skills and the service people received. Care staff received the training they required to support people with individual needs and had access to effective supervision (one to one meetings with their manager).

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

13 January and 11 March 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection on 29 and 30 July 2014. During this inspection we found breaches of legal requirements. The provider was asked to take action to meet the requirements of the regulations. The provider sent us an action plan as required detailing when they would be compliant with the regulations.

As a result of this we completed a focused inspection on 13 January and 11 March 2015 to follow up whether action had been taken to meet legal requirements. We also met with the provider on the 5 February 2015. This was to discuss concerns that had been shared with us by Gloucestershire City Council safeguarding team and visiting health and social care professionals. The provider was able to demonstrate they were taking action to address these concerns. The provider shared their action plan with us and the steps they were taking to ensure people were safe and received a quality service. The provider has been providing regular email updates between the 5 February and 12 March 2015 in respect of the actions they were taking. This included sharing information about the staffing levels and the on going recruitment taking place to ensure suitable numbers of staff were supporting people.

Comprehensive inspection 29 and 30 July 2014.

This was an unannounced inspection.

When we visited there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Deanwood Lodge is a care home that provides personal and nursing care. The home can accommodate up to 47 people. At the time of our inspection there were 46 people living in the home. The service supports older people who live with dementia.

The service was not always notifying us about information they had to report including allegations of abuse and an incident where the police were called to the home. However, they had reported this to the local safeguarding team. Care plans did not always include sufficient details to guide staff on how people should be supported.

People told us they were well cared for and staff treated them with kindness. There were some social activities taking place however, the manager was making improvements in this area. This included employing a second activity co-ordinator and taking advice from external agencies to assist in improving the activities on offer to people living with dementia. People’s and their relatives views were sought to improve their experience of living in Deanwood Lodge.

Relatives we spoke with were generally positive about the care and support that was in place. Some relatives raised concerns about some people who used the service going into other people’s bedrooms. The manager and the team explained how they were managing this to reduce the risks to people living in the home.

Staff were knowledgeable about the people they were supporting and how their dementia impacted on their day to day living. They had received training relevant to their roles and felt supported by the management team.

People who used the service, their relatives and staff were positive about the management of the home, which was open and approachable. They also commented on the improvements which had been made over the last couple of months.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Findings from the inspection 13 January and 11 March 2015

This was an unannounced focused inspection to ensure the provider had taken action to meet legal requirements. There were 35 people in residence at the time of this inspection.

We found the provider had made the required improvements. Since July 2014 we have been receiving notifications about incidents, accidents and any allegations of abuse. A notification is information about important events which the provider is required to tell us about by law. We reviewed accidents and incidents that had occurred in the service and found where we were required to be notified the registered manager had informed us appropriately. This enabled us to monitor what action the provider had taken to protect and reduce risks to people.

People’s care records included sufficient information to enable the staff to meet their care needs effectively and responsively. These had been kept under review. Care documentation had been checked to ensure all relevant information was recorded.

There had been a number of improvements since our last inspection. This included people having access to regular activities seven days a week from dedicated activity staff. A new handover system had been introduced to ensure staff knew about people’s care needs. In addition staff had received training in wound care, dementia and meeting people’s nutritional needs.

People and their relatives spoke positively about the staff, the registered manager and the care they were receiving.

We have reviewed the ratings under the five key questions. However, to ensure this is consistently put into practice the overall rating for the service remains the same until the next inspection.

29-30 July 2014

During a routine inspection

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 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service. 

This was an unannounced inspection. 

When we visited there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Deanwood Lodge is a care home that provides personal and nursing care. The home can accommodate up to 47 people. At the time of our inspection there were 46 people living in the home. The service supports older people who live with dementia.

The service was not always notifying us about information they had to report including allegations of abuse and an incident where the police were called to the home. However, they had reported this to the local safeguarding team. Care plans did not always include sufficient details to guide staff on how people should be supported.  

People told us they were well cared for and staff treated them with kindness. There were some social activities taking place however, the manager was making improvements in this area. This included employing a second activity co-ordinator and taking advice from external agencies to assist in improving the activities on offer to people living with dementia. People’s and their relatives views were sought to improve their experience of living in Deanwood Lodge.

Relatives we spoke with were generally positive about the care and support that was in place. Some relatives raised concerns about some people who used the service going into other people’s bedrooms. The manager and the team explained how they were managing this to reduce the risks to people living in the home.

Staff were knowledgeable about the people they were supporting and how their dementia impacted on their day to day living. They had received training relevant to their roles and felt supported by the management team.

People who used the service, their relatives and staff were positive about the management of the home, which was open and approachable. They also commented on the improvements which had been made over the last couple of months.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities)Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

23 July 2013

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not all able to tell us their experiences. We spoke with seven people and we also asked them if they enjoyed the food and all said "yes". We observed staff treating people with respect and maintaining their privacy during any personal care tasks.

In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We found that two compliance actions issued at a previous inspection had been addressed. These related to the management of people’s medicines and how the service monitored people who were nutritionally at risk. There were arrangements that ensured medicines were managed safely and a system to monitor people who had been identified as being nutritionally at risk was now in place.

The environment was cleaned to high standards and no offensive odours were found. A system was in place to monitor the control of infection.

The provider had arrangements in place to regularly assess and monitor the service provided to people who used the service.

6 March 2013

During an inspection in response to concerns

We used a number of different methods to help us understand the experiences of people using the service. Because people using the service had complex needs which meant they were not able to tell us their experiences. We observed staff interacting with people and spoke to staff about aspects of people's care.

Prior to this inspection we had received some information of concern about the care people were receiving especially in relation to food and fluid intake and the recording of these.

We found that people who were assessed as being nutritionally at risk and had food and fluid charts in place were were not always being monitored by staff. Food and fluid charts were not always completed and there were gaps in the recordings on these. We also found they were not reviewed by a senior member of staff and actions taken when people had limited food and fluid intake. We fed back our findings to the representatives from the provider they told us they had already identified concerns with this and they were about to implement some actions to address it.

We found that some of the medication procedures in place were not being followed and we observed some unsafe practice for administration of people's medication.

We observed some people had alot of interactions with staff but other people who were not able to communicate verbally received very little.

14 January 2013

During an inspection looking at part of the service

People who used the service were not able to tell us about their experiences because they had complex needs.

We followed up on the compliance actions we issued at a previous inspection. We found that a system had been put in place to monitor people who were nutritionally at risk and that any weight loss was being identified and actions taken.

We examined the care records of three people who used the service and found that some improvements were still required. However, the registered manager explained the actions she had planned to address the shortfalls with some people's care records.

15 August 2012

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service, because the majority of people using the service had complex needs which meant they were not able to tell us their experiences. We spoke to the relatives of three people. They felt their relatives were being looked after well. One relative said they had a few concerns over the care but these had been addressed and their relative was now settled.

One person who used the service told us they were well looked after and had no complaints. The three relatives and one person spoken with thought the environment was “lovely” and “well maintained”. One relative thought it was “nicely decorated”.

We examined the care of one person in detail and examined the care records of some other people. We found their care records were not always personalised to their individual needs. We identified some people had lost weight but this had not been identified and acted upon.

Prior to the inspection we had received some information of concern about staffing levels and the use of agency staff. The registered manager told us they had recruited some new staff but were waiting for their pre-employment checks to be returned. Where agency staff were being used the home was trying to make sure they had the same member of staff for continuity, however this was not always possible.