We carried out a review of the data available to us about Dean Wood Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Dean Wood Manor, you can give feedback on this service.
Dean Wood Manor is a nursing home registered to support younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 49 people were living at the home.
People’s experience of using this service and what we found
People felt safe living at Dean Wood Manor. Relatives told us their loved ones received safe care from staff who knew people well. Enough staff were deployed to keep people safe and meet needs. People told us request for help were met timely. Accidents, incidents and falls had been documented and reviewed to look for trends and help prevent a reoccurrence. We found the home to be clean, with effective cleaning and infection control processes in place. Overall, medicines were managed safely. We identified some recording issues; however, these were addressed promptly during the course of the inspection.
Staff received sufficient training, support and supervision to carry out their roles effectively. People and relatives spoke positively about staff’s competence. 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. People’s healthcare needs were being met. Referrals had been made in a timely manner to professionals when any issues had been noted or concerns raised. Equipment was in place to support people to stay well. People were happy with the food provided, with choices available at each mealtime, along with snacks in between.
People were treated with dignity and respect by staff who were described as kind, caring and friendly. Relatives explained how they had observed staff showing patience and empathy when supporting people.
Care records explained people’s needs and how they wanted to be supported. People and relatives were involved in the care planning process and any subsequent reviews, to ensure care continued to be appropriate. Peoples’ social and recreational needs were met through an activities programme, facilitated by an activity co-ordinator and staff members. The complaints process was displayed around the home and people and relatives we spoke with, felt comfortable raising concerns, although the majority had not needed to.
The home used a range of systems and processes to monitor the quality and effectiveness of the service provided. Actions had been identified and added to the home’s improvement plan, which was regularly reviewed. People and relatives told us the home was well run and spoke positively about the registered manager. Everyone we spoke with said they would recommend the home to others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
This was the first full ratings inspection since the provider had applied to change from a partnership to a limited company. This change, which took place on 19 July 2021, resulted in a new legal entity being created. We carried out a focused inspection of the safe and well-led domains only in August 2021. Following this inspection both domains were rated requires improvement, but as all domains were not inspected, an overall rating was not provided.
Why we inspected
This was a planned inspection based on the date of re-registration in order to provide a rating for the service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Dean Wood Manor is a nursing home registered to support younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 48 people were living at the home.
This was the first inspection since the provider had applied to change from a partnership to a limited company. This change resulted in a new legal entity being created, albeit no actual changes to the home, staffing structure or wider governance occurred as a result of the re-registration process.
People’s experience of using this service and what we found
We found improvements were required with the management of medicines, along with the audit and governance process. People’s medicines were not always managed safely and the audit process had not identified issues we found during inspection with medicines, record keeping and inconsistent information in care documentation.
People told us they felt safe living at Dean Wood Manor. Risk assessments and care plans provided staff with information to enable them to care for people in line with their wishes and keep them safe, although greater care was needed to ensure information was accurate and up to date. Staff knew how to identify and report safeguarding concerns, with training provided and refreshed. Accidents and incidents had been documented and reviewed monthly to identify trends and help prevent reoccurrence. Enough staff were deployed to keep people safe. The necessary employment checks had been completed, to ensure staff were suitable to work with vulnerable people.
People, relative and staff’s views were captured via conversations, meetings and questionnaires. People and relatives spoke positively about how the home was managed and said they would recommend it to others. Staff told us they enjoyed working at the home, felt supported in their roles and listened to.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for the service under the previous provider was requires improvement published on 12 January 2021. No overall rating was awarded at this inspection, which only covered the safe and well-led domains.
Why we inspected
We carried out a focused inspection of this service under the previous provider on 18 November 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do to improve. This inspection was carried out to check if the new provider was meeting legal requirements, as despite the creation of a new legal entity following the recent re-registration process, no changes to the actual service or people involved in its operation had taken place.
We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by following the links to the old providers page and then selecting the ‘all reports’ link for Dean Wood Manor on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
We have identified breaches in relation to the management of medicines and the audit and governance process at this inspection. 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.