Background to this inspection
Updated
10 February 2024
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
One inspector and an Expert by Experience carried out the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Dunelm is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Dunelm is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. The service had a manager registered with the Care Quality Commission.
Notice of inspection
This inspection was announced. We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be available to support the inspection.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 2 people who used the service, 1 advocate and 2 relatives about their experience of the care provided. We also spoke with 4 members of staff including the manager and support workers.
We reviewed a range of records. This included people’s care and medication records. We looked at staff files in relation to recruitment. A variety of records relating to the management of the service, including risk assessments and procedures were reviewed. We also carried out a visual inspection of the premises.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We also looked at quality assurance records.
Updated
10 February 2024
About the service
Dunelm is a residential care home providing care and support to people with a learning disability, autism, or both. At the time of the inspection 3 people were receiving care and support. The service can support up to 4 people.
Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last inspection we rated this key question good. At this inspection, the rating remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
Managers and staff being clear about their roles, and understanding quality performance, risks, and regulatory requirements.
¿ People’s support plans and relevant documentation included risk assessments that highlighted where risks needed to be mitigated. These were reviewed by the manager.
¿ Audits were carried out regularly by the manager, who was able to identify and address issues effectively.
¿The provider invested in staff by providing them with quality training to meet the needs of all individuals using the service.
Promoting a positive culture that is person-centred, open, inclusive, and empowering, which achieves good outcomes for people
¿ The manager encouraged people and staff to be open with each other. Staff felt supported by their colleagues and the manager.
¿ The manager promoted equality and diversity in all aspects of the running of the service.
¿ Staff felt able to raise concerns with the management.
¿ People’s relatives shared their feedback with us on the positive culture of the service.
How the provider understands and acts on the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong
¿The manager was aware of their responsibility under the duty of candour regulations.
¿There had been no recent incidents that required a response under the duty of candour.
Engaging and involving people using the service, the public and staff, fully considering their equality characteristics
¿ Regular staff and resident meetings were held which gave the opportunity for people to raise any concerns and for the management team to inform people of any changes within the service.
¿ People, and those important to them, worked with managers and staff to develop and improve the service.
Continuous learning and improving care and working in partnership with others.
¿ The manager and staff team worked in partnership with advocacy organisations, social workers and other health and social care organisations to develop their service to meet people’s needs.
¿ The provider had an action plan for the service that was regularly updated and highlighted areas for improvement. One relative told us. “I can’t suggest anything to change. They provide a very safe and happy environment. The continuity of the staff helps. There have always been the three residents. They don’t take in more like so many other homes, putting money before the residents. I am very comfortable with everything about the home.”
¿ The provider ensured people and their families were involved in improving the service. One relative told us, “We had a family Zoom meeting recently about the new way of assessment. It was all explained on the Zoom meeting and then they sent all the paperwork out to read too. It was all very interesting and informative. Everything has been relayed back to let us know that staff are being trained now from senior management down. They said they would keep us informed and I am sure they will.”
Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last inspection we rated this key question good. At this inspection, the rating remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
Managers and staff being clear about their roles, and understanding quality performance, risks, and regulatory requirements.
¿ People’s support plans and relevant documentation included risk assessments that highlighted where risks needed to be mitigated. These were reviewed by the manager.
¿ Audits were carried out regularly by the manager, who was able to identify and address issues effectively.
¿The provider invested in staff by providing them with quality training to meet the needs of all individuals using the service.
Promoting a positive culture that is person-centred, open, inclusive, and empowering, which achieves good outcomes for people
¿ The manager encouraged people and staff to be open with each other. Staff felt supported by their colleagues and the manager.
¿ The manager promoted equality and diversity in all aspects of the running of the service.
¿ Staff felt able to raise concerns with the management.
¿ People’s relatives shared their feedback with us on the positive culture of the service.
How the provider understands and acts on the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong
¿The manager was aware of their responsibility under the duty of candour regulations.
¿There had been no recent incidents that required a response under the duty of candour.
Engaging and involving people using the service, the public and staff, fully considering their equality characteristics
¿ Regular staff and resident meetings were held which gave the opportunity for people to raise any concerns and for the management team to inform people of any changes within the service.
¿ People, and those important to them, worked with managers and staff to develop and improve the service.
Continuous learning and improving care and working in partnership with others.
¿ The manager and staff team worked in partnership with advocacy organisations, social workers and other health and social care organisations to develop their service to meet people’s needs.
¿ The provider had an action plan for the service that was regularly updated and highlighted areas for improvement. One relative told us. “I can’t suggest anything to change. They provide a very safe and happy environment. The continuity of the staff helps. There have always been the three residents. They don’t take in more like so many other homes, putting money before the residents. I am very comfortable with everything about the home.”
¿ The provider ensured people and their families were involved in improving the service. One relative told us, “We had a family Zoom meeting recently about the new way of assessment. It was all explained on the Zoom meeting and then they sent all the paperwork out to read too. It was all very interesting and informative. Everything has been relayed back to let us know that staff are being trained now from senior management down. They said they would keep us informed and I am sure they will.”
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support
People were supported by staff to pursue their interests. People took part in activities at home and within their local area. Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcomes.
The service made reasonable adjustments for people so they could be involved in how they received their support. Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.
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.
Right Care
People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so.
Right Culture
People led inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff. People’s care, treatment and support plans had clear guidance on what people’s goals and aspirations were. The service enabled people and those important to them to work with staff to develop the service. We received positive feedback from people’s family members about the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at the last inspection and update
The last rating for the service was good (5 April 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service and due to the length of time since the previous inspection. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for
Dunelm on our website at www.cqc.org.uk
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.