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Derwent House Residential Home Inadequate

We are carrying out a review of quality at Derwent House Residential Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 20 August 2019

About the service

Derwent House Residential Home is a residential care home providing personal and nursing care to 52 people aged 65 and over at the time of the inspection. The service can support up to 65 people across two separate areas. Derwent House supports people with nursing and residential care needs and Riverview Lodge supports people living with dementia.

People’s experience of using this service and what we found

People were not kept safe from harm. Risk assessments were not up to date, specific or followed by staff to ensure individuals were safe.

Processes and records were not maintained to ensure people always received their medicines safely as prescribed. There was gaps in the application of topical creams and a lack of communication meant one person’s medicines were delayed in being administered after being received from the pharmacy.

Some people told us they had to wait for staff support. Staff were not sufficiently supported to fulfil their role. This had impacted on people’s dignity.

Care was not always person-centred. Some staff had good knowledge about people’s needs but this was not captured and reflected in care planning. People’s diverse needs were not always considered.

Staff did not receive appropriate training or assessment of their competency to ensure they had the appropriate skills to meet peoples’ individual needs. Lessons had not been learnt from accidents and incidents to reduce the likelihood of reoccurrence.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People, their relatives and health care professionals had mixed views about the care provided. Person-centred care was not reflected within people’s care plans and associated records.

The provider failed to have adequate oversight of the service during periods when there was no registered manager. This had impacted on the quality of care being provided.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

Rating at last inspection

The last rating for this service was Good (published 23 March 2018).

Why we inspected

The inspection was prompted in part due to concerns received about medication issues, fire safety, staff training, staff knowledge, lack of staffing, poor moving and handling procedures and a lack of up to date care planning. A decision was made for us to inspect and examine those risks.

The inspection was also prompted in part by two notifications of specific incidents. Following which, one person using the service died and another sustained a serious injury. These incidents are subject to a criminal investigation. As a result, this inspection did not examine the circumstances of these incidents.

The information CQC received about the incidents indicated concerns about the management of falls and falls from moving and handling equipment. This inspection examined those risks.

We have found evidence that the provider needs to make improvements. Please see the full report.

The provider had taken action to mitigate the immediate risks to people.


We have identified breaches in relation to keeping people safe, not working within the principles of the MCA, staff not trained and supported, people not treated with dignity and respect, a lack of systems to investigate and take action following complaints, a lack of oversight, monitoring and learning.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

Inspection areas



Updated 20 August 2019

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 20 August 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 20 August 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 20 August 2019

The service was not always responsive.

Details are in our responsive findings below.



Updated 20 August 2019

The service was not well-led.

Details are in our well-led findings below.