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Donisthorpe Hall Requires improvement Also known as Donisthorpe Hall Management Committee

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 November 2019

About the service

Donisthorpe Hall provides accommodation and nursing for up to 189 people in one adapted building. The home is split into units, Willow, Maple, Silver Lodge ground and Silver Lodge first floor. At the time of inspection 59 people were living in the home.

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

The registered manager was responsive to any concerns we raised during the inspection; implementing corrective actions where this was apparent and discussing plans where further improvements were required.

Checks and audits had been completed to identify any areas the service needed to improve. However, even though files had been audited capacity assessments had not been picked up by the deputy manager. We did not see people had an input in relation to mental capacity and best interest decisions. We found evidence throughout care plans where not all decisions had been recorded, what had was completed by one senior staff member. Consent to bed rails had not always been looked at.

As a result, 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.

We have made a recommendation in the ‘effective’ section of the full report about some areas of people’s care plans and the care planning process.

There were enough staff on duty to meet people's needs in a calm and unrushed manner, but further recruitment was required to minimise the use of agency staff. However, the provider made every effort to use the same agency staff, thereby giving people consistent care. We spoke to the registered manager about the deployment of staff.

Recruitment procedures continued to make sure staff employed were suitable to work with vulnerable people.

Staff supported people in a compassionate, caring, responsive and friendly manner. They encouraged them to be as independent as possible, while taking into consideration their abilities and any risks associated with their care. Overall, people we spoke with made positive comments about how staff delivered care. They told us they were happy with the general environment and how the home had improved.

People received safe care and treatment. Assessments had been completed to help make sure risks associated with people's care were identified and managed in a way which respected their freedoms and choices. People were safeguarded from the risk of abuse. Accidents and incidents were monitored to identify and address any patterns or trends. People's medicines were on the whole managed in a safe way.

Staff had received the training they needed to develop and update their skills and knowledge. Support and supervision sessions had been provided.

There was a range of social activities and events available for people to take part in if they wished to.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Requires Improvement (published October 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will request an action plan from 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.

Inspection areas



Updated 1 November 2019

The service was safe.

Details are in our safe findings below.


Requires improvement

Updated 1 November 2019

The service was not always effective.

Details are in our effective findings below.



Updated 1 November 2019

The service was caring.

Details are in our caring findings below.



Updated 1 November 2019

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 1 November 2019

The service was not always well-led.

Details are in our well-Led findings below.