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Dudley Court Care Limited Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 April 2020

About the service

Dudley Court Care Limited is a residential care home providing personal and nursing care to 19 people aged 65 and over at the time of the inspection. The service can support up to 22 people in one adapted building over three floors.

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

Systems and processes did not always keep people safe as not all safeguarding matters were escalated and shared. Some aspects of risk management had improved since our last inspection however risk assessments did not consistently provide enough information to staff. People told us they received their medicines when they needed them however medicines where not always stored safely. The provider recruited staff safely. Infection control procedures were in place.

The service did not work within the principles of the Mental Capacity Act. People told us they were supported to access healthcare.

People’s preferences and choices were generally promoted by staff. Staff completed an induction and training program although this was not always effective. People were not always supported to eat and drink enough to maintain a balanced diet. A maintenance and a decoration improvement plan was underway.

Systems had not identified a lack of clarity and accuracy in plans pertaining to choking risks. Systems had failed to identify proper upkeep of the premises and the provider’s systems and processes had not identified medication storage concerns. Audit systems were not sufficiently robust to identify areas of concern and develop action plans. The provider and registered manager understood their legal responsibility under the duty of candour

People told us they did not know about their care plans. People told us they are able to communicate effectively with staff in most instances. The variety of activities had improved, and people were supported to engage in them. People told us they knew how to complain. End of life plans were in place which detailed peoples wishes.

People told us staff took time to spend with people and there were positive interactions between staff and people living in the service. Staff had received equality and diversity training however equality and diversity needs of people were not consistently met. People’s voice was heard and acted upon. People told us staff promote their independence and their privacy was respected and they were treated with dignity.

Sufficient improvements had not been made and the provider is still in breach of regulations.

Our last inspection identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment. The provider remained in breach of this regulation. This was because people's risks including choking, weight management, evacuation plans and medicines were not effectively managed at all times.

Our last inspection identified a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Safeguarding service users from abuse and improper treatment. The provider remained in breach of this regulation. This was because the provider had not identified incidents of concern and reported these to the Local Safeguarding Authority.

Our last inspection identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to governance. The provider remained in breach of this regulation. This was because governance systems failed to effectively assess, monitor and improve the quality and safety of the service.

During this inspection we also identified a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to consent. This was because people had been restricted without the completion of capacity assessments and best interests’ meetings.

We prompted the provider to address concerns including a referral to the Local Safeg

Inspection areas

Safe

Requires improvement

Updated 10 April 2020

The service was not always safe.

Details are in our safe findings below.

Effective

Requires improvement

Updated 10 April 2020

The service was not always effective.

Details are in our effective findings below.

Caring

Requires improvement

Updated 10 April 2020

The service was not always caring.

Details are in our caring findings below.

Responsive

Requires improvement

Updated 10 April 2020

The service was not always responsive.

Details are in our responsive findings below.

Well-led

Requires improvement

Updated 10 April 2020

The service was not always well-led.

Details are in our well-led findings below.