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Archived: Donness Nursing Home Inadequate

Inspection Summary

Overall summary & rating


Updated 13 March 2020

Donness Nursing Home is a residential care home that was providing personal and nursing care to 20 people aged 65 and over at the time of the inspection. The home is registered to support 34 people.

In 2017, the service was rated as 'good' by CQC. The appointment of a second registered manager had helped improve the standard of care and the management of staff. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as 'inadequate' and 'requires improvement' following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017.

In July 2018, there was a further inspection and the service was rated as 'inadequate'. This showed the provider was unable to sustain the improvements made. A team of multi-disciplinary health and social care professionals provided further input to support the provider. The provider chose to employ an interim management team to help them make improvements. When we inspected in February 2019, the service was rated as Requires Improvement in all key areas of care. The interim management team withdrew their services in September 2019 and a proposed sale of the home to a new provider did not happen.

At the time of our inspection the local authority adult safeguarding team were investigating allegations of poor care, and the service was being supported by the local authority quality and improvement team. Following our inspection and the number of concerns identified, the provider decided to voluntarily suspend all new placements to the service until improvements were made.

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

The systems to help identify where improvements were required had been ineffective. The systemic failings found at this inspection demonstrated the provider had failed to ensure people received a well-managed service which was safe and compassionate; placing people at risk of potential and continued harm.

Since our last inspection, the ratings for all key questions had either stayed at Requires Improvement or deteriorated to Inadequate.

People told us they felt safe living at the service. However, practices were not safe. Poor monitoring of people’s fluid and nutritional intake put people at risk of dehydration and malnutrition. This risk was increased by poor monitoring of weight loss. Changes to people’s health needs were not routinely addressed in a timely way.

People received or experienced unsafe or inconsistent care. Risks associated with people's care were not always documented and/or monitored effectively by staff. People were not effectively protected from abuse because some staff did not recognise their responsibilities to ensure people were safe.

Communal areas were clean but there were bedrooms that had an unpleasant odour. The environment had been assessed for safety. Fire training did not take place regularly which put people at risk in the event of a fire as staff may not be competent and confident to respond appropriately. The staff training matrix showed some staff had undertaken little training. Staff competency in using a person-centred approach was variable.

The level and standard of activities and meaningful occupation did not meet the social needs and wellbeing of everyone living at the home.

People were not involved in planning their care and support; people’s care was not effectively reviewed and changes to their health needs were poorly managed.

Concerns were not routinely responded to in a consistent manner, so some people lost trust in the staff because their complaints had not been handled appropriately. When the manager was made aware of complaints, they followed the formal process and took steps to address issues and reassure people.

People and relatives said staff were kind and

Inspection areas



Updated 13 March 2020

The service was not safe.

Details are in our safe findings below.



Updated 13 March 2020

The service was not effective.

Details are in our effective findings below.


Requires improvement

Updated 13 March 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 13 March 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 13 March 2020

The service was not well-led.

Details are in our well-Led findings below.