Deepdene Court

Updated 5 October 2023

The inspection

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

The inspection was carried out by 2 inspectors and an Expert by Experience. 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

Deepdene Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Deepdene Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

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. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

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 Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 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 5 people who used the service and 2 relatives of people who use the service about their experience of the care provided. We spoke with 3 health and social care professionals who visited the service. We spoke with 9 staff members including the nominated individual, regional manager, registered manager, registered nurses, care workers, house-keeping staff, and office staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 6 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed.

Updated 5 October 2023

About the service

Deepdene Court is a residential care home providing personal and nursing care to up to 35 people. The service provides support to people with a range of mental health needs, including complex and enduring conditions or addictive behaviours such as substance misuse. At the time of our inspection there were 34 people using the service.

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

People did not always follow the provider’s smoking policy and smoked within the premises putting themselves and others at risk. The registered manager and staff were aware of the disregard to the policy and had reiterated the policy to people at various meetings; however, a robust assessment of risk had not been completed to identify all risks and implications.

Checks and audits did not always highlight where some areas of the service required deeper sanitation. Where areas were identified as requiring deep cleaning, actions to address these were not always followed through. Some communal spaces were not included on the infection control audit and needed attention.

People told us they felt safe and could speak with staff or management if they have any concerns. A person told us, “I feel well cared for and safe.” Staff understood their roles and responsibilities to escalate any safeguarding concerns with the management team or to external bodies, such as, the local authority and CQC. People were given information to enable them to raise any concerns if required, both internally and externally.

People and staff gave mixed feedback about staffing levels. Comments included, “Yes, there is definitely enough staff, they are always available, and at night as well,” and, “Sometimes it can be a bit low on staff.” We observed enough staff supporting people and spending meaningful time with them. Staff were recruited safely, following recruitment they completed an induction period which included shadowing an experienced member of staff. Staff were trained to administer medicines, storage and record keeping of medicines were completed in line with current guidance.

People’s mental and physical health needs were assessed. People’s support plans detailed signs to watch out for in the event of a relapse in mental health. These were person-centred and included the level of support people required and how much staff intervention was appropriate depending on the circumstances. A person told us, “Staff are very supportive. They do activities with us, take us out for coffees. They comfort you if you are having a bad day.” We observed staff responding to an incident well with a person-centred approach during our inspection.

People contributed to their support plans and received person-centred care tailored to their needs. People were regularly asked for feedback and were listened to. People gave feedback through surveys, a suggestion box, at keyworker meetings and house meetings. The registered manager displayed a ‘you said, we did’ board which detailed people’s ideas and the outcome.

People were complimentary about the registered manager as they knew people using the service well and built trust with them. Comments included, “I know the manager, they’re very good, it is well run,” and, “The manager is cool.” Staff gave positive feedback about the registered manager, a staff member told us, “[Registered manager] is great, very supportive, gets heavily involved with the residents, couldn’t ask for better really.”

The registered manager was keen to develop themselves and staff to continually improve people’s experience of care. They worked alongside a regional manager and met with managers of the provider’s other services to share ideas and mutual support. The management team gave examples of lessons learned within the services and changes made to improve people’s support.

People had access to health and care services, visiting health and social care professionals mostly gave positive feedback about the service. We were told, “If we suggest something they are good at taking it on board and implement it,” and, “I can see theoretical downside, I know they are a large service with many complex people with differing support, but they manage it very well.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 18 August 2021).

Why we inspected

The inspection was prompted in part due to concerns received about risk management and following a review of information we had received from the service. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Deepdene Court on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to assessing and managing risks, infection prevention and control, and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.