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The New Deanery Care Home Requires improvement


Inspection carried out on 12 August 2020

During an inspection looking at part of the service

The New Deanery provides accommodation and personal care for up to 93 people, including support for people who may be living with dementia. At the time of our visit 63 people were living at the service.

We found the following examples of good practice.

The registered manager had effective systems in place for managing the Covid-19 pandemic and keep people safe.

The registered manager had implemented protocols before the government issued advice on restricting visiting to keep people safe. Since visiting had resumed, a designated room had been made safe for visits as well as outdoor space utilised. A booking system and screening checks were in place to protect people from the risk of cross contamination.

Arrangements were in place to ensure safe social distancing. There was signage throughout the service encouraging handwashing, the wearing of protective equipment (PPE). Notices included guidance as to the numbers of people allowed to enter each room to ensure safe social distancing.

The use of Use of PPE was in accordance with current government guidelines.

Risks to people’s safety from Covid-19 had been assessed. Staff had included an assessment of the emotional impact on people and how PPE may cause fear and anxiety for people with limited mental capacity. Staff were encouraged to use hand signals, thumbs up, winking as well as written and pictorial prompts to aid communication where the use of staff face masks hindered the ability to lip read.

There was a strong focus on promoting a sense of wellbeing for the people staff cared for. Colourful badges for staff to wear had been created to remind members of the public to keep safe social distances.

Staff had been provided with the appropriate training and had sufficient supplies of PPE to keep them and people safe from the risk of cross infection. Infection prevention control measures and cleaning regimes had been increased with additional hand sanitising stations added throughout the service.

We recommended the provider review their policy of staff wearing their uniforms outside of the service to further prevent the risk of cross contamination.

Further information is in the detailed findings below.

Inspection carried out on 4 April 2019

During a routine inspection

About the service: The New Deanery is a residential care home that was providing personal and nursing care to 68 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

People told us they felt happy and safe living at The New Deanery. People told us there was a wide range of activities and they were supported by kind, compassionate staff who took a real interest in them. People told us, and records confirmed, they were given plenty of opportunities to provide feedback about their care, and the provider acted on any concerns they raised. People spoke very highly of the standard of decoration in the home and the quality of the gardens which were well maintained and well used by people. People and relatives told us they appreciated the range of different spaces within the home where they could meet with visitors and spend time.

Some people were less positive about their experience of care, and we found this reflected the inconsistencies we found in the quality of care plans and risk assessments. Some risk assessments and care plans were less personalised, detailed and up to date and this meant there were risks that people did not always receive personalised care. Assessments did not consider the impact people's sexual and gender identity may have on their care. We have made a recommendation about this.

People told us staff supported them to attend medical appointments and to take their medicines. The provider updated medicines information in response to issues we found during the inspection.

People were supported by staff who understood the values of the organisation, and had received the training and support they needed to perform their roles. Staff felt valued and were rewarded when they demonstrated the values of the organisation.

There were various different audit and quality assurance systems in place. These had not always operated effectively and had not identified the issues we found during the inspection with medicines information and the consistency of care plans. The provider had not submitted notifications to us as required by law.

The provider worked closely with the local authority quality improvement team and other organisations to keep up to date with best practice in the field. They were piloting new technology and systems to support people to maintain their independence.

Rating at last inspection: The service was rated Good when it was last inspected in August 2016.

Why we inspected: This was a scheduled inspection.

Enforcement: Please see the end of the full version of this report for details of the actions we told the provider to take.

Follow up: We will require an action plan and will closely monitor the service. We will return to complete a further inspection in line with our published policies and procedures.

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

Inspection carried out on 4 May 2016

During a routine inspection

This inspection was unannounced and was carried out on 4 May 2016. We had previously visited on 25 And 26 November 2014 and rated the service as ‘requires improvement’. At this inspection we found that the provider and manager had looked at the detail of our report and had indeed responded positively to our findings and addressed those areas for improvement. The previous report did not find breaches in regulation.

The New Deanery provides accommodation and personal care for up to 93 people. Some of whom have a degree of living with dementia and some people who have a physical disability. At the time of our visit 39 people resided at the service. This location is required to have a registered manager and one was in place. They were present through the whole inspection and were enthusiastic to share developments with our team. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found a care service that was fully compliant with regulations. It was extremely well led. The vision and values were well known by everyone. Staff were enthusiastic about their areas of responsibility and keen to share with the inspector how much they enjoyed their job. The management oversight was thorough and effective so that people were as safe as they could be.

People and their families experienced an inclusive service that was responsive to ideas and dealt with complaints well to peoples satisfaction. Management was open and actively listened to people through their quality assurance processes.

People told us that staff were caring and knew their individual needs. People felt that staff were compassionate and were able to develop meaningful relationships. Relatives told us they were informed and were able to develop trust in the staff. People told us that any concern was readily addressed. People had good interesting opportunities about how they spent their day. The catering was responsive to individual preferences and needs with care and attention paid to presentation of food and peoples individual needs such as a soft diet.

There were sufficient numbers of staff so that people were given the time and attention that they needed. People told us that they were never rushed. Our observations were that staff were responsive to people’s needs and readily available at all times.

Staff were well trained and had good support in place. The induction that staff received was thorough and comprehensive and meant that staff at the end of induction were capable of performing their role to a good standard as confirmed in their weekly review and confirmation in post. Staff were provided with sufficient information in care plans to offer a tailor made service for people. Care plans were developed with people, individualised and easily accessible. Care and risk assessments were regularly reviewed and peoples capacity and ability to make decisions was well managed.

Inspection carried out on 25 and 26 November 2014

During a routine inspection

We Inspected The Old Deanery on the 25 and 26 November 2014, this inspection was unannounced.

At our last inspection on the 8, 9 and 17 July we found that the provider was not meeting the requirements of the law and had multiple breaches of regulations. These included; Respecting and Involving people, Consent to Care and Treatment, Safeguarding, Staffing, Supporting Staff, and Records. We served Warning Notices for Regulation 9, Care and Welfare and Regulation 10, Assessing and Monitoring the Quality of Service Provision. We asked the provider to take action to make improvements and this action has been completed

The service has the capacity to accommodate 93 people and is set over three floors. On the day of our inspection there were 32 people using the service. The provider had taken steps to change the service offered at The Old Deanery. They had recognised that they were unable to meet the individual needs of people with more complex needs and took the decision to concentrate on giving support to people who were less dependent. A review of all people using the service found that they were unable to offer continuing services for 23 people. Those people were supported by their families and the local authority to find alternative accommodation. These changes have had a significant impact on the people, their families and others who used the service. Most of the people who needed to move had left the service but three remained at the time of our inspection.

The service does not currently have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new care manager had been in post and was going through the process to apply to be the registered manager.

We found the service employed sufficient numbers of staff to meet people’s needs. New staff had the appropriate checks before they started work, however we found their induction was short and needed improvements to ensure the training they received was effective and skills were being developed in order to meet people’s needs.

The service carried out some risk assessments on people’s healthcare needs, but did not complete individual assessments on how to support people who used wheelchairs and hoists. We saw that one person was moved inappropriately, the lack of information for care staff meant people may not always be supported with using equipment consistently and in the correct manner.

People told us they felt safe living at the service. Staff and the care manager were able to explain to us what they would do to keep people safe and how they would protect their rights. We saw that staff were adhering to policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLs) to ensure that people who could not make decisions for themselves were protected.

We saw that people were relaxed in the company of each other and staff. Staff were attentive to people's needs and were able to demonstrate they knew people well.

New care plans had been implemented and developed with the involvement of people and their relatives. However it was not easy to locate relevant information about people quickly and easily. Staff did not always have access to the information they needed about people’s health, safety and welfare.

People who used the service were provided with the opportunity to participate in activities which interested them. Activities were diverse to meet people’s personal choices and individual needs.

Where appropriate, support and guidance was sought from health care professionals, including a doctor, chiropodist and district nurse.

The service had a number of ways of gathering people’s views from holding meetings with staff, relatives and people, to completing surveys and talking to people individually. People’s suggestions and ideas about how to improve the service had been listened to and action taken to make changes.

The manager and provider carried out a number of quality monitoring audits to ensure the service was running effectively. These included audits on care files, medication management and the environment. These audits were used to monitor trends and drive improvements. However they had not identified that there were not risk assessments in place for moving and handling, or care plans for medication.

Inspection carried out on 8, 9, 17 July 2014

During a routine inspection

We visited the home on 8, 9 and 17 July 2014. We spoke with 32 staff, the registered manager, five relatives and thirteen people using the service. We looked at the care plans of 16 people using the service and also looked at other records relating to the running of the service.

The inspection team who carried out this inspection consisted of four inspectors, three specialist advisors who specialised in differing areas of care delivery and an expert by experience. An expert-by-experience has personal experience of using or caring for someone who uses this type of care service.

Due to the complex needs of some people living at The Old Deanery Care Home they were unable to talk with us. We therefore used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed two mealtimes and spent time in a communal lounge.

During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is it safe?

The service was not consistently operating in a way that ensured people were safe. Some people told us they felt safe and secure and we found staff had knowledge of when and how they should report any concerns about the safety of people using the service. However, we found that some concerns, had not been investigated by the manager. This meant action had not been taken to investigate some incidents and determine if referrals to the local authority for consideration under their safeguarding vulnerable adult�s procedures were needed.

We found that recruitment procedures in the home were rigorous and thorough to ensure staff were safe to work with vulnerable adults. However when arranging staffing, the management team did not always ensure there was a suitable skill mix in relation to competencies, knowledge, qualifications and experience.

We saw that where people had been assessed as being at risk from acquiring infections or were at risk of falling, the assessments did not give staff information on how they could support people and minimise these risks.

We looked at whether the service was applying the Deprivation of Liberty Safeguards (DoLS) appropriately. We found that although some staff had a lack of knowledge of DoLS, the registered manager had a good understanding and there were people with a DoLS authorisation in place in line with current policy. However, we found the Mental Capacity Act 2005 (MCA) was not being adhered to. This meant people were not always being supported with decisions made in their best interest.

Is the service effective?

The service was not consistently effective. Communication between staff was inadequate at times and led to delays in people receiving appropriate healthcare support from external professionals such as a GP.

We found that although staff were given training, they were not always putting this training into practice to ensure people were cared for safely.

Is the service caring?

The service was not consistently caring. We saw that some staff showed patience and gave encouragement when supporting people. We received some positive comments from people who were more independent. One person said, �Very pleasant here. I am glad I moved here.� Another person said, �It is a friendly place. It is pleasant.� Three other people told us they were very happy in the home with one saying, �I wouldn�t have anything to complain about.�

However, the needs of people who lived with a dementia related illness were not consistently understood or met in a caring way, by staff that supported them. We observed some people receiving care and support from staff who had little understanding of how to care for people with dementia. We saw this led to people with a dementia related illness not being supported to have choices, not always being treated with dignity and being placed at risk, for example burning themselves on hot food.

Staff had a good understanding of how they should support people with their privacy and dignity and we observed examples of staff respecting this. However we also saw examples of when people and their belongings were not treated with dignity. We heard staff refer to people as room numbers and tasks rather than by their name. This meant people were not always treated as individuals.

We saw inconsistencies in care plans in relation to people�s likes, dislikes and information about the person�s life history. This meant staff did not have the information they needed to make sure people were cared for in a way which they preferred.

Is the service responsive?

The service was not consistently responsive. We found that people who had a high level of need were not always being given the same choices as people who were more independent. People who were more independent told us they were happy with the level of care they received however our observations of people who needed more support from staff were not as positive.

We found that when people made complaints these were not always responded to and resolved appropriately or to the satisfaction of those that had raised them.

Is the service well led?

The service was not consistently well led. We found concerns in relation to the care and support people using the service were receiving. Throughout our inspection it was clear there was a lack of leadership of staff and systems were not robust enough to ensure people received a service that provided consistent good quality care. Other than the matron and the registered manager�s reviews there was no system for the provider to check that those reviews were effective in identifying issues and/or improving the quality of the service.

We found that the service was not learning from experience because there was a lack of oversight when analysing or evaluating events to establish cause; identify any trends or themes and continually review practice. Whilst in some cases investigations were being, or had been, undertaken in relation to the conduct of some staff, there was no system in place to develop solutions and risk reduction actions to protect people and ensure future lapses were minimised.

The service did not have effective systems to assure the quality of the service they provided. The way the service was run had been regularly reviewed but action had not always been taken to improve the service or put right any shortfalls found. Information from the analysis of accidents and incidents had not been effective in identifying changes and improvements to minimise the risk of them happening again.

Inspection carried out on 26 February 2014

During an inspection in response to concerns

We inspected because we had received information of concern about the welfare and safety of people who used the service. The service was aware of these concerns and shared their actions with us. They were working with the local authority safeguard team to ensure appropriate action was being taken and people were protected.

We carried out this inspection on 26 February 2014 at 6am. We spoke with 12 people who used the service, 11 staff and two members of the management team. We found that there were not always adequate numbers of staff on duty and that the care provided for people did not always meet their individual needs. Some people experienced care that was not managed in a way that protected them from the risk of harm or further decline in their health or wellbeing.

People who used the service told us that they felt safe and generally considered they were well cared for by staff. However some people told us that they had to wait unacceptably long periods of time for staff to respond to their call bells.

We found that the service had effective systems in place to manage complaints.

Inspection carried out on 13 November 2013

During a routine inspection

We spoke with fifteen people who used the service, eight care staff, the manager and three visitors as part of this inspection.

People told us that they were generally happy with the care that they received and that they felt safe, however two people told us that they had to wait unacceptably long periods of time for staff to respond to their call bells.

We saw that people were provided with a wide range of meals and meaningful activities. Three people told us that The Old Deanery was, "A good place to live." Another person told us that they were, "Very pleased with it and it felt like home."

We found that staffing levels were adequate on the day of this inspection and that care planning and record keeping had improved.

We saw that on occasions, the language used by staff both verbally and within care records did not always ensure that people's dignity and respect was upheld.

Inspection carried out on 25 June 2013

During a routine inspection

We spoke with nine people who used the service, six relatives and eight staff members as part of this inspection. Four people who used the service told us that they were happy with the support they received and that they felt safe. One person told us that response times to call bells, on occasions, were too long.

We found that people's dignity and privacy was maintained and that people were respected by staff. People had mixed views and opinions on the food provided. One person stated that "The food is variable, very hit and miss". However three other people told us that they enjoyed the food, there was plenty and that they were happy with the choice available.

We found that the service had sufficient numbers of staff employed to ensure people's health and welfare was maintained at all times. We saw that generally people's preferences and choices were upheld . We observed staff being caring and professional. We saw that care staff worked hard to provide the support people required. We saw that staff consulted people with regard to the care, treatment and support they received.

We found that the service was not maintaining accurate records that related to the care and welfare of the people who used the service. There was a lack of information provided within some records that could place people at risk of harm and compromise their health and safety.

Inspection carried out on 20 February 2013

During an inspection looking at part of the service

When we inspected this service on 26 September 2012 we found concerns with regard to respecting people�s choices; the care and welfare of people; safeguarding and the safety and suitability of the premises. We took enforcement action against the provider in relation to inadequate staffing levels. At this follow up inspection we found improvements had been made, but people�s dignity and independence was not respected sufficiently at meal times.

Care plans contained detailed bathing records that confirmed people received regular baths/showers and their personal care needs were met.

There was an up to date safeguarding policy and procedure in place and four staff spoken with had a full understanding of what constituted a safeguarding concern and how they would report this.

The provider had fitted automatic door closures to all bedroom doors that were seen propped open at the last inspection.

We spoke with four people who used the service and seven staff. One person told us that, "It feels as though staff have more time to spend with me and are around to help me.�

Three staff we spoke with all confirmed that morale had improved and that staffing levels had increased.

Suitable arrangements were not in place to ensure that people�s dignity was maintained, especially at mealtimes. We noted that there continued to be scope to better promote people�s rights to independence and personal choice.

Inspection carried out on 26 September 2012

During an inspection in response to concerns

As part of this inspection we spoke with a total of ten people who used the service, staff and one relative. People told us that they found the staff kind, caring and professional. Two people living within the service told us that staff are approachable but do not have enough time to carry out their role effectively.

One person told us that �Response times to call bells can be unacceptably poor on occasions.� Another person told us that �They would like more opportunities to go out of the home.�

People told us that they found the environment and facilities very comfortable and homely and enjoyed the garden areas during the summer months.

Inspection carried out on 29 May 2012

During an inspection in response to concerns

People we spoke with were satisfied with the care and support that was provided by care staff. One person told us, "I am happy living here and I cannot fault the staff. They go out of their way to make me comfortable". People also told us that they enjoyed using the communal areas and that they liked joining in with the arranged activities. Two people we spoke with said that the meals were sometimes not to their liking. Eight people told us that the food was good.

Three people told us that they have recently been concerned about staffing levels. One resident explained, �Sometimes I wait twenty or thirty minutes for assistance in the morning. I don�t think there are always enough staff to help people to get to the dining room and back.�

People we spoke with felt that they could raise any concerns and have them satisfactorily dealt with by senior care staff and managers.

Inspection carried out on 26 January 2012

During a routine inspection

People with whom we spoke confirmed that they felt respected and involved by staff. They confirmed that they were happy in the home and if they required any assistance staff would respond promptly. They were generally satisfied with the level of care and attention provided by staff and were able to approach staff if they had any concerns and felt confident that these would be addressed appropriately.

Visitors with whom we spoke confirmed that they were consulted about and involved with the care that their relative were receiving and felt able to talk to senior staff if they had any concerns.

Reports under our old system of regulation (including those from before CQC was created)