Archived: The Dean Neurological Centre

We found the following examples of good practice.

¿ The provider’s policies and procedures for infection, control and prevention were in date and included those relating to a pandemic and other infections such as Influenza. Regular audits and checks were taking place to ensure the service was operating in line with these policies and procedures, and in line with national and local COVID-19 guidance.

¿ Risks to people and staff arising from COVID-19 had been assessed and measures were in place to reduce these risks. This included regular COVID-19 testing of people and staff, appropriate and safe use of personal protective equipment (PPE), use of shielding and self-isolation where appropriate and required, and enhanced cleaning, waste and laundry arrangements.

¿ Staff had received appropriate and relevant training and were competent in their practice. This included the donning and doffing of PPE and adherence to Aerosol Generating Procedures (AGPs) relevant when caring for people receiving mechanical support to breathe.

¿ Admissions to the service from hospital or other care settings were managed safely. The service was adhering to national COVID-19 guidance in relation to this. One person’s admission had been postponed (during the period of the national lockdown) until managers were assured, they had access to the specialist support required to safely facilitate this admission.

¿ The service had made adaptions to how it worked and communicated with other professionals to ensure a multi-disciplinary approach was maintained. This meant that people’s needs and treatment plans were regularly reviewed by all the healthcare professionals and disciplines involved in a person’s care and treatment. The same approach applied when making decisions in people’s best interests.

¿ Arrangements were in place to support safe visiting by relatives. The service was adhering to guidance given by the local Director of Public Health as well as wider national guidance in relation to care home visiting. Relatives were kept informed about necessary changes to visiting arrangements and staff were supporting both people and their relatives during these times.

¿ People were supported to remain in virtual contact with their family members using electronic devices. Wi-Fi to the building had been enhanced and additional mobile phones had been purchased.

¿People were supported to socially distance but to remain socially engaged and to take part in activities which benefitted them.

¿ Managers met regularly with staff and people in order to support effective communication. People had access to a ‘residents forum’ which met with managers regularly to discuss any issues arising and listen to people’s feedback. Managers gathered feedback from this forum to support their monitoring of the use of PPE.

Further information is in the detailed findings below.

The Dean Neurological Care Centre is a care home providing personal and nursing care to adults with complex and life changing neurological disorders. 44 people were in receipt of care at the time of the inspection. The service can accommodate up to 60 people.

The home was purpose built and people received care and therapy support in one adapted building. Each person had their own bedroom with washing and toilet facilities; they shared spacious communal areas. Outside there was an easily accessible decking area.

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

People told us they felt more settled than when we last inspected. They were aware there had been changes in the management of the service and they spoke with us about the improvements they were aware of. People were generally happy with their care and had opportunities to discuss with staff areas they wanted altered.

Following our previous inspection, the provider had appointed an interim management team to drive their improvement plan and improve standards. We found the provider had effectively implemented their improvement plan and the improvements they had reported on every month were evident.

New and permanent home managers had recently been employed and time was needed for the new management team to get to know the service and to ensure all the planned improvements were completed.

Staff morale had improved, and staff spoke positively about working at the service.

Engagement with people and relatives was meaningful and extensive. Regular Residents Forums and surveys took place and we found lessons had been learned from complaints and incidents.

People felt safe and able to talk with senior staff if they needed to. Staff knew what action to take to maintain people’s safety. Security measures were in place to keep people safe.

Risks to people’s health, safety and the environment were assessed, monitored well and action taken to reduce these.

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.

People had access to medical and emergency support when needed. People’s medicines were managed safely.

People’s complex care and treatment was reviewed regularly by specialist healthcare professionals. Visiting professionals told us the service had improved how it communicated with them about people’s conditions and needs.

Some improvements had been made to people’s care and treatment records. Professionals told us they had noticed this and could more easily find the information they required when they visited. Managers told us further improvements to people’s records were planned.

Staff training, and support had improved, and they were supported to provide safe care and treatment to people which was in line with best practice guidance.

Staff had access to the information they required about people’s care and therapy needs. Guidance for staff was now provided in a way which supported a person-centred approach to care.

People’s care and therapy was reviewed regularly with them and their views and choices on this incorporated into the planning of their care.

Staff described a “wholesale change” in how care and therapy staff worked. A more collaborative way of working had been adopted and people had benefited from this.

Staff showed warmth and compassion towards people and were concerned for people when they were distressed or poorly. There was a genuine desire for people to live as well as they could and as comfortably as they could.

People were supported with activities they enjoyed, and, despite people’s complex conditions and personal preferences, a great effort was made by staff to make these fully inclusive of everyone.

We observed staff interacting positively with people. People looked relaxed in the staffs’ company. This demonstrated that important, supportive and meaningful relationships had been built between people and those who cared for them.

There were no restrictions on visiting and one person told us their dog was able to visit them.

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

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (report 5 July 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating and to follow action we had told the provider to take following the last inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

The provider had not made sufficient progress since our last inspection in May 2018 to ensure that people received safe care and treatment and met their regulatory obligations. Progress to improve the service had not been fully established and sustained due to changes in the management team and staff turnover and vacancies.

Since our last inspection, there had been several changes in the management team at The Dean Neurological Centre. A registered manager was in post however a senior leadership team was managing the day to day management of the centre. Prior to our inspection the provider had identified shortfalls in the service. The provider had arranged for a specialised ‘support team’ to be deployed to The Dean Neurological Centre to assess and address gaps in the service with the aim to improve people’s quality of care and improve the clinical governance systems. The support team were working against an action plan to prioritise and address the needs of people with high clinical risks.

CQC and the local commissioners have requested weekly updates to discuss their progress in improving the quality of people’s care and running of the service. The updates and action plans have provided CQC and other stakeholders with assurances that the provider was taking immediate action to address our concerns.

People were at risk of potential harm as it was not always clear if they had received care and treatment in line with health care professional recommendations and current evidence-based guidance. Staff had not always recorded their care provision or updated people’s records to reflect the management of their current needs. Records of people’s advance and end of life care had not been recorded to provide staff with guidance if people entered the final stages of their life. There was limited clinical oversight and effective systems being used to monitor people risks, progress and well-being. We found some areas of good practice such as safe management of people’s mobility and hoists. However, safety concerns raised through the provider complaints and accident process had not been consistently addressed to drive improvements.

People had not always received personalised care in a timely manner as staff had at times not been effectively deployed to be responsive to their needs. People’s care was not always personalised and centred on their emotional and social requirements.

Staff told us they could speak to the leadership team and registered manager but reported that management changes had impacted on their morale and well-being. The skills and knowledge of staff to support people with complex needs had not been sustained due to a high turnover in staff and use of agency staff. The training needs and competencies of staff were being analysed and any gaps were being acted on. Plans were in place to ensure staff were trained in recognising early warning signs of changes in people’s health and in current end of life care practices. Action was being taken to ensure people would be supported by sufficient numbers of staff who were familiar with their needs.

A recruitment campaign and training/competency analysis of staff skills was being undertaken to ensure people were supported by staff that could provide effective care and were familiar with their needs. Dedicated staff were working on an action plan to improve the management of people medicines and shortfalls found in a recent infection control audit and improve the quality and details of people’s care records.

Staff were working more openly and collaboratively with external health care professional and relatives to improve the quality of care and improve positive care and treatment outcomes for people. Systems were being established to provide people with opportunities to express their views, suggestions and comments about living at the service. Learnings from accident, incidents and complaints had not always assisted the service to improve their practices. Progress was being made in improving the centre’s environment and range of activities for people.

People and their relatives praised the kind nature of staff and told us they were kind and compassionate. People were treated with dignity and respect and their right to a private life was upheld. Where possible people were offered choice or staff supported them in their best interests based on people’s likes and dislikes.

Rating at last inspection: At the last inspection the service was Requires Improvement (last report was published on 17 July 2018)

Why we inspected: The inspection was brought forward due to increased information of risk and concerns about the centre and based on the previous rating of the service. We followed up on progress against agreed action plans, to address the breach of regulation found at our previous inspection.

Enforcement: Full information about CQC’s regulatory response to more serious concerns found in inspection and appeals is added to reports after any representation and appeals have been concluded.

Follow up: Following the inspection, we asked the provider to take immediate action and provide a weekly action plan to demonstrate the actions that have taken to address our concerns and to meet the regulatory requirements to improve the service. We are also working in partnership with other agencies to monitor the service.

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

The Dean Neurological Centre provides accommodation for 60 people who require personal care with nursing. There were 47 people living in the centre at the time of our inspection. The centre provides personal care and support to people with complex long term neurological conditions, brain or spinal injuries and people who require on-going support and assistance to maximise their functional ability. The centre is purpose built and set over two floors, each floor comprising of 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is a therapy department, sensory room and people have access to several decked areas in the garden.

Following our last inspection in June 2017, we met with the provider and asked the provider to complete an action plan to show what they would do and by when to improve the key questions in the domains of safe, effective, responsive and well-led. At this inspection we found that progress had been made in the recording of people’s care needs, the delivery of personalised care and the monitoring of the service to drive improvement. However further improvement was still needed as people’s care records were not always current and some people did not always receive personalised care.

There was a registered manager in post. 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. However an interim manager had been allocated to the home by the provider to support the registered manager to drive improvement across the home. The centre was also being supported by specialist internal and external advisors as well as representatives from the provider.

Systems and initiatives to monitor the service were being implemented. Through their own quality assurance assessments, the provider had identified concerns in the running of the home and was acting on these shortfalls. However we found that their systems had not always identified gaps in the recording of people’s current needs and the delivery of personalised care. We have recommended that the service seeks advice in designing and reviewing people’s support to ensure that it reflects their needs and preferences.

Systems were being put into place to gain the views of relatives and staff and improve communication and assess the quality of the service being provided.

Relatives and staff had been concerned that people had not always been supported by staff who were familiar with their needs. A high turnover had resulted in people being supported by agency and/or new staff who may not have a sufficient understanding of their care requirements. The centre was actively recruiting new staff and plans were in place to implement an effective management structure and keyworker system to help to assist with the monitoring of people’s needs and care records.

People were supported to access health care services when their medical needs had changed and received their medicines as prescribed. We received mixed comments about the quality of food people received, however we found that people’s dietary needs and choices were catered for.

We found the centre was clean and free from offensive odours. The provider was in the process of employing additional housekeeping staff to maintain the level of cleanliness on a daily basis and reduce the risks of cross contamination.

People and their relatives were positive about the staff who cared for them. Staff ensured that people’s dignity and privacy was respected, although people did not always have access to social and meaningful activities. However action was being taken to address the environment and activities in the centre.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

The centre is purpose built and set over two floors, each floor comprising 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is therapy department and people have access to several decked areas in the garden.

There was registered manager in place as required by their conditions of registration. 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.

People and their relatives were mainly positive about the caring nature of staff; however people’s care plans and daily care records did not support the safe delivery of care. Not all people had recorded guidance or care planning which reflected their support requirements and risk management. Staff did not always follow safe infection control practices. People were not continually informed of the care being provided.

People benefited from a new medicines management system to ensure they received their medicines as prescribed.

Staff enjoyed working at the centre. There were suitable numbers of staff to support people; however the registered manager was reviewing the deployment of staff across the centre to ensure people received care and support in a timely manner. Effective recruitment systems were in place to ensure people were cared for by staff with good character. Staff understood their responsibility to report any accidents, incidents or safeguarding concerns.

Systems to monitor staff training and support had generally improved. Staff told us they felt trained; however their work based skills were not regularly assessed to ensure they were competent to support people with complex skills. A series of competency assessments were being developed to evaluate the skills and knowledge of staff. Not all staff training was mandatory which meant some staff were at risk of having gaps in the knowledge to care for people. A clear frame work to monitor the specialist clinical skills that nurses required to carry out their role was not in place other than the nurse’s professional registration requirement. Not all staff had supervision records which highlight their professional development or act on any concerns.

Staff and people’s their relatives felt communication across the centre needed to improve. A quality improvement lead was helping to recognise shortfalls in the service and drive improvement in the centre. The provider had different means to regularly audit and check on the quality of the service being delivered, although the system had not always been effective in driving improvement across the service.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

The centre is purpose built and set over two floors, each floor comprising 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is therapy department and people have access to several decked areas in the garden.

There was registered manager in place as required by their conditions of registration. 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.

People and their relatives were mainly positive about the care they received however we found people’s safety and well-being was compromised in a number of areas.

There were inconsistencies in the detail and information in people’s care records. Information was not always accessible or consistently recorded to provide staff with guidance. There was an irregular approach to the monitoring of people’s risks and well-being. There was limited evidence that people’s mental and social well-being had been addressed. Staff supported people who lacked mental capacity in their best interest and knew their preferences well; however assessments of people’s mental capacity had not been consistently carried out. Protocols were not in place for people who required their medicines ‘as required’.

Staff were confident in their role and said they felt trained and supported. However their skills and care practices had not been continuously checked or updated. Staff had not received regular private support meetings to discuss their development and performance.

People were supported by staff who were kind and compassionate and knew people well. Staff interactions were positive and caring. They respected people’s dignity and privacy when supporting people with their personal care. Staff understood their responsibility to safeguard people and report any concerns.

People enjoyed the meals provided. Those who had specific dietary needs were catered for. People’s medicines were mainly managed well, although accurate stock levels of medicines were not always kept. People were supported to access a variety of health care services as required.

The centre was adequately maintained and clean. Staff demonstrated good infection control practices.

The manager dealt with any issues from people and their families on a day to day basis and had acted on people’s concerns. Their views were sought but not always acted on. Systems to monitor and improve the quality of service people received and the training of staff were in place. However these systems were not effective in driving improvements within the service. The registered manager and provider were aware of concerns found during this inspection, and were formulating actions to improve the service.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

Changes had been made to the activities provided. People were able to join in group activities or have one to one time. All staff were involved in providing activities for people.

People had access to external health and social care professionals to help the service meet their assessed needs.

Suitable arrangements were in place for obtaining and recording people's consent to treatment and care.

Improvements had been made to the management of medications that were administered via percutaneous endoscopic gastrostomy tubes (PEG).

Nearly all people we spoke with told us they were bored because of a lack of activities. We found there was a lack of activities for people. The registered manager told us after the inspection that all staff provided activities as part of people's treatment and rehabilitation, but their recording of this was not very clear.

We found care staff demonstrated good knowledge of people's needs, especially those who required one to one care. All staff had access to on-going training and competency assessments were in place for care staff that used specialist equipment.

We found that further work was needed to ensure that people using this service were fully protected against the risks associated with medicines.

A compliance action issued at the last inspection had been addressed in relation to recruitment of new staff. A system was in place to monitor the service provision and obtain the views of people and their relatives.

People told us how they received enough help to meet their needs and how they did not have to wait long for staff to respond to call bells. People also told us that they felt The Dean was a safe place to be. We looked at staff recruitment and found that in some cases the required checks were not being carried out. Although we did not ask people specific questions about staff recruitment, we did hear positive comments about the staff.

We found that the service had an effective complaints system and some of the people we spoke to were aware of who to approach if they had a complaint.

The pharmacist inspector also spoke to a further three people about their medicines. People were able to look after their own medicines if this was appropriate. Although the people spoken to were happy with the way their medicines were managed, we found some areas of medicines management needed to be improved.