Dunwood Manor Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons

were learnt to continually identify and embed good practice

When incidents had been reported, they were recorded and analysed for themes and learning to be shared with the team. In February, to improve the quality of analysis, registered nurses, (RNs) participated in training to develop their skills.

We attended a ‘flash meeting’ during our inspection. This involved all department heads who gave and received updates and nominated staff for ‘high fives’ if they had done a particularly good job.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We saw pre-admission assessments for people using the service which were in-depth and clear. This ensured staff could provide appropriate support from admission.
There was a facility on the electronic care record system that allowed a hospital passport to be printed to provide hospital staff with current and relevant information to inform their care.
The ‘handover sheet’ was informative and had photos of people with a brief description of their conditions. Important information such as their food and drink textures, information as to how they transferred and advice such as, for example, to elevate legs. In addition, there was a brief overview of important events such as medicines changes, wound updates, reminders to staff to chase up prescription requests and incidents such as symptoms of the recent diarrhoea outbreak. The information was clearly presented and an effective way of sharing the most important points about the person to the staff team.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately
We saw records of 1 incident that described a person absconding from the service, an incident that should have been alerted to safeguarding. The provider acknowledged the incident had not been accurately recorded and staff had been present at all times therefore not meeting the threshold to make a safeguarding referral.

The provider made safeguarding referrals when accidents and incidents occurred that met the threshold for reporting. The provider clarified the threshold for reporting to assure us they were working in line with them. This ensured external scrutiny of the service was possible to ensure people were safe from the risk of harm. The actions taken immediately following the incidents, in house, had been appropriate and there had been no actual harm to people.

When safeguarding referrals had been made, they were investigated, measures were taken to reduce possible reoccurrences and learning shared amongst the staff team.

Most staff told us they believed the current management team would act should they raise issues such as conduct of colleagues or safeguarding concerns.

Score changed from 2 to 3.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and those closest to them had been involved in assessments to assess people for any risks from falls, poor skin integrity and from their medical conditions such as epilepsy. Assessments contained sufficient detail and appropriate measures for staff to take to mitigate the risk of harm to people. However, we were not assured the risks and mitigations around the management of diabetes were always recorded. We saw a person had a diabetes plan that stated if their blood sugar levels exceeded 20 mmol/L the healthcare provider should be contacted, fluids encouraged, and they should be monitored for symptoms of diabetic ketoacidosis. Diabetic ketoacidosis is when a lack of insulin causes harmful substances called ketones to build up in the blood. It can be life threatening and needs urgent medical treatment. On 3 occasions over a 4 day period, blood sugar levels were recorded at above 20 mmol/L. No information had been recorded to demonstrate what action had been taken to manage this.
Diabetes in the service was managed by registered nurses who had been trained in diabetes. However, on the blood sugar record sheet there was no documented ‘target’ for blood sugar levels, therefore there was no prompt to staff to act.
The provider had been proactive in arranging for additional staff support for people when their condition required it. For example, a person at very high risk of falls had 1-to-1 staff support, and another person whose presentation could pose a risk to both themselves, and staff members had 2-to-1, 24 hours per day. The provider was committed to offering safe care to people and ensuring staff were not subject to unnecessary risks of harm.
The provider also ensured staff were safe in their roles. A staff member told us they had a medical condition and had needed a risk assessment to mitigate risks to people, colleagues and themselves. They were happy with the providers response to this but noted the changes to the management team had caused the information to not be handed over and shared with the new team.

 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider ensured contracted inspections and servicing took place of equipment and in house checks were completed to schedule.

Some areas of the premises needed refurbishment. For example, water ingress had caused plaster to become rough, a radiator had been damaged, and the metal cover was held together with tape. Both areas posed a risk to people should they brush up against them or fall on them.

We saw some cupboards in the premises had signs that read, ‘fire door keep locked shut’. These doors were not always locked and contained various care items. In a shower room, an unlocked cupboard held a carpet cleaner and chemicals to use in it. The shower room was also unlocked.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were calculated using a dependency tool. Staff numbers were in line with the most recent calculated level. If there were not enough contracted staff to cover shifts, the provider used agency staff, most of whom were familiar with the service.

Additional staff had recently been deployed as 1-to-1 and 2-to-1 staff and agency staff covered any shortfall. Staff took turns throughout each shift working as 1-to-1’s and as care assistants on general duties to ensure staff remained fresh in this role which could be intensive at times.

Staff completed a range of training courses on commencing in post as part of their induction and continued updating and completing additional training throughout their employment at Dunwood Manor. The provider supplied their training matrix and training statistics. These showed there were a number of staff who had overdue courses; however, these were mostly not significantly overdue, and staff were in progress towards completing them.

The provider had a supervision policy, and most staff had participated in some form of supervision in 2025. There were several types of supervision including individual support and wellbeing 1-to-1’s, group supervisions, medicines competency checks, medicines supervisions and probationary meetings. Most staff told us they felt supported by the provider. A relative told us, “My impression of the staff is that they are well trained and caring. They are friendly and approachable when I visit. They appear to be kind and patient with the residents.”

Recruitment records were mostly complete with all Schedule 3 checks completed in advance of staff commencing in post. We saw one staff record for an overseas worker on sponsorship did not have a full employment history. The provider supplied this before the end of our inspection.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had managed an outbreak of a respiratory infection successfully, linking in with the infection prevention and control (IPC) leads from the local Integrated Care Board and the UK Health Protection Agency (UKHPA). An appropriate response including antiviral medicines for all residents was organised and the outbreak was contained.

Other guidance was followed to ensure hygiene was maintained in line with good practice standards however we noted some areas of concern. For example, a door by the main kitchen was extremely sticky and a floor where dining trolleys were stored was heavily soiled. Some hard floor areas were also soiled with build-up around door strips.

We were concerned that in 1 person’s bedroom there was a very strong odour of urine from the carpet. The regional manager advised this was as a result of the carpets being cleaned the previous day. We reviewed the cleaning schedule records and during February and March 2025 could see no record of the carpet being deep cleaned. A relative told us, “Inevitably there is an odour associated with an older person’s home. I would certainly say that Dunwood is better in this respect than a lot that I have visited.”

We saw staff wearing personal protective equipment (PPE) appropriate to the tasks they were completing and there were sufficient supplies of PPE.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as and when prescribed. Medicines were stored in treatment rooms where temperatures of the room and fridges were monitored. These were within safe range and, there was adequate ventilation should temperatures become too high. Doom kits were available to denature medicines such as controlled drug patches and the provider held the required licence to complete this.

People had medicines care plans and medicines administration records (MAR’s) were completed as medicines were given. We saw some care plans were not completely person-centred. For example, a person’s diazepam was administered to ‘treat anxiety and agitation’. Additional beneficial guidance would be some descriptors of the signs and symptoms of the persons anxiety and agitation as it can manifest in numerous ways.

When required medicines, or PRN medicines were given as intended however there were not always recorded outcome. PRN medicines are usually prescribed to treat short term or intermittent medical conditions and are not to be taken regularly. The clinical lead advised these notes would often be made in care records and not in the medicines record and told us they would address this.