Archived: Dean Wood Manor

Dean Wood Manor is a nursing home registered to support younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 47 people were living at the home.

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

We found improvements were required with the management of pressure care; particularly the recording of pressure relief, and with medicines. This included medicine administration practices, stock control and record keeping. The medicines audit process also required strengthening, to ensure where issues had been identified, clear action plans had been documented.

We have made a recommendation about the management of pressure care.

People felt safe living at the home and told us they received a good standard of care. Staff had received regular training in safeguarding and knew how to report any concerns. Staffing had been challenging throughout the pandemic due to absences and shielding, with the home reliant on agency staff to ensure enough staff were deployed to keep people safe. Recruitment was ongoing, with the required safety checks being completed for each new staff member. Accidents and incidents had been documented and reviewed to identify trends to prevent reoccurrence and keep people safe.

The home had a detailed audit and quality monitoring schedule in place, to ensure all aspects of care, support and safety were regularly assessed and actions taken to address any concerns. People, relatives and staff spoke positively about how the home was currently being run. The current manager was reported to be open, approachable and supportive.

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 good (published October 2019).

Why we inspected

We received concerns in relation to staffing levels and the management of medicines, dietary management and people’s pressure care needs. 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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines management and the home’s governance process.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Dean Wood Manor is a nursing home that is registered for younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people. At the time of the inspection 44 people living at the home.

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

People and their relatives spoke positively about the care provided at Dean Wood Manor. Staff were described as kind and respectful, ensuring people received support in line with their needs and wishes.

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 told us they felt safe living at the home. Staff, people and the relative we spoke with, felt enough staff were deployed to safely meet people’s needs. Staff were knowledgeable about how to identify and report any safeguarding concerns, which had been referred to the local authority as per guidance.

Accidents, incidents and falls had been documented and reviewed to look for trends and help prevent a reoccurrence. We found the home to be clean, odour free with effective cleaning and infection control processes in place.

Medicines were being managed safely. People received their medicines as prescribed by staff who have been trained and assessed as competent to do so.

A strong focus had been placed on ensuring staff were up to date with any required training. Staff spoke positively about the training and support provided, including the completion of supervision and appraisals.

People and their relatives were complimentary about the food and drink available, telling us enough was provided and they were offered choice. People requiring a modified diet received these in line with guidance.

People’s healthcare needs were being met. Referrals had been made timely to professionals when any issues had been noted or concerns raised. Equipment was in place to support people to stay well, such as pressure relieving mattresses and cushions, for people at risk of skin breakdown.

Care files contained personalised information about the people who lived at the home and how they wished to be supported and cared for. Observations demonstrated staff knew people well and provided care and support in line with people’s wishes.

Peoples’ social and recreational needs were met through an activities programme, facilitated by activity co-ordinator and staff members. A mix of activities were organised throughout the week which catered for all interests and abilities.

The home used a range of systems and processes to monitor the quality and effectiveness of the service provided. Actions plans had been generated and completed timely to address any issues identified through the auditing process.

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 requires improvement (report published March 2019).

Why we inspected

This was a planned inspection based on the previous rating.

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

Dean Wood Manor is a nursing home that is registered for younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people and there were 42 people living at the home at the time of our inspection.

People’s experience of using this service:

People living at Dean Wood Manor were not receiving safe, effective, compassionate or high-quality care. The management of medicines remained ineffective which had resulted in people receiving the wrong dose of medicine and medicines not being available as required.

The management of specific risks to people was poor, it was observed during the inspection that a person requiring a specialist diet was not provided this in line with their assessed needs. Documentation did not provide assurance that this was an isolated incident and there was no audit in place to identify this internally to prevent re-occurrence.

Pressure care was lacking and despite appropriate equipment being in place it was not being used in line with manufacturer’s instructions which exposed people to the risk of skin breakdown. Care plans and comfort in care records did not contain guidance to support staff in ensuring equipment was being used effectively.

We were concerned records did not enable us to ascertain that people’s care needs were being met. There were gaps in comfort in care records and documentation regarding people’s personal and oral care. The frequency people needed to be repositioned to maintain their skin integrity was ambiguous, with staff recording different times this was required on the same record.

There had been no operational structure in place at Dean Wood Manor following the deputy manager and clinical lead leaving which had consequently affected the quality of the service provided. Staff attendance at training had adversely been affected which included engagement with the hospice in your care home training, mandatory training and the frequency staff received supervision and appraisal.

Quality assurance systems had not picked up on some of the issues we found during the inspection which included; the use of pressure equipment and managing peoples assessed dietary needs.

A week prior to the inspection, two clinical leads had commenced working at the home and were providing direct support to the manager in addressing the medicines and issues identified during the inspection.

People were supported by staff who cared about their welfare and spoke fondly of them.

Visitors and relatives spoken with during the inspection were overwhelmingly positive about the care provided to their family members at Dean Wood Manor and expressed feelings that their family member would have missed out on good care had they paid credence to previous inspection reports.

Detailed findings are in the full report below.

Rating at last inspection:

The service was last inspected 22 and 23 January 2018 and was rated as requires improvement. The report was published 04 April 2018. Following the last inspection, we met with the provider, regional manager, and compliance manager on 18 April 2018 to discuss the rating and concerns identified. Attendees at the meeting also included the local authority and care commissioning group. Prior to this meeting we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective and well-led to at least ‘Good’.

At this inspection it was identified the provider had failed to achieve this and the quality of care people received living at Dean Wood Manor had deteriorated.

Why we inspected:

The inspection was brought forward because we had received complaints about the home and intelligence to indicate that the quality of care people were receiving had deteriorated.

Enforcement:

We served two warning notices for the breaches of regulation identified at inspection. This was in regards to regulation 12; safe care and treatment and regulation 17; good governance.

Follow up:

Following our inspection, we informed the local authority of our immediate concerns in relation to people’s safety. The local authority are currently supporting the home with a service improvement plan (SIP) which was implemented in December 2018. We attend bi-monthly updates as part of the SIP process.

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

The home was last inspected on 30 November 2016, when we identified four continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment and good governance. Following this inspection the home was rated as requires improvement overall and in the key lines of enquiry (KLOE's); safe, effective, responsive and well-led. The home was rated as good in caring.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, responsive and well-led to at least good. The home has also been provided on-going support through a service improvement programme with the local authority. We reviewed the progress the provider had made as part of this inspection.

At this inspection we identified three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; safe care and treatment, meeting people’s nutrition and hydration needs and good governance. You can see what actions we told the provider to take at the end of the full version of this report.

Dean Wood Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people living with a diagnosis of dementia. The premises are based around an original Grade II listed building which has been extended and modernised. Communal space within the home included two dining rooms and three lounges. There were also designated seating areas on corridors. The home has extensive gardens and on-site car parking is available. At the time of inspection 47 people were living at Dean Wood Manor.

There was a registered manager in post at the time of this inspection. 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.

Although people’s relatives felt their family members were safe living at Dean Wood Manor, we identified continued concerns with the management of medicines. We found discrepancies on people’s medicine administration records (MAR) that had resulted in medicines being missed. We also identified concerns when responding to people’s changing medical needs and complying with the person’s care plan and referring to health care professionals for appropriate assessment.

The home had a system in place to determine the required staffing levels. Staffing was also determined on observation and in recognition of people being more unsettled in the evening, the staffing compliment was being increased to respond to this identified need.

The home was clean and was commended by people’s relatives for the level of cleanliness maintained.

Staff completed nutritional risk assessments but we identified two people that according to their assessment score should have been referred for dietetic assessment. However, the registered manager could not demonstrate this referral had been made and care plans did not contain sufficient details to guide staff in reducing the risk of further weight loss.

There was a system in place to manage people that had specialist dietary needs but records needed strengthening to determine the foods provided were in line with their assessment.

Staff received a service induction and were commencing completion of the care certificate by the end of February 2018. A trainer had commenced at the home and there was an emphasis on improved training for staff. Supervision had been received but improvements were required to ensure staff received regular support.

Staff we spoke with demonstrated a good knowledge and understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), which is used when someone needs to be deprived of their liberty in their best interest. We found the home was working within the principles of the MCA and had followed the correct procedures when making DoLS applications. Best interest meetings had been held and documented when decisions had been made for people who lacked capacity.

The environment had received significant investment and was sensitive to the needs of people living at the home. There were plans and investment to transform the courtyard in spring so people would have an accessible outdoor space in summer.

Throughout the inspection we observed positive and appropriate interactions between the staff and people who used the service. Staff were seen to be patient, caring and treated people with dignity and respect. People’s relatives were complimentary about the staff and the standard of care provided.

People’s dignity was maintained and initiatives like dignity bags had been introduced so care products were stored discreetly in people’s bedrooms.

Relatives told us they felt engaged with their family member’s care and able to approach staff and discuss changes when required.

The home had received a number of compliments commending the home for the care provided.

Relatives were happy with the activities on offer and spoke favourably of a staff team that was responsive to their family member’s needs.

The home worked closely with the hospice in your care home team and had been awarded ‘most improved care home’ and a senior support worker had been commended as a ‘dignity champion’ and received an award the end of year celebrations.

Relatives spoke favourably of the registered manager and staff team at Dean Wood Manor and the improvements they had observed. Family member’s felt consulted and that they could have their say. They told us the relative meetings were informative and an opportunity to discuss initiatives implemented.

The registered manager was part of the ‘butterfly group’ which discusses best practice and initiatives to get better outcomes for people living with dementia.

The provider had a range of systems and procedures in place to monitor the quality and effectiveness of the service. Audits were completed on a daily, weekly and monthly basis and covered a wide range of areas including medication, care files, infection control and the overall provision of care. We saw evidence of action plans being implemented to address issues found, however not all of the issues we noted during inspection had been captured via the auditing process. Where the same issues had been identified; we found changes to practice had yet to become embedded.

We carried out an unannounced inspection of Dean Wood Manor on 30 November 2016.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people living with a diagnosis of dementia. The premises are based around an original Grade II listed building which has been extended and modernised. Communal space within the home included a dining room and three lounges. There were also designated seating areas at the end of some of the corridors. The home has extensive gardens and on-site car parking is available. At the time of inspection 26 people were living at Dean Wood Manor.

At our previous inspection on 08, 09 and 15 June 2016, we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; person-centred care, dignity and respect, safe care and treatment, good governance, staffing and safeguarding service users from abuse and improper treatment.,

During this inspection, although we found some improvements had been made, we identified four continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment and good governance.

At the time of our inspection, there was no registered manager in post. The home had undergone several changes of management in the last couple of years and the current home manager had only commenced working at the home in September 2016. The home manager confirmed they would be applying to register with CQC. 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.

The people and their relatives we spoke with said they felt Dean Wood Manor was a safe place to live.

We found medication was not always given to people safely. New systems in place demonstrated that improvements had been made but further improvements were required. Procedures regarding cream application needed strengthening as staff did not refer to cream charts prior to applying cream and completed records retrospectively. People prescribed medicines to be given ‘when required’ had insufficient information recorded which meant they were at risk of not receiving their medication safely and consistently. We found there was still insufficient information recorded regarding people’s blood sugar levels to enable nurses to administer insulin safely.

This is a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found risk assessments had improved but required strengthening further as information contained in some of the care files we looked at was contradictory, which meant staff did not have consistent guidance to follow.

Recruitment practices required strengthening. Recruitment documentation was missing in some of the staff files that we looked at.

The home had suitable safeguarding procedures in place and staff demonstrated they knew how to safeguard people and follow the alert process.

At our last inspection, there were not sufficient numbers of staff effectively deployed to meet people’s needs. At this inspection, we observed staff responding to people in a timely way and staff were proactive in encouraging people’s freedom of movement.

Staff received an induction and appropriate training applicable to their role. We found some staff required refresher training in mental capacity, deprivation of liberty and dementia but the home manager confirmed the training was scheduled for early 2017.

The service was not compliant with the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). Mental Capacity assessments had been completed but they were not decision specific, with multiple unrelated decisions being considered as one assessment. The system in place at the time of the inspection was ineffective and we found granted DoLS that had expired or not been resubmitted to the local authority in the required timeframe. The home manager addressed this during the inspection and all required applications were made. The home manager also devised a new monitoring system to prevent future re-occurrence.

This is a continuing breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff completed nutritional risk assessments but care plans did not contain sufficient details to guide staff in managing the risks.

We found people’s food preferences were catered for and people were provided sufficient quantities of quality food to eat. We observed the meal time experience which was relaxed and staff took the time to sit and chat with people.

The environment had significantly improved to meet the needs of people living there. We saw there was a continued works plan in place which detailed when further improvements to the home were to be carried out.

People living at the home and their relatives described the staff as kind and willing to help them when needed. We found the staff were friendly and engaging which made for a relaxed and warm atmosphere. Staff were visible throughout the inspection and when spoken with, staff expressed being proud of the care they were now providing.

People were treated with dignity, respect and were given privacy at the times they needed it. We observed staff knocking on people’s doors before entering and providing explanation to people prior to undertaking care tasks.

People’s independence was promoted and people were encouraged by staff to do as much for themselves as possible.

Dean Wood Manor was engaged in a 12 week end of life education programme with the local hospice. The programme provided support, training and visits to review processes and support assessment.

We saw care files had improved since our last inspection but not all documentation was fully completed and some records provided conflicting information. This meant staff did not have consistent guidance to help meet people’s needs.

During our inspection, we checked to see how people were supported with interests and social activities. The home had employed a new activities co-ordinator, however they were not scheduled to commence their role until the 12 December 2016. This meant staff were attempting to provide stimulation and activities whilst also being responsible for care tasks. During the inspection, we did not see people engaged in meaningful activities and although there was some Christmas activities scheduled in December this was not sufficient to meet people’s needs.

This is a continuing breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw the complaints procedure was displayed around the home and saw the one complaint received had been responded to in the required time frame.

We found historical records, for example food and fluid charts were not organised or filed systematically which resulted in us being unable to find the information we required efficiently. This meant the information would not be readily available for staff if they were required to find the information quickly.

In addition to the new home manager, a regional manager from the Dovehaven Care Group had been working at Dean Wood Manor to provide oversight and consistency of the service improvement plan, which the local authority had implemented following our last inspection. We found the clinical oversight provided required strengthening. The processes in place to monitor the performance of the home were not effective in securing service improvements across all the areas of concern identified at our previous inspections.

This is a breach of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.

The new home manager and clinical lead had only commenced in post September 2016 but we found the progress made in the home since this time could be attributed to their leadership. We found them to be open, honest and transparent during the inspection.

People, their relatives and staff corroborated our findings and all spoke positively regarding the current management and progress made since they started at the home. The home manager and clinical lead presented as motivated and committed to making a positive difference to the lives of people living at the home. We feel confident that the home manager and clinical lead will address the required improvements in a planned and structured way.

At our last inspection on 03, 05 and 12 November 2015, we found multiple breaches of regulations. The home received a rating of ‘Inadequate’ and was placed into special measures.

During this inspection visit, we found sufficient progress had not been made and there were continued systemic failures across the home. We found continued multiple breaches of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to: Person-centred care; Dignity & respect; Need for consent; Good governance; and, Staffing. We are currently considering our enforcement options in relation to these regulatory breaches.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people. At the time of this inspection, there were 32 people living at the home . The premises are based around an original Grade II listed building that has been extended and recently modernised. There are extensive gardens surrounding the home and on-site car parking is available. The home is owned and operated by a partnership trading as Dovehaven Care Group. Throughout this report, the Dovehaven partnership is referred to as the ‘Provider’.

We looked at how people’s medicines were managed and found the service had continued to fail in ensuring that medicines were manged safely and administered appropriately; and had failed to ensure that staff responsible for the management of medicines were competent, skilled and experienced to do so safely.

We looked at people’s care records to ascertain that care, treatment and support which people needed was being delivered safely and that risks to people's health and wellbeing were being appropriately managed. We found people’s care records contained a variety of risk assessments and associated documentation. For example, skin integrity, allergy status, nutritional risks, continence, falls and waterlow. However, we found that risk assessments had not been consistently updated in response to people’s changing needs and, in some cases, risk assessments were incorrectly scored which meant that effective measures were not taken to minimise risk.

We looked at staffing levels to ensure there was sufficient numbers of staff to meet people's needs. At the time of our inspection visit 32 people were living at the home. The home was not at full occupancy because the Provider had agreed to a voluntary embargo on admissions following our last inspection. At this inspection, we saw that a dependency tool had been implemented and was used to determine the number of staff required to meet people’s needs. However, despite the use of a dependency tool, we found that throughout our inspection visits, their continued to be insufficient numbers of staff deployed to keep people safe and to meet their needs.

We looked at the recruitment policy and associated procedures and found safe recruitment practices were in place. Disclosure and Barring Service (DBS) checks had also been completed to ensure the applicant's suitability to work with vulnerable people. Records were maintained which demonstrated nursing registrations were valid and up-to-date.

We looked to see how the service sought to protect people from abuse and found there were appropriate safeguarding and whistleblowing policies and procedures in place. Staff were able to describe the homes alert process and the local authority procedures. All the staff spoken with demonstrated they had a working knowledge of the types of abuse and the procedure to follow if they suspected that a person was at risk of, or was being abused.

We asked staff about whistleblowing. All of the staff we spoke with told us they would not hesitate to use the policy and identified internal reporting protocols.

Since our last inspection of Dean Wood Manor, the Provider had given reassurance that all staff would be enrolled in a new training & development programme that was being managed through a new ‘Dovehaven Training Academy’. However, during this inspection, we found insufficient progress had been made to ensure that staff were fully supported and qualified to undertake their roles.

Training records we looked at demonstrated that progress had been made in relation to mandatory training and that the vast majority of staff had completed, or were scheduled to complete, all of the required training. However, in respect of key additional training, we found low numbers of staff had completed recent training in respect of the mental capacity act, deprivation of liberty, dignity & respect, dementia, record keeping, equality & diversity and nutrition & hydration. This was of particular concern given the specialist nature of the service provided at Dean Wood Manor.

We looked at supervision records and found progress had been made in the frequency staff received supervision. However, we saw the vast majority of supervision sessions were being used as a punitive measure to address issues when staff had made an error.

During this inspection, we found serious systemic problems in respect of the Providers failure to adhere to the principles of the Mental Capacity Act 2005 and the application of legislation which governs the use of Deprivation of Liberty Safeguards within a care setting. We also saw restrictive practice was commonly used which constituted a deprivation of people’s Human Rights. For example, towards the end of our first day of inspection, just before the day shift handed over to the night shift, we found 18 people who used the service had been moved into the West Lounge and we observed people were prevented from leaving the lounge whilst the staff changeover took place. We noted the impact that this had on people as there were several people displaying high levels of agitation during this time. All the staff we spoke with confirmed that moving people into the West lounge was custom and practice at the home and that people were moved to the lounge whether they were agreeable or not. We ascertained from the staff that this was done at this time due to handover because there was insufficient staff at that time to supervise people in other areas of the home.

We looked at how people who used the service were supported to eat and drink and the meal time experience. Since our last inspection, we saw improvements had been made to ensure people with additional needs were appropriately supported to eat and drink. However, the overall meal service remained chaotic and staff lacked supervision and direction to ensure other people who used the service received their food and drink in a timely manner.

We looked at Dean Wood Manor’s approach to end of life care and found that since our last inspection improvements had been made. The home was now taking part in a pilot scheme working with Wigan Hospice to support people nearing the end of life, their families and staff.

The vast majority of people who used the service at Dean Wood Manor were not able to actively participate in planning and agreeing their own care and support. This meant that care planning documentation was completed solely by staff from the home. However, we found that care plans did not always demonstrate that people’s lawful representatives had been consulted. We also found that information contained in people’s care plans was confusing, contradictory and did not adequately guide staff to the care and treatment needs of the people they were supporting.

Since our last inspection, we found that clinical and operational oversight provided by Dovehaven Care Group was inadequate. Overall governance was ineffective and there was a continued lack of co-ordinated leadership which directly impacted on the quality of care being provided. In particular, we found governance arrangements for clinical audit and questioning of practice was wholly inadequate.

The overall re-rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve;

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made;

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

During our last inspection of Dean Wood Manor, we placed the service into special measures. Services placed in special measures are inspected again within six months; therefore this inspection was a comprehensive re-ratings inspection. Where insufficient improvements have been made such that there remains a rating of ‘Inadequate’ for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.