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Danes Lodge Requires improvement Also known as Danes Lea

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 August 2018

Danes Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide personal care and accommodation for up to 27 older people, including those with dementia related conditions. It is located in the seaside town of Bridlington, in East Yorkshire. At the time of our inspection there were 25 people living at the home.

This inspection took place on the 19, 20 and 25 June 2018. The 19 June was unannounced and we told the provider that we would be returning on the 20 June. The 25 June was unannounced and during the evening. This attendance was prompted by anonymous concerns that were received by the local safeguarding team. Some of these concerns were substantiated.

The service had previously been rated Requires Improvement in June 2017. There was a breach in regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the provider did not ensure adequate standards of cleanliness. During this inspection we have found that there were four breaches in regulations, regulations, 9, 12, 17 and 18.

The service is required to have a registered manager in post. A registered manager is a person who has registered with CQC 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. At the time of the inspection there was a manager in place and they were in the process of being registered with the CQC.

Processes in place for the administration of medicines at night were not sufficient and put people at risk. There was insufficient staff working at night on a regular basis and night staff were inappropriately trained to meet the needs of people.

Accidents and incidents were not always monitored and investigated effectively to ensure safe practices. Lessons learnt were not evidenced in all incidents. Not all incidents had been notified to CQC or the local safeguarding authority.

There was a lack of provider oversight which meant risks to people’s safety were not picked up by the provider.

Morning routines for some people were service led and not person centred.

Staff received training in safeguarding and had knowledge of whistleblowing procedures. Recruitment processes were in place and were found to be robust.

Infection control measures were in place to prevent the risk of infections spreading to people. Although the domestic staff and night staff felt that recent cuts in cleaning hours had impacted on the cleanliness of the service, we found that standards were maintained during the inspection.

Staff aimed to deliver a good standard of care that was caring. Staff demonstrated knowledge of people and this helped them to provide some person-centred care. Feedback from relatives and friends was very positive about the caring nature of the staff.

Care plans demonstrated that the principles of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) had been applied. Gaps in the reviews meant some care plans did not contain up to date information. Risk assessments were in place to reduce the risk to people. Peoples wider needs were met by the provision of activities and people’s care plans recorded their end of life preferences.

People’s nutrition and hydration needs were catered for however, the provider needed to make changes to the meal time experience to ensure that this followed best practice.

The manager had used a variety of methods to assess and monitor the quality of care. However, the governance systems had not picked up all the shortfalls identified during the inspection. Where shortfalls had been identified, action to address these were not clearly identified, recorded and monitored.

We made a recommendation about staff inductions, supervisions and appraisals.

We made a recommendation about provision of activities to meet people’s wider needs.

You can see what action we told the provider to take at the back of the full version of the report

Inspection areas

Safe

Requires improvement

Updated 15 August 2018

The service was not always safe.

Medication management did not follow best practice and put people at risk.

Some incidents placed people in the service at risk of abuse from staff.

Not all incidents had been investigated to provide lessons learnt.

Risk assessments were in place.

Effective

Requires improvement

Updated 15 August 2018

The service was not always effective.

Not all staff had been provided with regular supervision or a thorough induction and training to support them to understand their role.

People’s mealtime experience required improvement to follow best practice.

Staff sought consent from people before providing support.

Caring

Requires improvement

Updated 15 August 2018

The service was not always caring.

Morning routines for some people were not person centred.

Staff demonstrated knowledge and understanding of people’s needs.

Families provided positive feedback about the caring nature of the staff.

Responsive

Requires improvement

Updated 15 August 2018

The service was not always responsive.

People had care plans in place that described their individual support needs but these were not reviewed in line with the provider’s policy. This meant some information was no longer accurate.

The service had an activities worker who provided activities to meet people’s wider needs.

There was a complaints’ policy and procedure in place.

Well-led

Inadequate

Updated 15 August 2018

The service was not well-led.

There was a lack of provider oversight at the service.

Some staff felt they were not listen to, valued or respected.

Governance systems for assessing and monitoring the quality of the service were in place. However, they were not robust enough to identify all concerns.

There was a manager in post who had commenced the registration process with CQC.