Archived: Durnsford Lodge Residential Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment, we rated this key question requires improvement. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was previously in breach of the legal regulation in relation to the need for consent and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. In addition, we found the provider was in breach of legal regulations in relation to person-centred care.

This service scored 38 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing, and communication needs with them.

One person told us they were not given a choice about where they lived and had not met anyone from the service before their arrival. We discussed what we had been told with the registered manager and nominated individual, who confirmed they had not met or assessed this person prior to their admission, and they did not know what information had been discussed by the hospital prior to signing the declaration formconsenting to the placement.

Another person was admitted to the service for 2 weeks’ respite. Care records indicated the person did not have the capacity to consent to this placement. However, we found there was no assessment of the person’s capacity or record detailing a best interest decision in relation to this placement.

The provider had systems and processes in place to help ensure people’s needs were fully assessed prior to offering support. The registered manager told us people's needs were assessed before they started using the service. Information from these assessments was used to develop care plans and risk assessments. However, we found information from these assessments were not always used to develop person-centred care plans, and some care plans contained minimal guidance for staff on how to care for people safely, according to their preferences and wishes, as detailed within the safe section of this report.

The provider’s failure to ensure staff undertook a pre-placement assessment and developed care and support plans which were reflective of people’s needs and preferences contributed to a breach of regulation in relation to person-centred care.

Most people were not able to tell us if they had taken part in an assessment of their needs before receiving support. We received mixed feedback from relatives about their involvement in the assessment process. Comments included, “Yes, there was a review. I sat in the office with them and went through everything.” “Yes, they do, and it’s annually”, and “No, I have not.” And “Not recently."

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

We identified a poor culture where there were low expectations and a lack of purposefulness to people's day. Some people spent long periods socially isolated within their respective bedrooms. Staff told us they did not have time to provide meaningful activities.

People were not involved in a meaningful way in the development of their care and support, and information was not provided in a way which met people’s individual communication needs.

Staff had not always been provided with appropriate training to ensure they were informed about and kept up to date with best practice guidance. Training did not always determine practice, and assessments of staff competencies could not be relied upon. [See the staffing section of this report.]

Systems were in place to help ensure care was delivered in line with best practice guidance. For example, nationally recognised risk assessments were used to assess risks, such as the Malnutrition Universal Screening Tool (MUST) and Water Low Risk Assessment. However, we found some care plans lacked sufficient guidance for staff to meet people’s needs safely. Fluid charts were not consistently completed, and there was a lack of effective oversight of these records. People were not protected from known risks which impacted their safety.

The failure to provide safe care and treatment that met people’s needs and reflected their preferences contributed to a breach of regulation in relation to person-centred care and safe care and treatment.

Most people we spoke with were happy with the support they received and complimentary about the ‘home-cooked food’. Comments included, “Very good,” “Oh yes, I have plenty to eat,” and “Really, really good.” However, 2 people said they felt sandwiches were repetitive and did not constitute an evening meal. One person said, “Food could be better as no flavour, would like HP sauce and salad dressing with my meal.”

We received positive feedback from relatives about people’s experiences. Comments included, “My brother will eat everything, there is always coffee, tea and drinks, yes, they look after him well.” “She eats what she likes. I have been there at mealtime, and the food looks lovely; they have a proper roast sometimes. They supply tea, coffee, biscuits and soft drinks made up in jugs.” “All the staff seem to communicate very well, we have a good laugh, and they seem quite caring.” “I know for a fact they do have activities; there is a singer who comes in, and I believe they have other activities – I have never asked, but I assume they have other activities. She did go out for a meal once.”

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The provider had systems and processes in place to effectively share information about people with the local hospital, their GP practice and primary care health services. For example, each person had in place a hospital passport which contained information about the person’s current health and care needs, medication, and communication needs, along with a treatment escalation plan [TEP]. This captures decisions about specific treatments, including intensive care, artificial ventilation, or life support, when a person cannot speak for themselves, ensuring decisions are made in line with their personal values and preferences.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or, where possible, reduce their future needs for care and support.

People received support to manage their health and physical care needs and were encouraged to engage with a range of healthcare services. Records showed staff supported people to attend appointments, and care records described the advice provided by healthcare professionals such as district nurses, GPs, OT [Occupational therapy] and the older persons’ mental health team. Information from these appointments were recorded in people’s care records. This helped ensure people’s healthcare needs were understood by staff. For example, one person required additional support with their mobility due to a number of recurring falls. Records showed staff were working closely with the occupational therapist and medical professionals.

However, whilst staff mostly understood people’s needs, and escalated concerns. Staff did not always follow the advice provided, and care plans did not always provide detailed information about people’s changing needs or contain guidance for staff on how to manage them. For example, following the fitting of a catheter, staff were instructed to take the person’s temperature for 7 days, to monitor for signs of infection. Records showed staff only monitored the person’s temperature for 3 days. There was no care plan or risk assessment to support staff in delivering effective catheter care. There was no information guiding staff on how to care for the catheter in terms of hygiene, infection prevention, what to look out for that might indicate a concern or when to seek advice. This contributed to a breach of regulation in relation to safe care and treatment.

People who were able to share their views with us said they were happy with the care and support they received. One person said, “Staff treat me well.” Another said, “I’m very happy here.” Relatives had confidence in the staff and told us their loved ones were supported to manage their care, support and health needs by staff who knew them well. Comments included, “Yes, I absolutely have confidence in what they do for dad,” “If he needs a doctor or hospital, they arrange it and it’s not a problem,” “She had a fall recently, they arranged for an X-ray and re-arranged her room to make her safer; they were very thoughtful,” and “He had a minor accident, and they took him to the hospital. They contacted me and kept me informed."

The provider had systems and processes in place to effectively monitor people’s health and well-being. However, we found these were not always effective.

The registered manager described how they monitored people’s health and care needs regularly. We found care plan reviews did not identify any of the concerns we found in relation to person-centred care, the management of risk, accidents and incidents and mental capacity as set out within the safe, effective and responsive sections of this report.

Staff had a good understanding of how people communicated and used this knowledge to support people to make choices about their everyday needs. However, staff did not always have a good understanding of people’s needs, as important information was missing from people’s care records. We found some care records lacked detail, and there was limited guidance for staff on how to identify and escalate concerns. For example, care records for 3 people identified they were at high risk of pressure injury and required an airwave pressure-relieving mattress to reduce the risk of them developing pressure ulcers. Pressure mattresses were not set at the correct pressure for people’s weights. There was no guidance in people’s care plans or risk assessments to instruct staff on what pressure the mattress should be set at, and there was no system in place to check that mattresses were set correctly. Whilst we did not find people had sustained skin damage. People were potentially placed at an increased risk of skin damage as mattresses may be too hard for their skin. This contributed to a breach of regulation in relation to safe care and treatment.

Support plans were not accessible to people, and there was limited information to show how people were involved in developing their care and support or how their views/wishes had been sought or used to inform their ongoing support.

Care records were not person-centred and did not provide an accurate view of people’s lived experience; as such, they could not be relied upon as a contemporaneous record of the care and treatment people received.

The provider’s failure to effectively monitor people’s health and well-being to ensure people's care was appropriate, met their needs and reflected their preferences contributed to the breach of regulation in relation to person-centred care and good governance.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

At the last assessment, we found the provider’s failure to accurately assess and record people's capacity and best interests’ decisions risked compromising people's rights. This was a breach of regulation in relation to the need for consent. At this assessment, we found improvement had not been made, and the provider remained in breach of this regulation.

People were not always supported to have maximum choice and control of their lives, and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA), including Deprivation of Liberty Safeguards. For example, the provider installed CCTV in July 2024 to monitor people’s safety. The registered manager and nominated individual confirmed people had not been consulted about the installation within their home or provided with any information to make an informed choice. They had not sought people’s consent, undertaken mental capacity assessments or followed a best interests decision-making process where people could not give consent. The failure to ensure staff accurately assessed and recorded people’s capacity and, where appropriate, best interest decisions, risked compromising people’s rights.

We reviewed a selection of mental capacity assessments and found some documentation was poorly completed and continued to show a lack of knowledge, understanding and application of the principles of the Mental Capacity Act 2005.

People were not supported to make decisions about their care, and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA), including Deprivation of Liberty Safeguards. This meant people who lacked capacity or who had fluctuating capacity did not always have decisions made in line with current legislation. For example, where staff restricted access to one person’s personal belongings. Staff did not recognise this as a restrictive practice, and the person’s capacity to consent to these arrangements had not been assessed, nor had staff followed a best interests process.

Where the service had submitted a DoLS application to the local authority for consideration. The person’s capacity to consent had not been assessed prior to the application being made, and the service was unable to provide evidence they had followed a best interests process.

The provider’s ongoing failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights. This was a continued breach of regulation in relation to the need for consent.