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Duchess Gardens Care Centre Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 16 September 2021

About the service

Duchess Gardens Care Centre is a residential and nursing care home providing personal and nursing care to 54 people at the time of our inspection. The service can support up to 131 people. At the time of our inspection, some units in the home were not in use.

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

Some of the concerns we found at this inspection related to issues found at our previous inspection, meaning action needed to achieve the necessary improvements had not been made.

Care plans along with privacy and dignity were areas of concern identified in our inspection of September 2019 when we took enforcement action. These concerns remained at this inspection.

A range of audits were carried out and whilst these identified where improvements were needed, it was evident that follow up actions were not always completed. The units lacked leadership and daily charts we looked at showed gaps which shift leaders were supposed to check.

Checks to ensure people were adequately hydrated and had access to drinks on the day of our inspection had not been carried out. This was dealt with immediately. Some staff were unsure about aspects of fire safety.

Improvements were needed to the cleanliness in two areas we looked in. Instead of being taken to the sluice room, bagged waste had been left outside a person’s room after personal care. Other areas of the home were found to be clean.

We received mixed feedback from people, relatives and staff around staffing levels in the home. There were several staff vacancies in key positions in the home and the home had a strong reliance on agency nurses. Four new care staff were being recruited at the time of inspection. Recruitment of staff was mostly well managed, although one staff file showed a concern had not been followed up.

Most caring interactions we observed were kind, although we identified privacy and dignity issues which we raised with the management team. Regular staff were familiar with people’s care needs and preferences and people told us they liked them and felt well cared for.

People felt safe living at this service and their relatives agreed they were protected from harm. Medicines were safely managed.

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.

Regular team meetings were taking place to communicate key messages. The provider was investing in improvements to the premises and equipment. The provider has demonstrated they have been responsive to our findings since this inspection.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update: The last rating for this service was requires improvement (published 17 December 2019) when there were multiple breaches of regulation. 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 some improvements had been made and the provider was no longer in breach of regulation regarding privacy and dignity. However, the provider remains in breach of regulation for safe care and treatment and having adequate oversight. This service has been rated requires improvement for the last four consecutive inspections (including this inspection).

Why we inspected

The inspection was prompted in part due to concerns received about people not receiving safe care and treatment, premises and equipment, medicines management as well as the culture in the home. A decision was made for us to inspect and examine those risks.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, caring and well-led sections of this full report.

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


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 monitor the service.

We have identified breaches in relation to the management of risk and systems which assess, monitor and improve the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Inspection areas



Updated 16 September 2021

The service was not safe.

Details are in our safe findings below.



Updated 16 September 2021


Requires improvement

Updated 16 September 2021

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 16 September 2021



Updated 16 September 2021

The service was not well-led.

Details are in our well-Led findings below.