Archived: Duchess Gardens Care Centre

Duchess Gardens Care Centre is a residential and nursing care home providing personal and nursing care to 45 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 taken.

The provider was unable to demonstrate robust governance arrangements and learning had not taken place. Systems and processes designed to identify shortfalls and drive improvement were not effective and had not identified the concerns we found.

Care plans and good governance were areas of concern identified in our inspection of July 2021 when we took enforcement action. These concerns remained at this inspection.

The provider had not assessed and mitigated risks to people, and people did not have accurate and complete care records. This included hazards in the home's living environment as well as risks associated with people's health, safety and wellbeing. Procedures failed to safeguard people from the risk of abuse.

People did not always receive their medicines in a safe way. The systems in place and management oversight had failed to identify shortfalls.

Staff were non-compliant in following government guidance on wearing personal protective equipment correctly.

Privacy and dignity were not always promoted. Staff were not always observed to be being respectful and caring and at times we observed a lack of interaction between staff and people.

Safe recruitment practises were not followed as the required background checks had not been undertaken before staff started work at the home.

Most people and relatives told us they felt safe, and most of the feedback from people was positive for the service.

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 inadequate (published 16 September 2021), when there were 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 the provider remained in breach of regulations. This service has been rated requires improvement for three consecutive inspections and inadequate for the last consecutive three inspections, including this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Duchess Gardens Care Centre on our website at www.cqc.org.uk.

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.

Enforcement and Recommendations

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 and will take further action if needed.

We have identified breaches of relation to, safe care and treatment, safeguarding, medicines, ensuring the premises are safe, infection prevention and control, staffing, dignity and respect and good governance.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 return sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains 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.

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 www.cqc.org.uk

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.

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 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.

Duchess Gardens is a nursing and residential care home providing personal care to 44 older people, people living with dementia and adults with physical disabilities at the time of the inspection. The service can accommodate up to 131 people in two adjoining buildings.

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

The service met the characteristics of requires improvement in all areas; more information is in the full report.

Where risks to individuals had been identified measures had not always been put in place to reduce or eliminate those risks. Staff understood how to keep people in their care safe from harm. Medicines were generally managed safely, however, medicine round were taking a long time and there was no assurance there were appropriate gaps between medicines being given. The home was clean and checks were in place to ensure the environment was safe. Staff had been recruited safely, however, we have made a recommendation about staff files being audited to make sure all the required documentation is in place. There were enough staff to provide people with care and support, however, the registered manager needed to look at the organisation and deployment of staff.

Staff were trained and were supported by the management team. People liked their rooms and they had access to safe outside patio areas. Staff generally made sure people’s nutrition, hydration and healthcare needs were met. People said the meals were good, however, the meal time experience for people was not always good.

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.

Staff were kind and caring and feedback from people using the service and relatives was positive. However, some practices showed a lack of respect for people. Staff were helpful and visitors were able to visit at any time.

People’s care needs were assessed before a place at the home was offered, to make sure staff would be able to meet their needs. There was very little or no information in people’s care plans about their cultural and religious needs. Some care plans lacked detail or did not accurately reflect people’s current needs.

Activities were on offer to keep people occupied and stimulated. Trips out were also organised on a group and individual basis. The registered manager had an ‘open door’ policy and people were encouraged to bring any concerns to their attention. Any concerns which had been raised had been dealt with and resolved.

The audits and governance systems which are in place are not effective in identifying areas which need improvement. The service has deteriorated since the last inspection and is now ‘requires improvement’ in four areas.

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 comprehensive inspection took place on 31 July 2018 and the rating for this service was requires improvement (report published 4 September 2018) and there was one breach of regulation identified. A focussed inspection took place on 13 December 2018 and the rating for this service remained requires improvement (report published 19 February 2019). The provider completed an action plan after each inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, however, the provider remained in breach of one regulation and we found two additional breaches of regulation. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement: We found three breaches of regulations in relation to safe care and treatment, dignity and respect and good governance. Please see the ‘Action we told 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 service provides personal care and nursing care to people living with dementia, older people, younger adults, people with physical disabilities, people with sensory impairments and people living with mental health issues. At the time of our inspection there were 44 people using the service.

At the last inspection in July 2018, the service demonstrated to us that improvements had been made and was no longer rated as inadequate overall or in any of the five key questions. Therefore, this service is now out of special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. However, while we concluded improvements had been made these needed to be sustained and further developed to make sure people consistently receive safe and effective care and treatment. This is reflected in the overall rating for the service which was ‘requires improvement.' Since then we have had some concerns raised with us about safe staffing levels.

At the last comprehensive inspection in July 2018 we found the service was in continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014(Regulation 19 (3) (a) and (b)). This was in relation to staff recruitment procedures which were not being operated effectively and required documentation was not available. The provider sent us an action plan of the action they had taken.

We undertook an unannounced focused inspection of Duchess Gardens on 13th December 2018. This inspection was conducted following information which we received that was of concern which included concerns about the staffing level at the service. The primary aim of the inspection was to check the safety of the service and any risk of harm to people. The team inspected the service against two of the five questions we ask about services; 'Is the service Safe?' and 'Is the service Well Led?'

There was a manager in post who had applied for registration with the CQC. 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.

We found there were not enough staff on duty to provide people with timely or person-centred care. We found the manager did not always deploy staff effectively.

We found at breakfast time there were not enough staff to provide people with the support they needed to eat and drink. People fell asleep at the table and were not moved to sit more comfortably in a lounge area.

Staff told us the staffing levels were low. They said people were becoming frailer and they thought more staff was needed. Relatives and people also told us staff levels were low and required improvement.

Whilst systems were in place to monitor training needs, these were not effective.

Redecoration and refurbishment at the home was on-going and we saw areas had improved since our last visit. The home was clean, tidy and comfortable.

Following the inspection, the manager sent us information showing/stating the service has increased its staffing level.

We found two breachs of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Duchess Gardens 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. The care home is registered to provide 131 places. However, the manager told us there are no longer any double bedrooms so the number has been reduced to 85 places. The accommodation is provided in an adapted building and is arranged over four floors.

The service provides personal care and nursing care to people living with dementia, older people, younger adults, people with physical disabilities, people with sensory impairments and people living with mental health issues. At the time of our inspection there were 48 people using the service and one person in hospital. The number of people using the service was reduced as no admissions had been taken since the last inspection.

There was a manager in post who had applied for registration with the Care Quality Commission (CQC). 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.

Our last inspection took place on 31 October, 2 and 20 November 2017 and at that time we found the service was not meeting nine of the regulations we looked at. These related to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, fit and proper persons employed, staffing and good governance. The service was rated ‘Inadequate’ and was placed in special measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. This inspection was therefore carried out to see if any improvements had been made since the last inspection and if the service should be taken out of ‘Special Measures.’

During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the five key questions. Therefore, this service is now out of Special Measures. However, while we concluded improvements had been made these need to be sustained and further developed to make sure people consistently receive safe and effective care and treatment. This is reflected in the overall rating for the service which is now ‘Requires Improvement.'

We found vast improvements had been made to the care and support people who used the service were receiving. They were being cared for by staff who knew them well and understood how they wanted their care and support to be delivered. People were treated with kindness, compassion, dignity and respect. There was a relaxed and friendly atmosphere in the home, with good positive interactions between people who used the service and staff. There were enough staff to care for people and to keep them safe.

Care plans were comprehensive, person centred and up to date. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified. People felt safe at the home and appropriate referrals were being made to the safeguarding team when this had been necessary.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare needs were being met and medicines were being stored and managed safely.

Staff knew about people’s dietary needs and preferences. People told us there was a good choice of meals and said the food was very good. There were plenty of drinks and snacks available for people during the day and night.

A good range of stimulating activities were on offer as well as trips out.

We found improvements still needed to be made in relation to staff recruitment. Staff training needed to be brought up to date and we made a recommendation about this. Staff morale was good and staff felt supported by the management team. Staff also received formal supervision where they could discuss their ongoing development needs.

Redecoration and refurbishment at the home was still on-going and we saw many areas had improved since our last visit. The home was clean, tidy and comfortable.

People knew how to complain if this was necessary. The complaints procedure was displayed and records showed complaints received had been dealt with appropriately.

Everyone spoke highly of the manager and said they were approachable and supportive. They were praised for the positive changes they had made in the service making it a nicer place to live and work.

The provider had some effective systems in place to monitor the quality of care provided. However, these needed to be developed further and sustained over time. We made a recommendation about this.

We found one continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This was the first inspection of the service since it was taken over by Qualia Care Limited in February 2017. Prior to this the service had been in administration and the last inspection had been completed in September 2015. At that time we identified three breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and assessed the service as being requires improvement in all domains and requires improvement overall. This meant the provider knew improvements needed to be made.

There was no registered manager in post. A manager had been recruited but had not made an application to CQC to be registered. A registered manager is a person who has registered with the Care Quality Commission (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. Since the registered manager left the service in March 2017and one of the nursing staff had been acting manager until a permanent manager was appointed in September 2017.

Staff were not always being recruited safely and there were not enough of them to keep people safe and deliver person centred care. Whilst some staff were seen to deliver caring, kind and compassionate care, others were not treating people with dignity and respect. A lot of staff training was out of date and some staff supervisions were overdue.

Although staff could tell us about safeguarding procedures, we found incidents were not always being reported to the safeguarding team. Important information was missing from the emergency fire files about people’s evacuation needs should an emergency arise.

People’s care plans were not person centred and did not always provide accurate and up to date information about their current needs. Information was difficult to find or contradictory. Risk assessments were being completed; however, these were not always being followed or had been completed incorrectly. This meant we were not confident action was being taken to mitigate risks to people using the service.

Medicines were being managed safely. However, advice about people’s healthcare needs was not always being sought in a timely way.

People who used the service made some positive comments about the meals; however, we found people’s nutritional and hydration needs were not always being met. We also found people’s mealtime experience was variable depending which unit they lived on.

There were some activities on offer and trips out were being arranged

We found the service was not working within the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. People were not supported to have maximum choice and control of their lives and staff did not support people in the least restrictive way possible; the policies and systems in the service did not support this practice.

Generally the home was clean and tidy; however, there were areas where unpleasant odours were present. A redecoration and refurbishment plan was in place.

There was a complaints procedure in place and formal complaints had been investigated.

There was a lack of leadership and direction for staff, with no oversight of clinical risks or key issues for people's care. Systems and processes for monitoring the quality of the care provision were weak and there was no robust management of the service. At the time of the inspection there was a new management team in place. They had produced an action plan for improving all aspects of the service. However, it was too soon for us to assess the impact of this upon people's care.

We found nine breaches of the Health and Social Care Act (2008) Regulated Activities 2014 Regulations. You can see what action we asked the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still 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 this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.