Deneside Court

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

Medicines were managed safely but some improvements were needed. We have made a recommendation about the management of some medicines. We were assured overall about infection prevention and control practices at the service.

Some areas of the home required further maintenance, repair and cleaning to maintain a good environment. We carefully reviewed the extent, impact and circumstances of these observations and received suitable assurances. The provider had action plans in place to manage the premises and dealt quickly with any immediate issues.

Assessments of people’s needs were completed, and systems and processes were in place to mitigate identified risks to people and staff. Incidents were dealt with appropriately. There were enough suitably skilled staff to meet people’s needs.

People were protected from the risks of abuse. Staff had received safeguarding training and processes were in place to support staff to raise any concerns.

The service worked well with other health professionals who were routinely involved with people’s care.

The service required a manager who was registered with the CQC. The service had a manager in post. The manager’s application process had been commenced but not progressed to the submission of an application as required due to events outside of the provider's control. We took this into account when making our judgement.

Managers understood their regulatory requirements and used audits and other checks to continually assess, monitor and improve the quality of the service. They involved people, relatives and staff in this process, using their feedback and complaints to make positive changes to the service.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture.

Right support:

¿ The model of care and setting maximised people's choice, control and independence. People, and where appropriate their relatives and advocates were involved in their care planning. Records were regularly evaluated and updated as people’s needs changed. Care planning included outcomes and goals for people. Case studies evidenced how peoples support from the service had led to positive outcomes with a focus on achieving maximum possible independence.

Right care:

¿ Care was person-centred and promoted people's dignity, privacy and human rights. Staff treated people with kindness, compassion and respect. Staff supported people in the least restrictive ways and in their best interests.

Right culture:

¿ Ethos, values, attitudes and behaviours of leaders and care staff ensured people using services led confident, inclusive and empowered lives. The service was well managed with an approachable and supportive leadership team in place. Management were open and transparent, and the provider was honest with people and their relatives when things went wrong. Staff told us they had a strong supportive team that had helped develop and strengthen the person-centred culture and ensured people were supported to make decisions for themselves to live their best lives.

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 good (published 10 April 2020).

Why we inspected

The inspection was prompted in part due to concerns received about staffing, and the ability of the provider to manage known risks of harm to people to keep everyone safe. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe, Responsive, and Well-led only. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe sections of this full report.

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 remained good. This is based on the findings at this inspection.

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.

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

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.

Deneside Court is a residential care home that was providing personal and nursing care to 33 people aged 18 and over at the time of the inspection. The service can support up to 40 people. The service provides care for people with complex needs including people with a learning disability. Care is provided over three floors in a single building.

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

Improvements had been made since the last inspection regarding the safe handling of medicines. The provider had sought external professional advice to drive improvements regarding this element of people’s care. However, although improvements had been made, we did identify some areas regarding medicines which still required further improvement. We have made recommendations about the management of some medicines.

The service did not have a manager who was registered with the Care Quality Commission in post at the time of inspection

Staffing levels were suitable to care for people safely. Safe recruitment practices were in place. Individual and environmental risk assessments were completed and reviewed as necessary. The home was clean and well maintained and staff had access to adequate amounts of gloves and aprons. Accidents and incidents were reviewed and analysed to identify any themes or trends. Safeguarding policies were in place and staff were confident in their ability to identify and act upon any potential safeguarding issues.

People’s needs were assessed prior to admission to the service. A regional manager told us the process of assessing people’s needs had recently been reviewed which had led to a more robust assessment process. People had access to and were supported to have input from various external and internal healthcare professionals. The service had recently appointed a new head chef who was in the process of revamping all current menus. People told us they enjoyed their food and had a choice of meals on offer. The service had recently undergone some refurbishment which had led to a more welcoming and homely environment. Staff had received the necessary training to care for people safely and told us they felt supported in their role.

People were supported to have maximum choice and control of their lives and staff assisted them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People’s ability to consent to their care and treatment was assessed. Where people lacked capacity to make a specific decision for themselves best interest’s assessments had been completed.

People and their relatives told us staff were very caring in their role. People felt valued and staff were aware of the importance of promoting people’s independence and maintaining people’s dignity.

People’s care plans were reviewed on a regular basis to ensure they were up-to-date. People had access to activities both internal and external to the services. People were supported by staff to maintain relationship and friendships which were important to them. A complaints policy was in place. No one we spoke with had raised any complaints.

The provider had a range of quality assurance processes in place which were used to drive improvements within the service. The service worked in partnership with various external organisations. People, staff and relatives told us they felt involved with the service. One staff member told us, “Staff morale is good, I feel listened to and I feel valued in my role.”

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 23 November 2019) and there were multiple breaches of regulations. This service has been in Special Measures since 23 November 2019. During this inspection the provider demonstrated that substantial improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions and the provider has achieved compliance with all regulations since the last inspection. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was a planned inspection based on the previous rating to check the actions the provider had taken following our last inspection.

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.

Deneside Court is a residential care home providing personal and nursing care to 40 people aged 18 plus at the time of the inspection. The service can support up to 40 people. The service provides care for people with complex needs including people with a learning disability. Care is provided over three floors.

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

People told us they received their medication. Some people told us there were times when errors had been made with their medication and staff had offered apologies for these errors.

At our last inspection the provider had failed to ensure people received their medication as per prescriber's instructions. At this inspection, we identified ongoing issues.

For more details, please see the report from this inspection which is on the CQC website at www.cqc.org.uk

We looked at the systems in place for the safe management of medicines. We found the arrangements for medicines management did not keep people safe. The majority of staff we spoke with who gave people their medication, told us they had received training regarding the safe handling of medicines and they felt confident to give people their medication.

For more details, please see the report from this inspection 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 23 November 2019, when there were multiple breaches of regulations. One of the breaches was Regulation 12 – safe care and treatment.

At this inspection enough improvement had not been made and the provider was still in breach of this regulation.

Why we inspected

We undertook this targeted inspection following concerns about risks raised with CQC in relation to the safe management of medicines. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC are currently trialling targeted inspections, to measure their effectiveness in following up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We have found evidence that the provider needs to make improvements. Please see the Safe section of this full report.

Follow up:

We will re-inspect the service in line with our current inspection planning methodology. We may return sooner if we become aware of increased risk to people who use the service.

Enforcement

We identified that there was an ongoing breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Deneside Court is a residential care home providing personal and nursing care to 40 people aged 18 plus at the time of the inspection. The service can support up to 40 people. The service provides care for people with complex needs including people with a learning disability. Care is provided over three floors.

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

People and relatives told us they were supported by staff who were very caring and who knew them very well. However, we found ongoing serious risks regarding medication. These issues had been identified at the last six inspections. In addition, further issues were identified regarding people's individual risk assessments in relation to their care needs.

Staff had not received the training they required to support people safely. This meant people were at risk of harm. Records reviewed of two safety incidents which had previously occurred in the home, confirmed the staff involved had not received the appropriate training. Staff had not received the required level of supervision in line with the timeframes shared with us by the registered manager.

The home was not clean. During inspection several areas of the home were found to be dirty including the kitchen, medication rooms and communal areas of the home. During inspection only one domestic was on duty from 09:00 to 15:15 and this person was expected to cover the whole building themselves. This was due to one member of the domestic team being on annual leave and the other member of staff being absent from the home for a period of six weeks. Monthly infection control checks had not identified issues highlighted during inspection.

Issues were identified with staff recruitment. The provider had failed to follow their own recruitment policy. Personal and environmental risk assessments were in place. However, some personal risk assessments lacked detail.

The provider had failed to carry out effective checks of the service. Those checks that had been carried out had failed to identify issues we found during inspection. The provider shared with us their plans to recruit an additional member of staff who would help them to make improvements in this area of work.

Some staff told us staff morale was low. The provider told us they had plans in place to recruit a member of staff whose job would be to improve and increase staff engagement and feedback.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

People had access to both external and on-site healthcare professionals. The majority of feedback from visiting professionals was complimentary regarding the impact of care people received and how staff supported people to achieve their personal goals. However, we also received mixed feedback from one professional.

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 requires improvement (published March 2019)

Previous breaches

At the last inspection the provider was in breach of Regulation 12 – safe care and treatment.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about unsafe medicines management, staffing levels, quality of food, overall cleanliness of the service, confidentiality issues, supervision of staff and one service user who was not receiving their dedicated time regarding one to one activities. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the key question section of this full report.

Enforcement

We have identified breaches in relation to people’s medication, staff training and supervision, cleanliness of the service, staff recruitment and the checks the provider carried out to make sure people are safe and the service is well run.

You can see what action we have asked 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.

The provider had failed to notify CQC of certain incidents and accidents which had happened in the home. It is a legal requirement of the provider’s registration that they should notify CQC of such incidents. We are dealing with this issue outside of the inspection process.

Special Measures:

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 six 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 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.

Follow up:

We will re-inspect the service in line with our current inspection planning methodology. We may return sooner if we become aware of increased risk to people who use the service.

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, is the service safe, responsive and well-led, to at least good. During this inspection we found further concerns with the management of medicines and determined the provider was continuing to breach this regulation.

Deneside Court 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.

Deneside Court accommodates 41 people in one adapted building. There were 36 people living at the home when we inspected. They had a range of needs such as nursing, a learning disability and older people living with dementia.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

A new manager had been recruited shortly before our inspection. They were intending to register to become the registered manager. Since we visited the home, this application had been submitted for consideration. 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.

People, relatives and staff told us the home was safe.

Staff showed a good understanding of the safeguarding and whistle blowing procedures operated at the home. They knew how to raise concerns and felt confident to do so if needed. The safeguarding log evidenced previous safeguarding concerns had been thoroughly investigated. However, we noted a statutory notification had not been submitted to the CQC for all safeguarding concerns as required.

Relatives and staff confirmed staffing levels had improved recently and the number of agency staff reduced. Staffing levels during our inspection were appropriate and the response to emergency calls was immediate. Staffing levels were monitored to check they were appropriate to meet people’s needs.

The provider continued to have effective recruitment checks to ensure new staff were suitable to work at the home.

Incidents and accidents were logged and analysed monthly.

Where risks to people’s safety had been identified, risk assessments had been carried out which identified measures to reduce the impact on people.

We identified issues with management about kitchen hygiene. For example, some food items were not stored safely and there was a poor state of overall cleanliness. Other areas of the home were clean.

Staff received good support and the training they needed for their caring role.

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 were supported to meet their nutritional and healthcare needs. People gave positive feedback about the meals provided. Where people has specific needs, these were met appropriately. Care records showed people had access to health professionals in line with their individual needs, such as GPs and community nurses. People also had access to support from an on-site therapy team including physiotherapists and occupational therapists.

People’s needs had been fully assessed, including a consideration of any religious, cultural or lifestyle needs. This was used as a baseline for developing detailed and personalised care plans. Care plans were reviewed regularly to keep them up to date with people’s changing needs.

People had opportunities to participate in a range of internal and external activities. People and relatives confirmed they could access these if they chose to but staff also respected people’s right to refuse.

People had opportunities to discuss their end of life wishes. These were documented in specific end of life care plans.

Complaints had been logged and fully investigated in line with the provider’s complaint policy. People and relatives knew how to raise concerns and said they felt able to do so if needed.

People, relatives and staff gave us positive feedback about the new manager. They described her as supportive and approachable.

Audits were completed and these were in the process of being restructured. The manager had created an improvement plan to develop the service further.

People, relatives and staff could provide feedback through attending meetings or taking part in consultation. There were good links with the local community and the new manager had plans to develop these further.

Deneside Court 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 service accommodated 40 people in a three storey building situated in its own grounds with an enclosed garden area.

We inspected Deneside Court in August 2016 and found the provider was not meeting six of the Regulations of the Health and Social Care Act 2008 (Regulated Activities).

We inspected the service again in January 2017 and found some improvements had been made, however the provider continued to breach four of the Regulations of the Health and Social Care Act 2008 (Regulated Activities).

We inspected the service again in April 2017 and found improvements continued to be made at the service. However, the provider continued to breach two of the Regulations of the Health and Social Care Act 2008 (Regulated Activities). At that inspection we found medicines were not being managed safely. People were not receiving their medicines as prescribed. Medicine administration records were not always accurately signed. Stock balances were not always correct. Care plans relating to medicine were not always up to date.

The provider had failed to implement and embed improvements to enable sustained and significant improvements in medicine management. As a result conditions were imposed on the registration of the provider, at this location, to help drive improvements in the safe management of medicines. We checked to see if the provider was meeting the conditions as part of this inspection.

At this inspection we found the provider continued to breach Regulation 12 and 17 of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines continued to not be managed safely. Medicine administration records (MARs) were not always completed correctly. Handwritten entries of prescribed medicines found on MARs were not accurate and had not been signed by two members of staff. People were not receiving their medicines at the correct time. Care plans relating to medicine were not always up to date.

The provider’s quality assurance process in relation to medicine audits had failed to address the shortfalls regarding medicine management. This failure to appropriately audit this aspect of the service resulted in the provider not identifying the shortfalls that we identified during our inspection.

This meant the provider had failed to meet some of the conditions imposed on their registration. We will deal with this outside the inspection process.

The provider gave assurances that the areas of concern found at this inspection would be discussed with the manager and clinical lead to address the shortfalls.

The registered manager had recently left the service. 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 service was being managed by a new manager. At the time of the inspection the manager had commenced their application to become the registered manager of Deneside Court.

We found staff were aware of safeguarding processes and knew how to raise concerns if they felt people were at risk of abuse or poor practice. Where lessons could be learnt from safeguarding concerns these were used to improve the service. Accidents and incidents were recorded and monitored as part of the provider’s audit process.

People received a holistic assessment prior to and on admission to the home. Information was used to work with people to develop care plans to support outcomes. Care plans were personalised to include people’s likes, dislikes and preferences.

Risks to people and the environment were assessed and plans put in place to mitigate them. The provider had a business continuity plan in place for staff guidance in case of an emergency. People had Personal Emergency Evacuation Plans (PEEPS) in place which were updated regularly providing support and guidance for staff in case of an emergency.

The provider ensured appropriate health and safety checks were completed. We found up to date certificates were in place which reflected that fire inspections, gas safety checks and portable appliance tests (PAT) had taken place.

Staff training was up to date. Staff received regular supervision and an annual appraisal. Opportunities were available for staff to discuss performance and development. Some competency checks were out of date. The provider had plans in place to address this.

We found recruitment processes were in place with all necessary checks completed before staff commenced employment. Staff received an induction on commencement of their employment, which included shadowing experienced staff. The provider used a dependency tool to ascertain staffing levels. Appropriate levels of care staff were deployed to work on specific units. We found one nurse was responsible for the whole home.

We made a recommendation for the provider to review staffing levels in respect of nurses.

People’s nutritional needs were assessed and we observed people enjoying a varied diet, with choices offered and alternatives available. Staff supported people with eating and drinking in a safe, dignified and respectful manner. People were supported to maintain good health and had access to healthcare professionals when necessary and were supported with health and well-being appointments.

People enjoyed a range of activities both inside and outside the home. The service had positive links with the community with people accessing the theatre, local centres and shops.

The provider had a complaints process in place which was accessible to people in a pictorial format.

Staff were extremely positive about the manager. They confirmed they felt supported and were able to raise concerns. We observed the manager was visible in the service and found people interacted with them in an open manner. People and relatives felt the management approach in the home was positive.

The premises were well suited to people’s needs, with ample dining and lounge space. The home was welcoming with a pleasant atmosphere. Bathrooms were designed to incorporate needs of the people living at the home. The corridors and reception area were spacious for people using mobility equipment.

This is the second consecutive time the service has been rated Requires Improvement.

Deneside Court is a 40 bed purpose built home and provides residential and nursing care to adults with learning disabilities and physical and neurological disabilities. At the time of the inspection there were 21 people using the service. The home is divided into three units. The ground floor unit comprises of 20 individual apartments with en-suite facilities. While the two upper units comprised of 20 self-contained flats containing kitchen facilities.

We had previously carried out a comprehensive inspection of Deneside Court on January 17 and 2 February 2017. At the inspection we found there were breaches of four of the Legal Requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines were not being managed safely. People were not receiving their medicines as prescribed. Medicine administration records were not always accurately signed. Stock balances were not always correct.

People’s emergency evacuation plans (PEEPS) were not up to date. Actions from recent fire audits seen at the last inspection had not been completed.

We found the registered provider was not always acting in accordance with the Mental Capacity Act in relation to people’s Lasting Power of Attorney (LPA).

Staff had not received regular supervision and appraisal. The registered provider had not checked the competencies of all new agency staff who formed part of the regular staffing team.

The provider had failed to implement and embed improvements to enable sustained and significant improvements.

At this inspection we found the provider continued to breach of Regulation 12 and 17 of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines continued to not be managed safely. Medicine administration records (MARs) were not always completed correctly. Medicine stock balances were not accurately recorded. Handwritten entries of prescribed medicines found on MARs were not accurate and had not been signed by two members of staff. Medicine care plans were not updated when changes in medicines were prescribed. The provider’s quality assurance process had failed to address the shortfalls regarding medicine management. This meant we could not be assured that people received their medicines as prescribed by their doctor.

We have judged that this has a moderate impact on people who use the service. This is being followed up and we will report on any action when it is complete.

The service did not have a registered manager. 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 service was being managed by a peripatetic manager. At the time of the inspection the manager had submitted an application to become the registered manager of Deneside Court.

Recruitment procedures were thorough and all necessary checks were made before new staff commenced employment. For example, two references and disclosure and barring service checks (DBS). These were carried out before potential staff were employed to confirm whether applicants had a criminal record and were barred from working with vulnerable people.

Environmental risks were assessed and reviewed to ensure safe working practices for staff, for example, to prevent slips, trips and falls. Where people had been assessed at being at risk, plans were in place for staff for support and guidance to mitigate risks.

Policies and procedures were in place for safeguarding and whistleblowing which were accessible to staff for support and guidance. We found staff had received training in safeguarding. We found staff were aware of safeguarding processes and how to raise concerns if they felt people were at risk of abuse or poor practice.

Accidents and incidents were recorded and monitored as part of the manager’s audit process.

The provider used a dependency tool to ascertain staffing levels on each unit. We found staffing levels to be appropriate to meet the needs of the service, these were reviewed regularly to ensure safe levels.

Staff received training to meet the needs of the service. New IT systems had been installed to enable further staff development using eLearning. The provider had arranged for staff to complete distance learning courses to cover condition specific training.

Staff received regular supervision and appraisal. Opportunities were available for staff to discuss performance and development.

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. DoLS authorisations were in place for relevant people and care workers supported people to make as many of their own decisions as possible.

People were supported by kind and caring staff, in a respectful manner. Staff discussed interventions with people before providing support. Staff knew people's abilities and preferences, and were knowledgeable about how to support with people. Advocacy services were advertised in the foyer of the service accessible to people and visitors.

People were supported to maintain good health and had access to healthcare professionals when necessary and were supported with health and well-being appointments.

People had access to a varied healthy diet. Nutritional assessments were completed where necessary. Where required people had their food and fluid intake recorded.

People’s needs had been assessed and the information used to develop personalised care plans. Care plans were reviewed regularly.

The registered provider had an activity planner with a range of different recreational and leisure opportunities available for people. We observed people joining in a range of activities during the inspection. People enjoyed listening to music, watching TV, accessing art projects and were seen in conversation with staff.

People using the service and their relative’s views and opinions were sought and used in the monitoring of the service. Regular meetings were held with people and relatives. Staff meetings were held on a regular basis. The service held a daily management teleconference with other homes to discuss any concerns or to share important information.

Processes and systems were in place to manage complaints.

The registered provider ensured appropriate health and safety checks were completed. We found up to date certificates to reflect gas safety checks, and electrical wiring tests.

A business continuity plan was in place to ensure staff had information and guidance in case of an emergency. People had personal emergency evacuation plans in place that were available to staff.

Statutory notifications were submitted to CQC in a timely manner. People’s personal records were held in line with the Data Protection Act.

Deneside Court is a 40 bed purpose built home and provides residential and nursing care to adults with learning disabilities and physical and neurological disabilities. At the time of the inspection there were 28 people using the service. The home was divided into three units. The ground floor unit comprises of 20 individual apartments with en-suite facilities. While the two upper units comprise of 20 self-contained flats which each contained kitchen facilities.

We had previously carried out a comprehensive inspection of Deneside Court on 28 July followed by 29 July, 4 and 11 August 2016 following concerns raised by external health and social care professionals and the police. At the inspection we found there were breaches of six of the Fundamental Standards of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We identified multiple concerns in respect of the safe care and treatment of people using the service. The registered provider failed to provide safe management of medicines. Staffing levels were insufficient to meet the assessed needs of people using the service. The registered provider’s recruitment process did not cover the reviewing or checking of agency staff’s clinical competencies or training. People's health and nutritional needs were not being met in a safe manner. The registered provider did not ensure staff received appropriate training and development to enable them to carry out the duties they were employed to perform.

The registered provider was not following the principles of the Mental Capacity Act 2005, no records of best interest discussions were available. Staff were not aware of people who were subject to a Deprivation of Liberty safeguard. Care records did not reflect people's needs and preferences. The registered provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and failed to ensure that people received appropriate care and support.

We undertook this comprehensive inspection to check that the registered provider now met legal requirements. During this inspection we found the registered provider had implemented actions and some improvements had been made. However, we found the registered provider continued to breach four of the Fundamental Standards of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

An inspection of the registered provider’s management of medicines procedures was undertaken by two pharmacy inspectors. Medicines were not managed safely. People’s records were not clear to demonstrate that medicines were administered. The stock balance of medicines was not accurate. Care plans relating to medicine administration had not been reviewed. Where people were prescribed as and when medicines, protocols for their administrating were not up to date. Prescribed medicines were not being administered in line with the GP prescription. The ordering system used for ordering medicines was not effective. Medicines were being used that were past their use by date. Keys for the excess stock cupboards and refrigerators were left unattended in the locks. Temperature recording of the refrigerator used to store medicines was not being consistently recorded.

People’s emergency evacuation plans (PEEPS) were not up to date, putting people at risk in the event of an emergency. Actions from recent fire audits seen at the last inspection had not been completed.

We found the registered provider was not always acting in accordance with the Mental Capacity Act in relation to people’s Lasting Power of Attorney. The registered provider was not always aware of people’s arrangements for decision making and seeking consent.

Staff had not received regular supervision and appraisal. The registered provider had not checked the competencies of all new agency staff who formed part of the regular staffing team.

We found staff levels were appropriate to meet people’s needs. Staff reported the service had improved in relation to staffing levels with dedicated staff deployed on each unit. Staff felt the service was now a safe place to work.

People accessed the community and took part in a variety of activities. Two activity coordinators provided support to people to continue with hobbies and interests. People were encouraged to prepare their own meals as part of their support. A choice of meals were available for people.

The service employed a therapeutic services team who worked closely with people to support positive behaviour strategies. People had access to the hydrotherapy pool as part of recreational and therapeutic activities.

We found evidence in care records to demonstrate referrals were made to community services when necessary. We found records of visits to and from health care professionals including dieticians, dentists, GP’s and community nurses. Social care professionals told us the service was providing a supportive environment and people they had commissioned support for had experienced positive outcomes.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

The service had a peripatetic manager (manager) who was overseeing the management of the home. The manager confirmed that they intended to submit an application to become the registered manager of Deneside Court. The manager was being supported by the Director of Nursing and Quality. Both acknowledged that areas of the service need improvements to be made.

We had previously carried out a focused inspection of Deneside Court in March 2016 following concerns raised by external health and social care professionals and the police. During the inspection a breach in one of the legal requirements was found. The provider had failed to take appropriate steps to ensure staff were trained to provide safe and effective care to people at all times.

We asked the registered provider to send us an action plan outlining what steps they would take to ensure the home complied with Regulation 18 (Staffing) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They told us the actions would be completed by 30 June 2016. We took this action plan into consideration during this inspection.

The service does not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

The service does have a manager who is new to post. They told us they intended to submit an application for registration with the Commission. The manager was being supported in the service by the area manager.

At this inspection we found that there were breaches of six of the Fundamental Standards of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, person centred care, consent, safeguarding, staffing recruitment and the overall oversight of the home.

Deneside Court is a 40 bed purpose built home and provides residential and nursing care to adults with learning disabilities and physical and neurological disabilities. At the time of the inspection there were 36 people using the service. The home was divided into three units. The ground floor unit comprises of 20 individual apartments with ensuite facilities. While the two upper units comprise of 20 self-contained flats which each contained kitchen facilities.

In addition to the above dates two pharmacy inspectors visited the service on 1 August 2016. This was to enable a full inspection of the registered provider’s management of medicines procedures as we found the oversight and management of medicines was not safe. There were errors in the administration of medicines. Records for stock balances were not accurate. Medicines were being used that were past their use by date. Emergency medicines were not available for people who may have required emergency administration. Although we found medication audits which identified issues the registered provider had failed to action these.

People’s risk assessments were generic and risks associated with people’s conditions for example, epilepsy, were not considered. Risk assessments were not subject to review in line with the changing needs of people or in line with the provider’s own prescribed timescales.

Staff did not always have the appropriate training and skills to meet the needs of the people living in the service. For example, diabetes, learning disabilities and mental health needs. There was a lack of suitably skilled and experienced nursing and care staff permanently employed and the registered provider relied on temporary agency staff to provide nursing care and support on a day to day basis. They had failed to check that agency nursing staff had the skills and competencies to deliver the care and treatment people needed, such as tracheostomy care and support with behaviours that challenge. Staffing levels and skill mix were not always at a level determined by the provider’s dependency tool. Staffing rotas were not always updated with changes.

The registered provider failed to have systems in place to ensure staffing levels were appropriate. They used a basic system of number of people to ratio of staff, which did not relate to the actual dependency of people who used the service or placing authority contractual agreements.

Staff told us they did not feel safe when supporting people with behaviours that challenge. We found the system for summoning support may not be appropriate to keep people and staff safe during periods of heightened behaviours.

We found that the staff had a limited understanding of the Mental Capacity Act 2005 (MCA) and what actions they would need to take to ensure the home adhered to the MCA Code of Practice. We found there were no capacity assessments even though evidence suggested some people might lack capacity.

We found that the main body of the care records, such as support plans and risk assessments were not person-centred. We saw generic templates were used and at times these referred to the person in the wrong gender so we could not be assured they had been created for the specific individual. Care records were kept in the nurse’s office which was not always locked. This meant that people’s personal care records and information was not stored appropriately to promote and ensure confidentiality.

The registered provider had ineffective systems for monitoring, assessing and reviewing the service. Where systems had identified poor practice, gaps in care practices or the need to make significant improvements, these were not always acted upon. Action plans we viewed contained timescales which had lapsed with outstanding actions remaining.

The manager was new to post and was being supported by the area manager. Both acknowledged that areas of the service need improvements to be made. The registered provider was in the process of holding a recruitment drive.

People told us they were given a choice of meals. One person told us, “It’s alright, but I go out and eat as well.” People were encouraged to prepare their own meals as part of their support plans.

We found evidence in care records to suggest referrals were made to community services when necessary and of visits by health care professionals including dieticians, community psychiatric nurses and advocates.

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, it 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.

Deneside Court is a care home providing accommodation with nursing and personal care for up to 40 people with learning disabilities, physical and neurological disabilities. The home is divided into five units which comprises 25 individual bedrooms with en-suite facilities over three units and two units consisting of 15 self-contained flats with kitchen facilities. A registered manager was in post at the time of the 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.

We found the provider had identified in most cases where improvements were required to keep people safe. However some arrangements had been not put in place in a timely way to keep people safe.

Staff had not received all the training they needed to do their job effectively and to ensure the safety of people who used the service.

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

This report only covers our findings in relation to those legal requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Deneside Court on our website at www.cqc.org.uk.

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

Below is a summary of what we found –

Is the service safe?

Some aspects of this service were not safe. We found there were insufficient numbers of suitable staff to ensure people were supervised and appropriately stimulated and engaged. We saw that people who required one to one assistance had their support interrupted as staff had to also see to other people’s needs at the same time. Additionally, some people were unable to engage in activities away from the home due to staff shortages on the day of our visit. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The person in charge told us that 14 applications in relation to DoLS had been submitted.

The provider assessed people, using recognised tools, against the risks of poor nutrition and skin damage.

Is the service effective?

Some aspects of the service were not effective. People had their needs assessed and most staff understood what people’s care needs were. However, care plans were often not updated. Although staff had received some relevant training, this was out of date and incomplete, which meant people were at risk of not having their needs met.

We viewed the care records for five of the 33 people who used the service. These confirmed that people, or relative’s on their behalf, had not been asked to give their agreement to the care plans. We saw examples of other formal consent, such as for sharing information and using people’s photographs. Information gathered during the initial assessment was used to develop people’s care plans. We found care plans identified specific aims and objectives for people, however they did not have regular reviews of their assessed needs and staff did not have up to date information to help them completely understand people’s care needs. We have set a compliance action and asked the provider to tell us what they are going to do to meet the requirements of the law in relation the maintenance of accurate records.

Is the service caring?

We found that staff interacted positively with people and were kind and caring. However, we found people were left for long periods of time without interaction from staff to ensure they were appropriately stimulated and engaged. This was because of staff shortages and the fact that staff were busy meeting the needs of the people who required one to one assistance. We observed care being delivered throughout our inspection and undertook specific observations over a lunch time and in the lounge area. We found that people had to wait an unreasonable time to be assisted, which impacted on their wellbeing.

People who used the service and their family members all gave positive feedback about the service and the staff members who delivered the care. Some people and family members said more staff were needed. People commented: “Yes I get good care” and, “I can easily get in touch with staff, very likeable people.” Family member’s comments included, “The carers are lovely, I cannot fault it”; my relative gets well cared for”.

Is the service responsive?

Some aspects of the service were not responsive. We found that due to insufficient staffing levels some people did not always have the support they needed to ensure they had their needs met in a timely manner. We saw examples within people’s care records of action taken to respond to people’s changing needs, such as referring people to specialists; including specialist nurses, and occupational therapist. However care plans were not being evaluated regularly to ensure they remained up to date and reflected people’s current needs. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service well-led?

The service was not well-led. We found reviews of staffing levels were inconsistent and ineffective to assess the impact on the safety and welfare of people who used the service. The analysis undertaken looked at staffing levels as a whole across the home and did not take account of how staff had been deployed. For example, the analysis did not consider dependency levels on the separate units and the need to carry out laundering duties. It also did not take account of particular pressure points throughout the day, such as meal-times and taking people out in the community.

The provider undertook regular audits to check the quality of service. However, we found the quality checks undertaken were infrequent and subsequent action plans not followed up to address gaps in record keeping. We have set a compliance action and asked the provider to tell us what they are going to do to meet the requirements in relation to the effective operations of systems to monitor the quality of services provided.

People had been individually assessed to see if they could make their own decisions. Care records had enough information so staff would be able to know how to support each person in the right way.

During this inspection we checked the issues relating to the environment which had previously raised concerns. Although some issues had been addressed, we found we had some further concerns regarding the laundry area which we have asked the provider to review.

We saw on the day of our visit, there were sufficient qualified, skilled and experienced staff to meet people’s needs. The provider had a system for checking the quality and safety of the service and records were maintained and held securely. Surveys were also carried out. The records of these processes were up to date which provided feedback to the manager and staff members regarding information they needed to run the home effectively.

People who were able told us they were happy with the quality of their care, and told us they felt relaxed and content in the home. People in the home were protected from abuse. Staff were aware of their responsibilities to keep people safe, and told us they would report any bad practice. People told us they felt safe and protected by the staff who, they said, "Were kind and caring". Staff had been fully supported in meeting people's needs because they received regular supervision or appraisal, and training was up to date.

The home had systems in place to regularly check the quality of the care and other services such as catering, the environment and fire safety. Actions had been taken where problems had been identified.

We did have some concerns regarding the absence of hand wash basins in the laundry or servery areas which we have asked the provider to review.