Deneside Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

People and relatives told us they felt Deneside Court was a safe place to live. When potential safeguarding incidents did occur, they were recorded and investigated. Medicines were given safely and risks related to care delivery were considered and mitigated. People and staff told us there were enough staff on duty to support their care needs. Whilst staff received supervision, this was not always consistently provided and there was a known lack of annual appraisals.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

It was not clear that lessons were always learnt when things went wrong. There was no evidence of the provider continually identifying and embedding good practice as a result. The care records were electronic so allowed for easy reporting and sharing of information between staff and managers, but we did not see lessons learned were shared with staff or other locations under the provider.

Staff told us that training was provided to ensure that they could carry out their role effectively and that the training was effective. There was some training being undertaken on site on the day of our visit. Staff told us that they felt listened to, when proposing new ways of working to aid in the safety of the people they worked alongside. Overall, the training matrix indicated training activities were mainly up to date. No appraisals had been undertaken within the last year.

Some supervisions had taken place. Although with some staff supervision seemed to be carried out very frequently, with others this was not the case. The supervision matrix showed approximately a third of staff listed, as not having had supervision in 2025. Audits of supervision records in January 2025 rated the process for supervision as inadequate, but the following audits did not show changes to reflect a positive response to that rating.

Relatives and professionals told us the manager was responsive when concerns were raised with them. A professional told us, “The current manager, [name] was prompt in reviewing and resolving a raised concern at the beginning of the year. I was impressed with the proactive management of my informal concern.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe from abuse. There was no evidence of bullying or harassment within the service. Safeguarding concerns were raised and dealt with accordingly. Safeguarding was taken seriously by the management and others, although some staff felt that action was not always taken in a timely manner. Safeguarding formed part of the induction and ongoing supervision with staff, who were confident how to report concerns, and who to.

The service had a safeguarding policy in place that was in date. There was a safeguarding log in place that had been completed and demonstrated what incidents had taken place and actions taken. However, whilst individual safeguarding records sometimes identified lessons to be learned there was no clear evidence of wider learning from these reviews or of identification of any recurring themes.

People and relatives felt the home was a safe place and they had not been subject to any instances of discrimination or bullying. A relative commented, “Yes, (I think they are safe), but obviously – I don’t believe there is anywhere fully secure. I have no complaints about that.” A person told us, “I can honestly say I can’t think of anything wrong here. I call this my home. I am happy here. I couldn’t dream of living anywhere else.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe from abuse. There was no evidence of bullying or harassment within the service. Safeguarding concerns were raised and dealt with accordingly. Safeguarding was taken seriously by the management and others, although some staff felt that action was not always taken in a timely manner. Safeguarding formed part of the induction and ongoing supervision with staff, who were confident how to report concerns, and who to.

The service had a safeguarding policy in place that was in date. There was a safeguarding log in place that had been completed and demonstrated what incidents had taken place and actions taken. However, whilst individual safeguarding records sometimes identified lessons to be learned there was no clear evidence of wider learning from these reviews or of identification of any recurring themes.

People and relatives felt the home was a safe place and they had not been subject to any instances of discrimination or bullying. A relative commented, “Yes, (I think they are safe), but obviously – I don’t believe there is anywhere fully secure. I have no complaints about that.” A person told us, “I can honestly say I can’t think of anything wrong here. I call this my home. I am happy here. I couldn’t dream of living anywhere else.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and welfare had been assessed. This covered all key areas, including falls, nutrition, and skin integrity, along with individual identified risks. Risk assessments were sufficiently detailed, person-centred and effective at reducing risk. Safeguards were not unnecessarily restrictive, and people’s rights and freedoms were respected.

Records showed staff followed the assessments to keep people safe. Staff knew people well and understood the risks people were exposed to and told us they were kept up to date with changes in people’s needs.  

There was evidence in care plans people had been asked if they wanted to be involved in care reviews. However, it was not explicitly clear from documentation that people and relatives had been actively involved in review processes. Relatives told us they had been part of meetings and the decision-making process. One relative told us, “He is (involved in decisions) but due to their needs they do not recollect; but good that they are given the opportunity to be involved. I am fully involved and kept up to date. I agree with plans made. I am able to suggest options or raise concerns. They do listen to me and address any issues, if not immediately (if they cannot be) then they will take the concerns raised away and deal accordingly.”

Professionals were positive about how the service supported and involved people. One professional told us, “Deneside works hard to make every decision inclusive with the service user, I have observed MDT meetings including them and also have seen family invited in to include them, to ensure a holistic approach.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental risk assessments were in place to protect staff and people. Risk assessments were thorough and well documented. Personal emergency evacuation plans were in place and staff knew what to do in an emergency to safely support people.  

There were audits of the processes in place that detected and controlled risks in the environments. Some staff and relatives raised concerns about the heat in some of the rooms due to the lack of appropriate window coverings. They felt temporary solutions had not been sufficient and that actions to fit blinds and other measures had taken too long.

The home was clean and tidy. Domestic staff were observed to be busy throughout the day, maintaining the environment and ensuring that high risk areas were well maintained. Equipment viewed as part of the inspection had been checked and serviced appropriately. We requested copies of key safety checks and certificates from the provider on three occasions. The provider took 4 weeks to provide some of these documents, but not all that had been requested.

People were supported to be safe within the environment of the home. Where people did not have capacity to understand risks then appropriate restrictions were in place, such as keypad locks and window safety catches. Where people’s freedom was restricted, applications had been made under the Deprivation of Liberty Safeguards (DoLS).

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. 

Staffing was safe and well-managed. The provider carried out pre-employment checks centrally and new staff went through a comprehensive induction. This included face to face training, shadowing and competency checks. Some staff files evidenced employment interviews and references being sought. Staffing levels were safe, and there was a good skill mix of staff members allocated to shifts. There were procedures in place in the event of staff member absence. Managers were available through the week, with senior staff members on shift when managers were not. 

The service made limited use of agency staff. Where they did, they received information about the staff member, before they came to work a shift. Agency staff received a verbal induction when they first worked at the service. We spoke with the manager about making this induction process more formal.

Staff told us there were enough staff to support people and that people received 1:1 support appropriately. They also told us they felt supported and encouraged within their role and development.  A member of staff said, “There are enough staff. – 6 per day usually, but at least 4 and that is enough. We swap around to gain more experience.” Some staff felt that staff could be encouraged to be more active with people when providing one to one care.

People’s care plans detailed the support they received from staff. Relatives told us staff knew people well and they received person-centred and effective support from staff. One person told us, “I have a call button here on the table – so I can get help if I need it. They come in a timely manner.”

Staff received a range of training and felt this equipped them to support people effectively. Training completion rates were high, and staff said the training was valuable. One staff member told us, “The training I have received so far has shaped me into been a better and more compassionate staff. I have also learnt new things and gained more knowledge about person centred care.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an Infection prevention and control (IPC) policy in place to reduce the risks of people and staff catching and spreading infections. IPC was well-managed. No concerns were raised. Staff used Personal Protective Equipment (PPE) when needed and maintained good hand hygiene and food preparation practices. PPE was readily available throughout the service. 

Staff received IPC training as part of their induction. Staff were aware of infection control issues.

The service was clean and tidy. Bathroom and toilet facilities were clean, tidy and free from clutter. We noted on the first day of the inspection that some bathrooms were used for excessive storage. This issue had been rectified by the second day. Bins were emptied regularly, and the facilities and equipment were cleaned between use. Domestics were seen working during the inspection. The laundry area was generally clean and tidy, although it could have been better organised and maintained.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were managed safely. The service had an effective electronic medicines administration system in place which highlighted any anomalies. The electronic system made closer scrutiny of medicines administration simpler and meant fewer errors.

People told us that they received their medicines on time. Care plans were in place for medicines. There were appropriate instructions for giving medicines, including, via a percutaneous endoscopic gastrostomy feeding system (PEG), or medicines for the control of diabetic conditions.

Staff received initial training, and regular competency checks of their practice to ensure they were safe and confident. The provider’s policies regarding medicines were up to date and in line with good practice. Where people were prescribed ‘as and when required’ or covert administration (medicines given in food or drink), medicines protocols were in place.  We observed staff administering medicines in a safe and person-centred way. 

The clinical room was clean and tidy, and the temperatures were monitored. Controlled medicines were managed effectively, as were returned medicines.