16 March 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 24 February 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
16 March 2022
We inspected Dean Wood Care Home on the 16 and 18 October 2017 and the inspection was unannounced. Dean Wood Care Home is registered to provide accommodation and care, including nursing care for up to 80 people, with a range of medical and age related and chronic conditions, including arthritis, frailty, mobility issues and dementia. The service is divided into three floors. The ground floor provided care and support for people living with dementia. The first floor provided care and support to people with nursing care needs and the second floor provided to care and support to people with lower level care needs.
Dean Wood Care Home belongs to the large corporate organisation called Bupa Care Homes (CFChomes) Limited. Bupa provide nursing care services across England and have several nursing homes within the local area.
The service had a registered manager in place. 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.
At the last inspection undertaken on the 13 and 14 September 2016 areas of improvements were found in relation to staff morale, lack of staff supervisions and further work required to embed the provider’s audits and action plans. Recommendations were made and at this inspection, we found improvements had been made. However, we identified new areas of care that needed improvement.
Systems and processes were in place for the provider to monitor compliance with the Health and Social Care Act 2008 (Regulated Activities) 2014. Audits were undertaken on a regular basis and the provider was able to demonstrate how audits were utilised to drive improvement. However, the provider’s internal quality assurance framework was not consistently robust and further work was required to strengthen the provider’s internal quality assurance checks. For example, shortfalls and omissions with documentation had not consistently been identified as part of the provider’s internal quality assurance framework. We have identified this as an area of practice that needs improvement.
Positive relationships had been developed between people as well as between people and staff. There was a friendly, caring, warm and relaxed atmosphere within the service and people were encouraged to maintain relationships with family and friends. One person told us, “I’m very happy, I’m having a ball.”
People were protected, as far as possible, by a safe recruitment system. Staffing levels were based on an assessment of people’s individual care needs. Safeguarding adult's procedures were robust and staff understood how to safeguard the people they supported from abuse. There was a whistle-blowing procedure available and staff said they would use it if they needed to.
The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate application to restrict people's freedom had been submitted. Staff had received training on the Mental Capacity Act 2005 (MCA) and worked in line with the principles of the Act.
People spoke highly of the food and said that they were able to make choices about what they had to eat. People received enough to eat and drink and risks associated with nutrition and hydration were managed effectively. People were supported to access the health care services that they needed.
The management of diabetes and catheter care was effective. Staff felt supported within their roles and staff morale had improved. The management team were dedicated to ensure staff’s and people’s voice was heard and acted on. Forums were in place for people and their relatives to give feedback on the running of the service.
People received care and support that was responsive to their needs. Care plans provided information on people’s day to day care and people participated in a wide and varied range of activities. Regular outings were organised and people were encouraged to pursue their interests and hobbies.
Systems were in place for the safe storage, administration and disposal of medicines. People told us they received their medicines on time and in their preferred manner. A complaints policy was available and people and their relatives felt confident raising any concerns.
People were treated with dignity and their rights and choices were respected. Observations showed people being treated in a respectful and kind manner. People's privacy was maintained; when staff offered assistance to people they did this in a discreet and sensitive way. People confirmed that they were treated with dignity and their privacy was maintained. People’s religious, sexual and spiritual needs were respected and upheld.