Background to this inspection
Updated
13 December 2019
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection was carried out by one inspector.
Service and service type
Denham Manor Care Home 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 had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with five people who used the service and five relatives about their experience of the care provided. We spoke with thirteen members of staff including the registered manager, deputy manager, nurse, care workers, maintenance worker, clinical analyst, housekeeping manager, receptionist, administrator, chef, contracts manager and regional manager.
We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three professionals who regularly visit the service.
Updated
13 December 2019
About the service
Denham Manor is a residential care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 53 people. The care home accommodates older people and people who experience dementia across two floors with adapted facilities. The provider has suspended the use of the top floor to be compliant with fire safety regulations.
People’s experience of using this service and what we found
Overall people and their relatives felt the service was safe. We found that some improvements were required to ensure safeguarding systems were consistently followed by staff. Appropriate action had not been taken in response to one person’s disclosure. This was rectified by the registered manager during our visit to make sure the person was safe. In general risk assessments addressed people’s needs, however we have made a recommendation about risk assessments in relation to welfare checks on people.
Medicines were received, stored and disposed of safely. Systems in place to identify gaps in medicines records were not always followed by staff. The service took prompt action to improve monitoring of these systems during our inspection, to make sure near misses were consistently acted upon. Staffing levels were based on people's needs. There were enough care staff and nurses to meet people's needs. Staff were recruited safely.
The home was comfortable and clean. People were supported to personalise their private rooms which appeared homely. There was not enough storage for equipment such as mobility aids and we have made a recommendation about this.
People benefitted from staff who received comprehensive training and supervision. People received support to keep healthy and had access to health care professionals as required. Daily handovers discussed any changes in people's needs and referrals to relevant health care professionals were promptly made.
People's needs were assessed before coming to the service. Care plans were person-centred including people’s likes, dislikes and what was important to them. 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.
People and their relatives gave positive feedback about the service. Comments from people included, "I’m looked after brilliantly here”, “Couldn’t do anything better, [they do a] marvellous job” and “It’s the perfect place [for family member], they love their room and we like staff.” People and relatives felt involved with decisions about their care. Staff were caring, and knew people, their preferences, likes and dislikes well. Staff understood the importance of protecting people’s privacy and dignity and promoted people’s independence.
People were supported to access a range of activities within the service. When people were at the end of their life their wishes were reviewed, recorded and respected. The registered manager took action to make sure all people’s end of life wishes were reviewed regularly and documented, to ensure the service was well prepared to meet people’s wishes.
The management team were committed to improving the quality of the service people received. Regular audits highlighted areas for development or improvement and were put into an action plan which showed progress. The service sought and acted upon people's, relatives and staff's feedback. People's views were listened to and investment was made to improve people's comfort and well-being.
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 18 March 2017).
Why we inspected
This was a planned inspection based on the previous rating.
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.