We carried out a review of the data available to us about Denham Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Denham Manor, you can give feedback on this 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.
The service had 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. At the beginning of our inspection we found the home manager had sent in their application to be the registered manager for the service. The home manager had an interview with our registration inspector during our inspection. On the last day of our visit we received confirmation from our registration team that the home manager's application had been approved.
At our previous inspection in November 2014, we rated the service overall, ‘requires improvement’. We found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there was a lack of proper information about people by means of inaccurate records and documentation of care.
During this visit we found records in relation to people’s care and other documents were accurate, up to date and regularly reviewed.
People and their relatives spoke positively about the care provided. Comments included, “All the staff provided consistent care” and “I have been here for four to five months. My son who is 73 and my daughter, visit me every week. I am happy. It is good here. I have my nails polished. Don’t they look good?”
Caring relationships were formed with staff and the people they provided care and support to. Staff understood the care needs of the people they cared for. People were supported to exercise choice and where possible encouraged to be independent.
People said they felt safe from abuse which was also supported by their relatives. Comments included, “I feel safe here day and night. The night staff say that they check me every 2 hours (A review of the person’s daily record chart confirmed this)” and “I will tell them (management) if they (staff) hurt me. “
People benefitted from a safe service where staff understood their safeguarding responsibilities. This was because staff recognised signs of potential abuse and knew how to raise safeguarding concerns and received the relevant training. There were sufficient staff to meet people’s care, treatment and support needs and staff were deployed in a way that kept people safe. Risk management plans were in place to promote people’s safety and to maintain their independence.
People and their relatives said staff were skilled to carry out their duties and due to this felt confident with the care and support received. Comments included, “They (staff) seem to be (skilled and experienced)” and “They (staff) appear to be skilled and caring.” Staff received appropriate induction, training and supervision. People's rights were protected because staff understood the issues of consent, mental capacity and Deprivation of Liberty Safeguards (DoLS).
The service introduced plans of care that reflected what people or their legal representatives said they wanted. People had a range of activities they could be involved in and were able to choose what activities they took part in. People and their relatives said they knew how to raise concerns and their concerns were responded to satisfactorily.
People and their relatives gave positive responses in regards to how the service was managed. Comments included, “(Name of manager) is spot on. They check to make sure everything is fine. She is very professional” and “I believe it’s a well-led service. Staff felt confident to raise any concerns in relation to poor work practices (this is commonly referred to as whistle blowing). The service had systems in place to drive continuous improvement.
This inspection took place on the 10 and 11 November 2014. At the last inspection on11 May 2014, we asked the provider to take action to make improvements to the management of people’s care and welfare, supporting staff and how they assessed and monitored the quality of service provision, and this action has been completed.
Denham manor is registered to provide care to 53 people who live with dementia or who are older people. On the day of our inspection there were 31 people living in the home. The home was undergoing refurbishment of people’s bedrooms and bathrooms.
The home 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.
Systems were in place to record the care provided. These included charts to record when people were moved to prevent pressure sores, consumed food and drink and had general care and attendance. Some people’s charts had not been completed. The forms were used to monitor the care given, without this information monitoring was not possible.
Extensive refurbishment of the home was underway; the registered manager had considered the risks to everyone entering the building. They had systems in place to protect people from harm whilst the refurbishments were taking place. Although people told us they felt safe living in the home we found some areas presented hazards to people. The provider had failed to restrict access to these areas. This placed people at risk of harm.
People told us the food they received in the home was good. However we observed a lack of staff available to support people with their food at lunchtime. This meant some people became upset and frustrated. We have made a recommendation about the management of staff at mealtimes.
We saw there were sufficient numbers of staff available at other times of the day and night to support people. Systems and checks were in place to ensure staff were safe to work with the people in the home. Staff were supported to carry out their role through induction training, supervision and appraisals. We observed staff and their interactions with people. They were caring and attentive, people responded well to this. Not all staff felt supported by the registered manager which made them reluctant to raise concerns or complaints.
Medicines were stored and administered safely. People’s health was monitored and when required staff acted quickly to refer them to other professionals to maintain their health.
The home was following the Mental Capacity Act (MCA) and making sure that the human rights of people who lacked mental capacity to take particular decisions were protected.
Care plans recorded people’s assessments of their needs, and how care was to be delivered to them. Risks associated with their care had been identified and documented. People told us they were happy with the way their care was delivered and staff took notice of their preferences.
The provider displayed a copy of the complaints procedure in the home, and people received a copy. Discussions took place in meetings to remind people how to make complaints or raise concerns. Where complaints had been made, the registered manager or the provider had responded appropriately. People were given the opportunity to feedback their views of the service through meetings, questionnaires and discussions with staff. The provider acted upon this information to improve the service.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to 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 the report.
Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
Concerns had been raised with the Care Quality Commission regarding the number of staff who had recently ceased working for the provider at the home, unauthorised access to the premises and insufficient staff to meet the needs of people who lived in the home.
We inspected Denham Manor over two days a Sunday and Monday. We found the provider had assessed the needs of people and from that had established what their staffing requirements were. We looked at the roster for the two weeks prior to the inspection and found for most of the days the provider had in place the required number of staff through the use of agency staff. The provider told us they were currently undertaking recruitment for the vacant posts.
When we arrived at the home we rang the front door bell several times. After a waiting for a response we tried to access the building using the keypad attached to the door lock. As certain numbers were worn through repeated use, we were able to key in the right numbers to allow us access without any staff being aware we were in the building. We informed the provider who took immediate action to change the keypad and key code.
We saw records which showed the provider had applied the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards to the care provided to two people. The provider had identified where the care and support provided to these people may have deprived them of their liberties in order to keep them safe. The least restrictive manner had been used to protect people and this had been authorised by the Supervisory body. This meant people who used service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards
People told us they felt safe living in the home. Although we found call bells were not always accessible to people and staff had not always responded in a timely way.
Systems were in place to make sure that managers and staff learnt from complaints and concerns. This reduced the risks to people and helped the service to continually improve.
Each person's care plan included a risk assessment to identify the risks of harm or illness and measures in place to reduce these risks. This protected people and staff from the risk of harm or injury when care is provided.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to care and welfare of people who use the service.
Is the service effective?
One person told us a lack of activities had led to boredom. We observed a lack of activities within the home. Other people told us the activities on offer were not to their liking. The provider told us they have recruited a new activity organiser, and plans will be made to improve the level of activities on offer.
Staff were not always able to communicate with people in a way that they were understood.
People told us the staff and management were responsive to queries and suggestions. One staff member told us how the staff are encouraged to make suggestions in team meetings. A relative told us how they were involved in the planning and delivery of care and this had been important to them.
We have asked the provider to tell us what they are going to do to ensure that people's social and communication needs are met.
Is the service caring?
One relative told us 'everyone is friendly'very considerate about Mum's needs as a person. I can only be complimentary about the staff; they are the most important thing when it comes to care.' Another relative told us 'the care has been second to none, it has been very good.' They went on to tell us the home offered them 'peace of mind, you can leave knowing the person is in safe hands.'
People using the service, their relatives, friends and staff involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.
We observed positive interaction between staff and people who used the service. However, we noted staff were focussed on completing care tasks and less on communication with people.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to providing care to people in a way that protects their welfare and meets their needs.
Is the service responsive?
Care staff told us how responsive the nurses were to any concerns regarding the health of people who used the service. They told us the nurses would respond immediately if they felt the person was unwell or the care worker was unsure of what to do.
The provider had in place a complaints procedure that was accessible to people in the home. One person told us they did not know how to make a complaint, whilst others did.
Where people or their relatives had made a complaint or comments the provider had responded appropriately.
Is the service well-led?
Everyone we spoke with told us they felt the service was well led.
We saw the provider had safe practices in place when recruiting staff. Currently the home is recruiting to fill staff vacancies, at this time the deficit is being met through the use of agency staff.
Induction, supervision and appraisal records for staff were not detailed or complete. Not all staff had received induction training, regular supervision or appraisal in line with the provider's policy.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.
People told us how staff asked their permission before carrying out care and support, and how the care and treatment was of a good standard. One person told us 'There are no problems here.' We did observe one staff member caring for a person without verbal interaction. This meant that the person may not have been aware of what was going on around them and did not show respect to the person.
We discussed with six staff how the home was run. Staff told us that the manager was effective. They felt that the home was well run, but there were things they could improve on such as record keeping. We found care plans were generally well written, but there were some omissions relating to checks of people's care.
We saw documentation relating to support for staff was in place, however the manager may wish to note that whilst there was evidence in the records we saw that supervision and training was available, not all staff reported frequent supervision was happening.
We saw records relating to complaints. We saw how the manager had responded appropriately and in a timely way to complaints. We were told by staff how they would respond to complaints in a way that did not discriminate against the complainant.