Denmead Grange Care Home

Updated 24 June 2023

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 Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors, a member of the commission’s medicines team and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Denmead Grange is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Denmead Grange is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since it was registered. 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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also observed lunchtimes across the home and activities in communal areas. We spoke with 10 people and 4 relatives about their experience of the care provided. We spoke with 17 staff including 7 care staff, 2 housekeeping staff, the chef, the provider’s clinical development nurse, head of maintenance, a regional director, senior general manager, registered manager and deputy manager and the lead activity coordinator.

We looked at the care records of 10 people and multiple medication records. A variety of records relating to the management of the service were reviewed. These included policies and procedures, records of accidents or incidents, staff training and quality assurance records. Following the inspection, the registered manager provided us with information and other documents to support our inspection.

Updated 24 June 2023

About the service

Denmead Grange is a residential care home providing accommodation and personal care to up to 60 people. The service provides support to adults some of whom are living with dementia. At the time of our inspection there were 51 people using the service. People are accommodated in one adapted building across two floors. One floor, memory lane, specialises in providing care to people living with dementia.

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

People and their relatives told us the staff provided safe care. Safeguarding concerns were recognised and reported and staff understood their responsibility to protect people from abuse. Risks to people were assessed and plans were in place to minimise the harm to people from risks such as falls, skin injuries, poor nutrition, and behaviours of concern. The registered manager acted promptly to address some incomplete guidance and monitoring records. Environmental risks were well managed.

Staffing levels were based on people’s assessed needs. We received some feedback from people and relatives about not enough staff being always available. No one told us their needs were not met. We discussed this with the registered manager who will investigate this further. Staff were safely recruited. The registered manager acted to address some concerns we found with the management of people’s medicines. People received their medicines safely. People were protected to minimise the spread of infection. Incidents and accidents were investigated and analysed to help prevent a re-occurrence. Improvements had been made in the number of accidents from falls because actions from this analysis had been carried out.

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’s needs were assessed, and staff completed an induction and ongoing training to support them to meet people’s needs. People spoke positively about the food provided and we saw this looked appetising and nutritious. People’s dietary needs and preferences were met. People were supported to meet their healthcare needs and a healthcare professional confirmed staff followed guidance to support people’s health outcomes. The environment was of a high standard and laid out in such a way as to promote people’s independence. People’s accommodation was personalised, and the environment had been adapted to support the needs of people living with dementia.

We received some positive feedback about the care and kindness of staff along with other feedback that staff did not have enough time to spend with people leaving them feeling staff didn’t care as much. We observed kind and caring interactions between staff and people and staff spoke knowledgeably about the people they supported. The registered manager has increased staff available for 1-to-1 time with people. People’s diverse needs and interests were supported by the service.

People were supported to make decisions about their care and care was planned in a person-centred way. The service was in the process of updating and reviewing people’s care plans, but people’s current needs were known by staff. There was a varied, stimulating, and meaningful programme of activities. These were based on people’s interests and wishes delivered by an internal activities team and external entertainers.

Positive feedback had been received about the care and compassion shown to people and relatives by staff caring for people at the end of their life. Care plans were being further developed to support this approach.

The registered manager promoted a positive culture which was confirmed by staff, people, and relatives. There was a leadership team in place with clearly defined roles and responsibilities. Regulatory responsibilities were met, and the provider had a quality assurance system in place to monitor the quality and safety of the service people received.

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

This service was registered with us on 13 March 2020, and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.