We carried out a review of the data available to us about Deepdene Care Centre 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 Deepdene Care Centre, you can give feedback on this service.
Deepdene Care Centre is a care home providing personal and nursing care for up to 66 people. The care home accommodates people over three floors, each having their own lounge and dining areas. Some people were living with dementia, others had long term health conditions. At the time of our inspection, only two floors of the service were being used as the top floor had been closed for refurbishment. There were 42 people receiving care at Deepdene Care Centre on the day of our inspection.
People’s experience of using this service and what we found
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. We have made a recommendation to the registered provider in relation to some detail in people’s capacity assessments.
Staff felt very supported by their peers, line managers and senior management. However, staff did not routinely receive supervisions to give them the opportunity to discuss their role, performance or training needs. We have made a recommendation to the registered provider in relation to this.
People said they were happy living at Deepdene Care Centre. They told us they felt safe at the service and staff treated them with respect and kindness. Risks to people had been identified and action taken when incidents and accidents occurred.
People received care from a sufficient number of staff who were suitably deployed around the service and people told us staff knew them well. People received the medicines they required and were referred to, or were involved with health care professionals when needed. People received sufficient food and drink and modified diets were prepared appropriately for those who needed them.
People lived in an environment that was clean and hygienic, checked for its safety and suitable for their needs. The quality of the service people received was monitored and audited to help ensure it was consistently good. Improvements had been made to the activities staff provided for people both in their rooms and communal areas.
People said staff were considerate of them and focused on their needs. People were comfortable speaking with staff or management should they have any concerns or complaints.
The service worked closely with external agencies and staff told us they had seen improvements at Deepdene Care Centre since the registered manager had started. The registered manager had a clear vision of where they wished to take the service, telling us, “I want people to have a normal life.”
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Requires Improvement (report published 28 July 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended that the registered provider checked people’s care plans for their accuracy and review staff deployment. At this inspection we found the registered provider had acted on these recommendations and improvements had been made.
Why we inspected
This inspection was prompted by a review of the information we held about this service and to follow up on the breaches of regulation found at our last inspection.
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.
Deepdene Care Centre is a care home providing personal and nursing care to 66 people aged 65 and over. The care home accommodates people across three floors, each having their own lounge and dining areas. Some people residing at Deepdene Care Centre are living with dementia. On the day of inspection, there were 48 people living at Deepdene Care Centre.
People’s experience of using this service and what we found
People told us they felt safe and we had no concerns that people were at risk at the service, despite our inspection being prompted partially in response to concerns received about unsafe care.
Senior management had made a positive impact to the service since joining. However, there was more work to be done for this improvement to be sustained and for people to feel confident they were receiving a high quality, good level of service at all times.
There was a lack of person-centred approach at times. This particularly related to a shortfall in activities provided for people and information held about them in respect of their past lives.
Staffing levels were inconsistent across the service; however, changes were made following our inspection. Staff were kind to people and people said they were enabled to make decisions about their care.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Although people said they enjoyed the food, a better dining experience was needed to ensure meals were served in an appetising way. The environment people lived in was clean and practice, however it would benefit from further development in relation to people living with dementia.
Infection control practices were good, and people received the medicines they required. Lessons were learnt from accidents and incidents and reflective practice was used to make changes in response to these.
Staff received the training they needed for their role and they told us things had taken a positive turn since the peripatetic manager had arrived.
Complaints were listened and responded to and senior management had a clear drive to improve the service.
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 the service under the previous provider was Good(published on 6 November 2018.)
Why we inspected
The inspection was prompted in part due to concerns received about poor practices within the service which included poor moving and handling, lack of appropriate care to people, falsification of records and unexplained bruising to people. A decision was made for us to inspect and examine those risks.
We also planned this inspection, as the service has not been inspected since the change of provider in January 2020.
Although we found no evidence during this inspection that people were at risk of harm from the concerns we had received, we found that there was further work required to embed the positive changes made at the service by the acting manager. Please see the Safe, Effective, Responsive and Well-led sections of this full report.
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 coronavirus and other infection outbreaks effectively.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to, lack of compliance with legal requirements, person-centred care and governance with the service. You can see what action we have asked the provider to take at the end of this full report.
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.
We found the following examples of good practice.
The registered manager had introduced rigorous processes for visitors to follow to help ensure they did not put people at risk of catching COVID-19. This included lateral flow testing and wearing personal protective equipment (PPE). A separate entrance was designated so visitors could avoid having to walk through the building during their visit.
Staff empathised with relatives whose family members were at the end of their life and additional ideas had been implemented. This included video facilities being set up which allowed relatives to see their family member when staff detected they were close to death. Relative’s had found this very comforting.
Risk assessments were completed for people being admitted from hospital or who had developed signs of COVID-19. National guidance was followed when people had to isolate. An additional activities co-ordinator had been recruited to help keep people socially engaged and feel less isolated. One person told us staff were, “Very good” and had been working hard throughout the pandemic.
The service was clean, and we observed housekeeping staff carrying out cleaning tasks. Staff told us they changed their mask and gloves between rooms. We observed staff wearing PPE and we were told by the registered manager that a heat sensor camera had been installed which alerted them if staff arrived on shift not wearing a mask.
Staff had access to enough PPE, testing facilities and information and training around infection control. One person said staff always wore their masks and gloves. Separate staff break and toilet facilities had been set up to reduce staff movement around the service.
Staff said they felt supported by their team members and the registered manager. In turn, the registered manager said they had received an enormous amount of support from the provider.
Further information is in the findings below.