Deepdene Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Managers and staff told us incidents and accidents, safeguarding concerns and complaints were recorded on their system. These were reviewed, discussed and analysed to determine any underlying causes or trends and identify any actions required to improve the service. However, we found that the care notes for a person who displayed episodes of agitation and aggression clearly recorded an escalation of risk to other people. However not enough had been done to protect others and a person had been seriously harmed as a result. Staff told us regular meetings were used to share information about any incidents along with any learning. People told us they were happy living at the home and felt safe and well cared for. Their comments included, “I do feel safe - much, much safer here than if I was still in my own home” and “Oh yes I feel safe all the time, the carers are so good.” A relative added, “Yes, definitely I think [family member] is safe here, [they] would certainly be unsafe if [they were] still living on [their] own.” Staff knew how to report and document any incidents or accidents. Lessons were learned when things went wrong.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People told us they felt safe living at Deepdene Care Centre. They told us the staff were available if they needed support. Relatives stated they were informed when their family members required support or treatment from different agencies.

The staff team and managers told us they worked well with other professionals to ensure continuity of care, including when people moved between different services or required temporary stays in hospital. Healthcare professionals told us they had a good working relationship with the service and communication was good.

Staff told us they were happy working at the home and felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service. A staff member stated, “Deepdene staff engage well with each other, the residents and their families. I like to think we treat each other with respect and value each other’s input. There is a loving atmosphere.”

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Systems in place to protect people from avoidable harm had not been effective. There had been a serious incident at the home whereby a person had been seriously injured by another person at the service. Records we reviewed indicated there was a known risk, and warning signs had not been identified therefore not enough had been done to ensure the safety of others. Following the incident, we saw the provider had put in place more robust systems to protect people. They had reflected on the incident with the staff team to learn from this and prevent reoccurrence.

We observed poor care practices during lunch in one of the units. A gravy jug was placed in front of a person, who accidentally dropped it. Staff only mopped up some of the gravy and the person sat with their slippers in this. The person was asked if they wanted soup. They declined, but a member of staff put a bowl of soup in front of them regardless. The person was then given orange juice which they dropped on their lap. No attempt was made by staff to clear this up and assist the person. We asked a member of staff if they were going to support the person to change. They said they would after the person had finished eating. This meant the person remained in wet clothing for the duration of lunchtime. We reported this to the management. They told us they were taking appropriate action with the relevant staff.

The provider had a safeguarding policy and procedures in place. The provider kept a log of all safeguarding concerns raised. This included the type of abuse, description of the incident, outcome date closed and reflective practice.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Most people said staff knew their needs and met these safely. However, one person told us staff were “forever” taking breaks. They said some staff cited breaks as a reason for not immediately support them. Another person added, “Often I need two carers. If I need the toilet, sometimes you have to wait a long time and when you want to go, that can be uncomfortable." We discussed this with the registered manager who told us, “This is unacceptable practice.” They assured us they would address this with the staff team. Processes to ensure risks to people were assessed and mitigated had not always been effective. It had been identified a person had shown aggression towards others and was frequently entering other people’s rooms. 30-minute checks were put in place, and a sensor mat was placed in the person’s room to alert the staff when they were up. However, this had not prevented a serious incident from happening. Following this, the provider had put more robust measures in place to help prevent further incidents. This included putting sensors on bedroom door frames so staff would be alerted if someone entered a bedroom. Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and post incident analysis. Following the incident, an action plan was put in place and care plans and risk assessments were reviewed. Care plans contained details to inform staff how best to support people with complex health conditions. The care plans for a person living with diabetes detailed how to recognise signs they were becoming unwell and what action to take. This meant the staff would be able to take appropriate action should they become unwell.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were supported in a safe and well-maintained environment that met their needs. People and relatives told us they liked the home and felt it was homely and well decorated.

There were effective systems in place to monitor and regularly check the safety and upkeep of the premises. The management team and staff worked together to help ensure any potential risks were identified and addressed promptly such as faulty equipment or trip hazards. Safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, fire safety checks and kitchen equipment. They also responded promptly to any reports from the staff where repairs were required.

Equipment used to support people was suitable, well maintained and stored securely. The provider had an up-to-date emergency plan in place to help ensure people were supported in the event of an adverse event.

The home was being refurbished at the time of our visit. This included lounges, dining rooms corridors and bathrooms on each floor, and updating of all the kitchenettes. The reception area was also being refurbished as well as the hairdressing salon and the garden. We saw evidence this had been discussed during meetings with people and relatives.

People’s bedrooms were personalised with photographs and items belonging to them. There was signage around the home, and objects and pictures to help people with reminiscence.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs.

Although the provider carried out checks on the suitability of staff before they started working at the service, we found some minor discrepancies in some of the records. The provider was able to provide an explanation for these. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom, Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

The provider used a dependency tool to help ensure there were always enough staff to meet people’s needs. We saw a dependency report, which showed a monthly analysis of people’s needs in all areas of their lives. Based on this, staffing levels were established to meet people’s needs.The provider did not require the use of agency staff. The regular staff often covered shifts when needed. They also had a pool of bank staff who were often able to cover shifts at short notice.

Healthcare professionals provided training sessions for all relevant staff. This included dementia training and falls prevention. Where people lived with a specific condition, staff were able to obtain training in this to equip them with the appropriate skills to care for the person. For example, a nurse specialising in motor neurone disease provided training. The management ensured nurses employed by the service received clinical training in medicines, catheterisation and syringe drivers.

Staff told us they were happy working at the home, felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us they felt safe from the risk of infection because premises and equipment were kept clean and hygienic, and relatives confirmed they did not have any issues with cleanliness of the service.

We observed a dedicated staff team ensured the service was kept clean, tidy and well maintained. Cleaning staff followed a cleaning schedule and used appropriate personal protective equipment (PPE). Care staff wore PPE when supporting people to help protect people from cross infection. A member of staff told us, “Training involved washing hands, using relevant colour coded PPE, disposing it in its relevant disposal bins etc... This also included training in quarantine, confinement and isolation. We have also been trained in managing food temperatures, food cross contamination such as allergies like gluten free and Coeliac.”

Appropriate systems were in place in relation to infection control. The provider ensured staff had access to PPE and were trained in the use of this. The provider’s infection prevention and control policy were up to date. Information about the risk of infection was shared appropriately with people using the service and visitors. The managers and senior staff carried out audits to ensure standards of cleanliness were good.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines safely and as prescribed and records confirmed this. However, the staff did not accurately check and record the medicines refrigerator temperatures. We found an out-of-date medicine in part of the ‘hypo kit’ which would be used in an emergency. A hypo kit is a medical kit to treat low blood sugar in people with diabetes. Also, we found out-of-date blood glucose monitoring test strips were in use. This meant the readings taken using these test strips may not have been accurate.

Medicines care plans were in place. However, these were not always person-centred and did not always have the necessary information. For example, one person’s care plan did not include information on how to monitor or manage the side effects of their high-risk medicine. In another person’s diabetes care plan, the prescribed dose of insulin had not been updated. Similarly, for two people we reviewed who were prescribed medicines for Parkinson’s to be administered at specific times, the care plan did not specify the specific times when they must receive these. This meant there was a risk that people might not receive these medicines as prescribed.

Staff carried out audits, but these had failed to identify the concerns we found during the inspection. This meant people were at risk of not receiving their medicines safely and as prescribed.

Medicines reviews were carried out by the local GP. There was a process to report and investigate errors and incidents. There was a process in place to receive and act on medicines alerts. Medicines were stored securely and at the required temperatures. Staff received training and were competency assessed to handle medicines safely.