About the service:

Dean Wood Manor is a nursing home that is registered for younger and older adults and people living with dementia, or a physical disability. The home is a grade two listed building that has been extensively refurbished to meet the needs of the people living at the home. Dean Wood Manor can accommodate up to 50 people and there were 42 people living at the home at the time of our inspection.

People’s experience of using this service:

People living at Dean Wood Manor were not receiving safe, effective, compassionate or high-quality care. The management of medicines remained ineffective which had resulted in people receiving the wrong dose of medicine and medicines not being available as required.

The management of specific risks to people was poor, it was observed during the inspection that a person requiring a specialist diet was not provided this in line with their assessed needs. Documentation did not provide assurance that this was an isolated incident and there was no audit in place to identify this internally to prevent re-occurrence.

Pressure care was lacking and despite appropriate equipment being in place it was not being used in line with manufacturer’s instructions which exposed people to the risk of skin breakdown. Care plans and comfort in care records did not contain guidance to support staff in ensuring equipment was being used effectively.

We were concerned records did not enable us to ascertain that people’s care needs were being met. There were gaps in comfort in care records and documentation regarding people’s personal and oral care. The frequency people needed to be repositioned to maintain their skin integrity was ambiguous, with staff recording different times this was required on the same record.

There had been no operational structure in place at Dean Wood Manor following the deputy manager and clinical lead leaving which had consequently affected the quality of the service provided. Staff attendance at training had adversely been affected which included engagement with the hospice in your care home training, mandatory training and the frequency staff received supervision and appraisal.

Quality assurance systems had not picked up on some of the issues we found during the inspection which included; the use of pressure equipment and managing peoples assessed dietary needs.

A week prior to the inspection, two clinical leads had commenced working at the home and were providing direct support to the manager in addressing the medicines and issues identified during the inspection.

People were supported by staff who cared about their welfare and spoke fondly of them.

Visitors and relatives spoken with during the inspection were overwhelmingly positive about the care provided to their family members at Dean Wood Manor and expressed feelings that their family member would have missed out on good care had they paid credence to previous inspection reports.

Detailed findings are in the full report below.

Rating at last inspection:

The service was last inspected 22 and 23 January 2018 and was rated as requires improvement. The report was published 04 April 2018. Following the last inspection, we met with the provider, regional manager, and compliance manager on 18 April 2018 to discuss the rating and concerns identified. Attendees at the meeting also included the local authority and care commissioning group. Prior to this meeting we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective and well-led to at least ‘Good’.

At this inspection it was identified the provider had failed to achieve this and the quality of care people received living at Dean Wood Manor had deteriorated.

Why we inspected:

The inspection was brought forward because we had received complaints about the home and intelligence to indicate that the quality of care people were receiving had deteriorated.

Enforcement:

We served two

We carried out an unannounced inspection of Dean Wood Manor on 22 January 2018. We made a second announced visit on 23 January 2018 to complete the inspection.

The home was last inspected on 30 November 2016, when we identified four continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment and good governance. Following this inspection the home was rated as requires improvement overall and in the key lines of enquiry (KLOE's); safe, effective, responsive and well-led. The home was rated as good in caring.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, responsive and well-led to at least good. The home has also been provided on-going support through a service improvement programme with the local authority. We reviewed the progress the provider had made as part of this inspection.

At this inspection we identified three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; safe care and treatment, meeting people’s nutrition and hydration needs and good governance. You can see what actions we told the provider to take at the end of the full version of this report.

Dean Wood Manor 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.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people living with a diagnosis of dementia. The premises are based around an original Grade II listed building which has been extended and modernised. Communal space within the home included two dining rooms and three lounges. There were also designated seating areas on corridors. The home has extensive gardens and on-site car parking is available. At the time of inspection 47 people were living at Dean Wood Manor.

There was a registered manager in post at the time of this inspection. 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.

Although people’s relatives felt their family members were safe living at Dean Wood Manor, we identified continued concerns with the management of medicines. We found discrepancies on people’s medicine administration records (MAR) that had resulted in medicines being missed. We also identified concerns when responding to people’s changing medical needs and complying with the person’s care plan and referring to health care professionals for appropriate assessment.

The home had a system in place to determine the required staffing levels. Staffing was also determined on observation and in recognition of people being more unsettled in the evening, the staffing compliment was being increased to respond to this identified need.

The home was clean and was commended by people’s relatives for the level of cleanliness maintained.

Staff completed nutritional risk assessments but we identified two people that according to their assessment score should have been referred for dietetic assessment. However, the registered manager could not demonstrate this referral had been made and care plans did not contain sufficient details to guide staff in reducing the risk of further weight loss.

There was a system in place to manage people that had specialist dietary needs but records needed strengthening to determine the foods provided we

We carried out an unannounced inspection of Dean Wood Manor on 30 November 2016.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people living with a diagnosis of dementia. The premises are based around an original Grade II listed building which has been extended and modernised. Communal space within the home included a dining room and three lounges. There were also designated seating areas at the end of some of the corridors. The home has extensive gardens and on-site car parking is available. At the time of inspection 26 people were living at Dean Wood Manor.

At our previous inspection on 08, 09 and 15 June 2016, we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; person-centred care, dignity and respect, safe care and treatment, good governance, staffing and safeguarding service users from abuse and improper treatment.,

During this inspection, although we found some improvements had been made, we identified four continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment and good governance.

At the time of our inspection, there was no registered manager in post. The home had undergone several changes of management in the last couple of years and the current home manager had only commenced working at the home in September 2016. The home manager confirmed they would be applying to register with CQC. 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.

The people and their relatives we spoke with said they felt Dean Wood Manor was a safe place to live.

We found medication was not always given to people safely. New systems in place demonstrated that improvements had been made but further improvements were required. Procedures regarding cream application needed strengthening as staff did not refer to cream charts prior to applying cream and completed records retrospectively. People prescribed medicines to be given ‘when required’ had insufficient information recorded which meant they were at risk of not receiving their medication safely and consistently. We found there was still insufficient information recorded regarding people’s blood sugar levels to enable nurses to administer insulin safely.

This is a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found risk assessments had improved but required strengthening further as information contained in some of the care files we looked at was contradictory, which meant staff did not have consistent guidance to follow.

Recruitment practices required strengthening. Recruitment documentation was missing in some of the staff files that we looked at.

The home had suitable safeguarding procedures in place and staff demonstrated they knew how to safeguard people and follow the alert process.

At our last inspection, there were not sufficient numbers of staff effectively deployed to meet people’s needs. At this inspection, we observed staff responding to people in a timely way and staff were proactive in encouraging people’s freedom of movement.

Staff received an induction and appropriate training applicable to their role. We found some staff required refresher training in mental capacity, deprivation of liberty and dementia but the home manager confirmed the training was scheduled for early 2017.

The service was not compliant with the requirements of the Mental Capacity Act (2005) and the Deprivation

We carried out an unannounced inspection of Dean Wood Manor on 08 and 09 June 2016. We carried out a further announced inspection visit on 15 June 2016.

At our last inspection on 03, 05 and 12 November 2015, we found multiple breaches of regulations. The home received a rating of ‘Inadequate’ and was placed into special measures.

During this inspection visit, we found sufficient progress had not been made and there were continued systemic failures across the home. We found continued multiple breaches of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to: Person-centred care; Dignity & respect; Need for consent; Good governance; and, Staffing. We are currently considering our enforcement options in relation to these regulatory breaches.

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people. At the time of this inspection, there were 32 people living at the home . The premises are based around an original Grade II listed building that has been extended and recently modernised. There are extensive gardens surrounding the home and on-site car parking is available. The home is owned and operated by a partnership trading as Dovehaven Care Group. Throughout this report, the Dovehaven partnership is referred to as the ‘Provider’.

We looked at how people’s medicines were managed and found the service had continued to fail in ensuring that medicines were manged safely and administered appropriately; and had failed to ensure that staff responsible for the management of medicines were competent, skilled and experienced to do so safely.

We looked at people’s care records to ascertain that care, treatment and support which people needed was being delivered safely and that risks to people's health and wellbeing were being appropriately managed. We found people’s care records contained a variety of risk assessments and associated documentation. For example, skin integrity, allergy status, nutritional risks, continence, falls and waterlow. However, we found that risk assessments had not been consistently updated in response to people’s changing needs and, in some cases, risk assessments were incorrectly scored which meant that effective measures were not taken to minimise risk.

We looked at staffing levels to ensure there was sufficient numbers of staff to meet people's needs. At the time of our inspection visit 32 people were living at the home. The home was not at full occupancy because the Provider had agreed to a voluntary embargo on admissions following our last inspection. At this inspection, we saw that a dependency tool had been implemented and was used to determine the number of staff required to meet people’s needs. However, despite the use of a dependency tool, we found that throughout our inspection visits, their continued to be insufficient numbers of staff deployed to keep people safe and to meet their needs.

We looked at the recruitment policy and associated procedures and found safe recruitment practices were in place. Disclosure and Barring Service (DBS) checks had also been completed to ensure the applicant's suitability to work with vulnerable people. Records were maintained which demonstrated nursing registrations were valid and up-to-date.

We looked to see how the service sought to protect people from abuse and found there were appropriate safeguarding and whistleblowing policies and procedures in place. Staff were able to describe the homes alert process and the local authority procedures. All the staff spoken with demonstrated they had a working knowledge of the types of abuse and the procedure to follow if they suspected that a person was at risk of, or was being abused.

We asked staff about whistleblowing. All of the staff we spoke with told us they would not hesitate to use the policy and identified internal reporting protocols.

Since our last inspection of Dean Wood Manor, the Provide

We carried out an unannounced inspection of this service on 3 November 2015, with a further two announced inspection visits on 5 and 12 November 2015.

Dean Wood Manor is owned and operated by a partnership trading as Dovehaven Care Group. The premises are based around an original Grade II listed building that has been extended. There are extensive gardens surrounding the home and on-site car parking is available.

We last inspected this location on 12 August 2014 and found the service to be compliant with all regulations we assessed at that time.

The vast majority of people who used the service at Dean Wood Manor were living with a diagnosis of dementia; therefore people were accommodated in the service depending on their assessed needs. The Woodlands Unit, located on the lower ground floor, provided residential type care, whereas the ground floor at Dean Wood Manor accommodated people living with more complex needs. For the purposes of this report, care provided on the ground floor of Dean Wood Manor, will be referred to as the ‘nursing unit.’

Dean Wood Manor is registered with the Care Quality Commission (CQC) to provide nursing and personal care to a maximum of 50 people. At the time of this inspection, 33 beds were occupied on the nursing unit, and each of the seven beds were occupied on the Woodlands Unit.

At the time of this inspection there was no registered manager in post at Dean Wood Manor. The acting manager told us they were applying to the CQC to register as the registered manager for the service. A registered manager is a person who has registered with the CQC. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection, we found multiple breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 in regard to person-centred care, dignity and respect, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. We are currently considering our enforcement options in relation to these regulatory breaches.

Following the takeover of Dean Wood Manor in March 2015 by Dovehaven Care Group, the new owners embarked on an extensive refurbishment programme. At the time of our inspection visit, the refurbishment work was still on-going and the building contractors were still on site. We looked at how the service had planned to manage and mitigate the risks associated with the refurbishment programme and found a risk assessment had been produced in July 2015. However, during our inspection visit, we found the service had failed to adhere to its own risk assessment which exposed people who used the service to the risk of avoidable harm.

During day one of our inspection, we found the service had failed to ensure that the building contractors were working in a way which would keep people who used the service safe. They were working in a way which exposed people who used the service to a risk of harm. We found a communal door leading to an area where building work was being carried out had been wedged open. This area was left unsupervised and contained power tools, trailing electric cables, and step ladders. We also observed a number of care staff going about their duties without recognising the potential danger for this situation.

We found the service had failed to deploy sufficient numbers of staff in order to meet the needs of people who used the service and failed to demonstrate a systematic approach in determining the number of staff required. Furthermore, the service failed to ensure staff were suitably qualified, competent, skilled and experienced; and failed to ensure staff received appropriate professional development and supervision.

The service failed to protect people who used the service against the risks associated with the safe management of medicines. We found medication was not administered as per instructions; errors were identified on Medication Administration Charts and the medicine’s fridge temperature was too high on the nursing unit.

People were not protected against the risk associated with the control of infection. We found that during refurbishment work, wall mounted personal protective equipment (PPE) such as disposable gloves and aprons and hand cleansing units had all been removed. This meant appropriate PPE was not available at the point of care.

Care plans and associated documentation were not of a consistently good standard with gaps and omissions in recording. Information was disorganised and not easy to understand. Care plans were not sufficiently person-centred and did not consistently demonstrate people’s likes, dislikes, personal preferences and their life history.

We found the service had failed to ensure that people who used the service, and/or their representatives, had been involved in decisions relating to the refurbishment work and that insufficient information had been provided.

We found the service had failed to follow nationally recognised evidence based guidance in the care and support of people living with a diagnosis dementia.

We looked at staff recruitment to make sure safe recruitment practices were being followed. We found the identity of people applying to work at the service had been checked, references had been sought and checks had been completed with the Disclosure and Barring Service (DBS). A DBS check helps to ensure that potential employees are suitable to work with vulnerable people.

The service had an appropriate whistleblowing policy in place and staff told us they were aware of the policy and were confident about how to use it.

Records confirmed that regular checks of the fire alarm had been carried out to ensure that it was in safe working order. Documentation and certificates demonstrated that relevant checks had been carried out on the gas boiler, electrical systems and fire extinguishers.

Personal emergency evacuation plans (PEEP) were not always completed and the evacuation status of each person who used the service was not readily available as the service did not maintain a ‘PEEP grab file’ for use in emergencies.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met.

The service had a policy in place concerning DoLS and information was included about best interests. We looked at a sample of DoLS documentation and found that due processes had been followed by the service and that decisions were made in those peoples best interests. However, we found the conditions of two peoples’ DoLS had not been adhered to and the service had failed to keep these people safe.

On the nursing unit, we found the mealtime service was rushed and chaotic, and noise levels were unacceptably high; all of which contributed to a poor meal time experience for people who used the service. On the Woodlands Unit, people who used the service were encouraged to eat and drink in a positive manner and the dining experience was calm and well managed.

We looked to see how the service supported people with their on-going health and support needs and found appropriate referrals were made to external professionals and agencies in order to meet people’s needs. For example, the service had regular contact with community older age mental health services and regular input from physical health teams such as community physiotherapy.

Throughout our inspection visit, we found a lack of co-ordinated operational leadership which impacted on the quality of care being provided. Additionally, since taking ownership of Dean Wood Manor, we found the provider had failed to demonstrate sufficient oversight to recognise and respond to existing and newly emerging issues. The Provider failed to deliver on reassurances made to CQC during the takeover of Dean Wood Manor. In particular, reassurances around training and development of staff and involvement of people who used the service and/or their representatives.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve;
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made;
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of ‘Inadequate’ for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.