Dene Place 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. Dene Place Care Home is registered to provide nursing and personal care for up to 30 people. There were 16 people living at the service at the time of our inspection.

This inspection site visit took place on 13 September 2018 and was unannounced.

There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 last comprehensive inspection on 7 November 2017 and focused inspection on the 12 February 2018, we asked the provider to take action to make improvements in relation to the deployment of staff, the delivery of safe care to people, activities available to people and the leadership and quality assurance at the service. At this inspection we found that this had improved.

There were appropriate levels of care staff to support people when they needed it. These were reviewed regularly dependant on the needs of people that lived at the service. Risks to people’s personal safety had been assessed and plans were in place to minimise these risks. Staff understood risks associated with people’s care. There were appropriate plans in place in the event of an emergency. Accidents and incidents were acted upon and steps taken to reduce the risks.

Steps were taken to review the care and the delivery with actions to make improvements. Methods they used included surveys, audits, resident and relative meetings and staff meetings. Where shortfalls were identified actions were taken to rectify this. People were supported to make a complaint if they needed to. Complaints were investigated and improvements made where needed.

People said that they felt safe. Staff ensured that people were protected against the risk of abuse and told us that they would not hesitate in reporting any concerns. Robust recruitment of staff took place before they started work. Staff understood how to protect people from the risk of infections.

People’s medicines were managed safely and appropriately by staff. People had access to pain relief when they needed. People’s nutrition and hydration were managed to ensure they received the most appropriate care. Health care professionals were involved with the care of people and people were supported to attend health care appointments. People’s needs were assessed fully before they started to receive care at the service.

Training and supervision were provided to staff that ensured that the most appropriate care was being provided to people. We saw through observations that staff were knowledgeable and effective in the care that they provided. Staff were effective in sharing information in relation to the care of people and worked in line with current guidance.

The Mental Capacity Act 2005 (MCA) is a legal framework about how decisions should be taken where people may lack capacity to do so for themselves. Staff had received training around the MCA and how they needed to put it into practice and staff were knowledgeable in this. There were people at the service that had the capacity to make decisions about their care and staff respected this. Where people were being restricted, applications were submitted to the Local Authority in line with the legal requirements.

Staff showed care and empathy towards people. It was clear that staff had good relationships with people and understood what was important to them. Staff showed patience, dignity and respect and people responded well to staff.

People receiv

Dene Place Care Home 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. Dene Place Care Home is registered to provide nursing and personal care for up to 30 people. There were 19 people living at the service at the time of our inspection.

The was no registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. We were supported by the new manager who has submitted their application to the CQC to become the registered manager.

We undertook a focused inspection following concerns that were raised in relation to people not having a choice over when they wanted to get up and concerns around the safety of the care being provided. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dene Place Care Home on our website at www.cqc.org.uk.

Staff were not effectively deployed around the service to ensure the safety of people. As a result people did not have choices around delivery of care. At times people were waiting for staff which put people at risk.

People were not always protected from the risks of unsafe care. Where risks had been identified staff were not always ensuring that the most appropriate care was being delivered. This included staff not updating wound care plans and not always completing care records when needed.

We identified that a safeguarding incident had not been appropriately investigated with actions taken to reduce further risks. After the inspection we were notified by the manager that this incident had now been addressed. We have made a recommendation around this.

Quality assurance was not effective and sufficient actions had not been taken by the provider in relation to the standards of care. The provider had not met breaches in regulation from the previous inspection.

People were supported to take their medicines as prescribed. People’s medicines were managed safely and appropriately by staff.

There were appropriate plans in place in the event of an emergency. Staff were following good infection control practices. Robust recruitment of staff took place before they started work.

There was a new manager at the service and staff told us that they had started to see improvements in the leadership.

After the inspection the provider notified us that they had sent in a ‘Service Recovery’ team to the service to support the manager with the improvements needed. We will check on these improvements at the next inspection.

The service was last inspected on the 7 November 2017 where breaches were identified in relation to the lack of person centred care, the deployment of staff and the lack of robust leadership and governance. At the inspection on the 7 November 2017 the service was rated as Requires Improvement.

This inspection was carried out on the 7 November 2017 and was unannounced. Dene Place provides nursing care and accommodation for a maximum of 30 older people. The home is owned and operated by Bupa and is a large detached property situated within National Trust grounds. At the time of our inspection 20 people were living at the service.

There was no registered manager in post on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Instead we were supported by the deputy manager and senior staff from BUPA.

People told us that there were not sufficient staff at the service. Through our observations we found that staff did not respond to people in a timely way as they were busy elsewhere. People were not always receiving support when it was needed by staff. There had been a lack of an activities coordinator at the service and care staff did not have time to fulfil this role.

People told us that staff did not have the time to spend talking to them and sometimes they felt that they were not listened to as staff were busy. People did not always have the choice as to when they got up and when they went to bed.

People told us that they did not have enough to occupy them. There were insufficient activities taking place. Relatives felt that their family members were bored.

There was a lack of consistent leadership at the service. There had been two changes of manager since the last inspection. As a result people, relatives and staff did not feel supported and they felt the service lacked management oversight. People and relatives did not always know who the manager was. Staff felt overworked and did not always feel valued.

Although there were systems in place to review the quality of care these were not always used to make improvements. Records were not always up to date and accurate. This resulted in a continued breach in relation to this. There were some aspects to the quality assurance that were effective in making improvements to the care provision.

People said that they felt safe with staff. Staff understood what to do in order to keep people safe from harm or abuse. All of the staff had received safeguarding training and knew what to do if they suspected abuse. There were robust recruitment systems in place to ensure that only suitable staff worked at the service.

Assessments of risks for people were undertaken when they first moved in and on a continuing basis. Other than the risk of falls where people were left unsupported by staff; staff understood the risks to people and took steps to reduce the risks. Staff understood what to do if there was an emergency in the service such as a fire or a flood. There were evacuation plans in place for people and a contingency plan if the service needed to close.

Staff understood what they needed to do to ensure people were protected from the risk of infections. Staff were seen to adhere to good infection control practices. The service was clean and well maintained. Accidents and incidents were analysed and actions taken to reduce further risks.

Staff understood the principles that related to the Mental Capacity Act 2005. Where there was a doubt about a person’s capacity appropriate assessments took place. Best interest meetings were held and where appropriate applications were submitted to the local authority if people were being restricted. .

Staff received a detailed induction and appropriate training for their roles. Regular supervisions were provided to staff to ensure they were providing the most appropriate care.

People had access to sufficient food and drink. Where people were at risk of dehydration and malnutrition there were care plans in place

This inspection was carried out on the 13 December 2016. Dene Place Nursing Home provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 30 people. At the time of our inspection 25 people were living at the service.

There was a registered manager in post however they were on leave on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Instead on the day we were supported by the deputy manager. At our last inspection on 24 September we found breaches of regulation around person centred care, dignity and respect, capacity assessments, safe care and treatment, safeguarding, good governance and staffing. We carried out this fully comprehensive inspection to check to see if improvements had been made.

Care and treatment was not always provided with the appropriate consent from people and staff did always not work within the principles of the Mental Capacity Act 2005. People did say that staff asked them for consent before providing care.

Not all aspects of the management of medicines were safe. Medicines were not always properly accounted for or dispensed safely. People’s Medicine Administration Records did include appropriate information about people.

There were insufficient systems and processes in place to identify improvements in the service and records were always not up to date or accurate.

Clinical staff did not always receive appropriate supervision in relation to their role. Other care staff did receive regular one to ones with their manager to review the work they completed.

There were sufficient staff deployed to meet the needs of people. People told us that there were enough staff.

People said that they felt safe. There were systems in place to protect people from the risk of abuse. There were appropriate recruitment practices in place and staff were suitably trained in relation to their role.

Staff understood the risks to people and steps were taken to reduce the risks. Incidents and accidents were dealt with appropriately. There were plans in place to protect people in the event of an emergency.

People told us that they liked the food at the service and said they had enough to eat and drink. Appropriate assessments of people’s nutritional and hydration needs were undertaken and people had access to professionals to maintain their health.

People told us that staff were kind and caring towards them and that they felt included in their planning of care. We observed that staff treated people with respect and dignity. Family and friends were welcomed at the service.

Care was delivered to people in a personalised way and pre-admission assessments were detailed before people moved in.

There were sufficient activities for people and people said they enjoyed the activities on offer. We have recommended that work is undertaken to ensure that people are able to go to activities outside of the service.

Complaints were investigated thoroughly and people said that they were satisfied with the way complaints were dealt with.

People and staff were asked for their feedback on the service provided and improvements were made as a result.

People and staff felt the service was managed well. Staff said they felt supported in their role and they felt valued by the management team.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events.

We identified continued breaches of the Health and Social Care Act 2008. You can see what action we have taken at the en

This inspection was carried out on 24 September 2015. Dene Place provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 30 people. On the day of our inspection 24 people lived at the service. The accommodation is arranged over two floors.

There was a registered manager at the service on the day of the 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.

There was not always enough staff deployed around the service to meet people’s needs. People were at times left for long periods of time without support from staff. People did not feel that there was always enough staff. One person said that there were usually enough staff but said that on the day of the inspection they seemed short staffed.

Staff did not always have the knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. Safeguarding referrals were not always made to the local authority where necessary. However people did say that they felt safe with staff.

Risks were not always managed appropriately for people around concerns that had been identified. Accidents and incidents were not always recorded to identify any trends or minimise reoccurrences. Other risk assessments for people were detailed and informative and included measures that had been introduced to reduce the risk of harm.

Staff were not always knowledgable about their responsibilities under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes.

Staff were not kept up to date with the required service mandatory training or supervisions and there was a risk that people were not receiving the most appropriate care from skilled staff. However staff told us that they felt supported in their roles.

People’s nutritional needs were not always being monitored appropriately in relation to referrals to health care professionals. Other aspects of food and nutrition were good. One person said “The chef is great, they would do anything for me” Nutritional assessments were carried out as part of the initial assessments when people moved into the home.

There were occasions where staff were not as caring as they could be and did not always treat people with dignity. However people and relatives felt that staff were kind and caring. One person said “Staff seem to care about me, they check I have washed and help me with my clothes.” We observed some kind and caring interactions with staff and people.

People’s records did not always include sufficient information to enable staff to provide appropriate care and support. Whilst we were at the inspection we identified that people had not always had the most appropriate care for their needs. We found that not all of the records at the service were accurate and complete for each person.

There were no effective systems in place to ensure the quality of the service. Audits did not always identify the shortfalls in the service.

People said that they understood what medicines they were receiving. Medicines were stored appropriately and audits of all medicines took place. People received their medicines appropriately.

In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and made them safe.

People were safe because the provider carried out the necessary checks on staff to ensure that only suitably qualified staff were recruited to support the people that lived here.

People had access to other health care professionals in a timely way. For example the GP, opticians, community dentist and physiotherapist visited the service.

People told us that before they moved in the manager undertook a pre-assessment of their needs. One person told us that they were visited at home by the manager (with their family present) to assess their needs.

People and relatives said they felt involved in the planning of their care. One person told us that they were very much involved and they also chose to have their family involved as well. Relatives told us that they felt involved in the planning of care for their family members.

There was a complaints procedure in place for people to access and people knew how to make a complaint. One person said “If I wanted to complain I would tell the care assistant or the manager.”

People and relatives were complimentary of the activities that were on offer. One person said “The activities are great.” There was a wide range of activities on offer for people which included room visits for people, hand bells, musical workshops, manicures and crosswords However people told us that they would like to go out more on day trips but that this wasn’t always possible due to the service not having a vehicle.

People and staff felt supported by the manager. One member of staff said “I find her very approachable, everyone gets on well here.”

The registered manager had informed the CQC of significant events in a timely way. This meant we could check that appropriate action had been taken.

During the inspection we found breaches of 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.

During the inspection we spoke with 14 people who used the service, two visiting relatives, the manager, deputy manager and eight members of staff.

At our last inspection, we identified concerns with cleanliness and infection control, the availability of staff, the support staff received to do their jobs and record-keeping.

At this inspection, we found that the provider had taken action to improve these areas.

People who used the service and their relatives told us that the home was kept clean and fresh. We found that staff had attended training in infection control and that cleaning schedules had been introduced.

People who used the service and their relatives told us that staff were available when they needed them. They said that staff were kind and helpful. We observed that there were sufficient staff on duty to meet people’s needs during our inspection. Although there were sufficient staff available, the continuity of care people received had been affected by vacancies in the permanent staff team, which meant that agency staff were employed on each shift.

We found that all staff had received an appraisal or one to one supervision since our last inspection. Records of staff training were up to date and sensitive information was stored appropriately. We found evidence that staff had attended all elements of mandatory training but some staff identified training needs which had not been met.

As part of this key inspection we were accompanied by an expert by experience. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service. Using an expert by experience is a way of helping us find out about the experiences of people who use services.

The expert observed and spoke with people using the service to gain their views about how people are respected and involved and how they are cared for. They observed the meals that people received and gained their views about staffing, their care and support. Feedback from the expert has been included in this report.

People using the service told us that staff respect their privacy and that most staff are caring.People are supported to attend meetings to give their views. People we spoke to said that they enjoyed the range of activities provided. They also spoke positively about the activities organiser.

People told us that they can choose their meals and that they enjoyed the meals provided.

Generally people were happy with their care and support, although some people said that they were not aware of their plan of care.

Some people using the service told us that there is not always enough staff, which means they sometimes have to wait for assistance.

We spoke with seven members of staff, five people who used the service and two visitors. We also reviewed five care plans for people who used the service.

We saw that consent was gained from people who used the service using the correct procedure. Staff were also heard asking people if they could provide support and care where appropriate. One member of staff told us that they ask for consent when providing personal care, giving medication or even helping a person to eat.

We saw that people's needs were being assessed and care and treatment was being planned and delivered in line with their individual care plan. One person told us “I love it here and I always get the support I need.” We could see that there were lots of activities available for people and we also saw people who used the service being actively involved. For example, we saw the activities co-ordinator doing arts and crafts with people who used the service.

We saw that the home looked clean and tidy. However, we found concerns with the way the service managed their Infection Control. For example; dirty commodes, dirty bins, no cleaning schedule and problems accessing hand washing facilities.

Staff all told us that they did not feel supported and that their training was not up to date. We found evidence to show that the provider was failing to support staff and failing to maintain appropriate training and records.

We found concerns with record keeping which will be highlighted within our report.