Deneside Court

Updated 19 February 2022

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 Care Act 2014.

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

The inspection was completed by two inspectors, a pharmacist, a nurse specialist adviser and two Experts 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

Deneside Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager who was in the process of registering with the Care Quality Commission. Once registered they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, staff at the service, and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service, the manager, two members of the management team, two care staff, a physiotherapist, a domestic staff member, the chef, a maintenance employee and 14 relatives. We reviewed four people's care records and two specific records associated with supporting people’s emotional behaviours. We looked at the governance arrangements for the safe handling of medicines including the provider’s policy and audits. We looked at medicines’ records for nine people. We reviewed maintenance and cleaning records, three staff files, and a range of other records relevant to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked in more detail at arrangements in place for maintenance, repair and cleaning of the premises. We looked at training data and quality assurance records. We spoke with three care staff and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 19 February 2022

Deneside Court is a residential care home providing personal and nursing care to 38 people aged 18 and over at the time of the inspection. The service can support up to 40 people across three floors. The service provides care for people with complex needs including those with a learning disability or autistic spectrum disorder, mental health condition, older people, physical disability or people living with dementia.

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

Medicines were managed safely but some improvements were needed. We have made a recommendation about the management of some medicines. We were assured overall about infection prevention and control practices at the service.

Some areas of the home required further maintenance, repair and cleaning to maintain a good environment. We carefully reviewed the extent, impact and circumstances of these observations and received suitable assurances. The provider had action plans in place to manage the premises and dealt quickly with any immediate issues.

Assessments of people’s needs were completed, and systems and processes were in place to mitigate identified risks to people and staff. Incidents were dealt with appropriately. There were enough suitably skilled staff to meet people’s needs.

People were protected from the risks of abuse. Staff had received safeguarding training and processes were in place to support staff to raise any concerns.

The service worked well with other health professionals who were routinely involved with people’s care.

The service required a manager who was registered with the CQC. The service had a manager in post. The manager’s application process had been commenced but not progressed to the submission of an application as required due to events outside of the provider's control. We took this into account when making our judgement.

Managers understood their regulatory requirements and used audits and other checks to continually assess, monitor and improve the quality of the service. They involved people, relatives and staff in this process, using their feedback and complaints to make positive changes to the service.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture.

Right support:

¿ The model of care and setting maximised people's choice, control and independence. People, and where appropriate their relatives and advocates were involved in their care planning. Records were regularly evaluated and updated as people’s needs changed. Care planning included outcomes and goals for people. Case studies evidenced how peoples support from the service had led to positive outcomes with a focus on achieving maximum possible independence.

Right care:

¿ Care was person-centred and promoted people's dignity, privacy and human rights. Staff treated people with kindness, compassion and respect. Staff supported people in the least restrictive ways and in their best interests.

Right culture:

¿ Ethos, values, attitudes and behaviours of leaders and care staff ensured people using services led confident, inclusive and empowered lives. The service was well managed with an approachable and supportive leadership team in place. Management were open and transparent, and the provider was honest with people and their relatives when things went wrong. Staff told us they had a strong supportive team that had helped develop and strengthen the person-centred culture and ensured people were supported to make decisions for themselves to live their best lives.

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 this service was good (published 10 April 2020).

Why we inspected

The inspection was prompted in part due to concerns received about staffing, and the ability of the provider to manage known risks of harm to people to keep everyone safe. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of Safe, Responsive, and Well-led only. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has remained good. This is based on the findings at this 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Deneside Court on our website at www.cqc.org.uk.

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.