The inspector gathered evidence against the outcomes we inspected to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
Concerns had been raised with the Care Quality Commission regarding the number of staff who had recently ceased working for the provider at the home, unauthorised access to the premises and insufficient staff to meet the needs of people who lived in the home.
We inspected Denham Manor over two days a Sunday and Monday. We found the provider had assessed the needs of people and from that had established what their staffing requirements were. We looked at the roster for the two weeks prior to the inspection and found for most of the days the provider had in place the required number of staff through the use of agency staff. The provider told us they were currently undertaking recruitment for the vacant posts.
When we arrived at the home we rang the front door bell several times. After a waiting for a response we tried to access the building using the keypad attached to the door lock. As certain numbers were worn through repeated use, we were able to key in the right numbers to allow us access without any staff being aware we were in the building. We informed the provider who took immediate action to change the keypad and key code.
We saw records which showed the provider had applied the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards to the care provided to two people. The provider had identified where the care and support provided to these people may have deprived them of their liberties in order to keep them safe. The least restrictive manner had been used to protect people and this had been authorised by the Supervisory body. This meant people who used service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards
People told us they felt safe living in the home. Although we found call bells were not always accessible to people and staff had not always responded in a timely way.
Systems were in place to make sure that managers and staff learnt from complaints and concerns. This reduced the risks to people and helped the service to continually improve.
Each person's care plan included a risk assessment to identify the risks of harm or illness and measures in place to reduce these risks. This protected people and staff from the risk of harm or injury when care is provided.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to care and welfare of people who use the service.
Is the service effective?
One person told us a lack of activities had led to boredom. We observed a lack of activities within the home. Other people told us the activities on offer were not to their liking. The provider told us they have recruited a new activity organiser, and plans will be made to improve the level of activities on offer.
Staff were not always able to communicate with people in a way that they were understood.
People told us the staff and management were responsive to queries and suggestions. One staff member told us how the staff are encouraged to make suggestions in team meetings. A relative told us how they were involved in the planning and delivery of care and this had been important to them.
We have asked the provider to tell us what they are going to do to ensure that people's social and communication needs are met.
Is the service caring?
One relative told us 'everyone is friendly'very considerate about Mum's needs as a person. I can only be complimentary about the staff; they are the most important thing when it comes to care.' Another relative told us 'the care has been second to none, it has been very good.' They went on to tell us the home offered them 'peace of mind, you can leave knowing the person is in safe hands.'
People using the service, their relatives, friends and staff involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.
We observed positive interaction between staff and people who used the service. However, we noted staff were focussed on completing care tasks and less on communication with people.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to providing care to people in a way that protects their welfare and meets their needs.
Is the service responsive?
Care staff told us how responsive the nurses were to any concerns regarding the health of people who used the service. They told us the nurses would respond immediately if they felt the person was unwell or the care worker was unsure of what to do.
The provider had in place a complaints procedure that was accessible to people in the home. One person told us they did not know how to make a complaint, whilst others did.
Where people or their relatives had made a complaint or comments the provider had responded appropriately.
Is the service well-led?
Everyone we spoke with told us they felt the service was well led.
We saw the provider had safe practices in place when recruiting staff. Currently the home is recruiting to fill staff vacancies, at this time the deficit is being met through the use of agency staff.
Induction, supervision and appraisal records for staff were not detailed or complete. Not all staff had received induction training, regular supervision or appraisal in line with the provider's policy.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.