Deepdene Court

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

We identified two breaches of the legal regulations. People were not consistently protected from the risk of harm and abuse. Staff did not always identify allegations of abuse or make safeguarding referrals in line with safeguarding policy. People told us they did not always feel safe. One person described how they felt anxious when other people had incidents of distress or became angry and emotional. Incidents were not always recorded and reported in line with the provider’s policy. This meant there was a lack of scrutiny and missed opportunities for staff to learn from incidents and to ensure risks were appropriately managed. Risks to people were still not consistently identified, assessed and managed. Care plans did not always provide the guidance staff needed to support people’s needs and manage risks. People and their relatives were not consistently involved in planning care and in managing risks. Staff were not referring to care plans consistently and not all staff were familiar with people’s needs. This increased the risk that people’s needs might not be met. It remained that medicines were not managed safely. Some medicines required clinical oversight. Nurses were not on duty at night-time, this meant there was not always a nurse available to provide clinical oversight or to make clinical decisions when needed. Records were not always clear and accurate and this meant staff did not have all the information they needed to administer medicines safely and in line with prescriber’s instructions. However, there were now enough suitable staff to provide care safely and improved systems for the safe recruitment of staff. There were effective systems to manage infection prevention and control. People were satisfied with their accommodation although some environmental risks were not consistently managed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People had confidence in the regular staff and said they would speak with them if things went wrong. One person said, “The staff are always open and honest with me.” However, our assessment found shortfalls in some aspects of care. Lessons were not always learned following incidents, this meant people continued to be exposed to risks of harm.

Staff told us not all incidents that occurred were being reported in line with the provider’s systems. Staff did not always identify and implement changes to reduce risks to people. One staff member said, “I don’t feel listened to by management in terms of incidents. I’ve no idea what gets done to make a change – they (incidents) keep happening, so I guess not a lot.” We spoke with a leader about how incidents and accidents were analysed to support learning. They confirmed the person in charge would know about an incident when an incident report had been completed. They would undertake analysis to determine if all appropriate actions had been taken following an incident and would identify learning from mistakes. If the incident form had not been completed, the person in charge may not be aware that the incident took place. Medicine errors were reported, however care staff felt there was no shared learning from this. We noted there was a lack of documented medicines discussions in staff meeting notes which meant there were missed opportunities for learning from mistakes.

Systems for monitoring incidents and accidents were not effective. Daily records showed that not all incidents were being reported in line with the provider’s policy. This meant the person in charge was not aware of all incidents that were happening. Systems for oversight and analysis did not consistently include the route cause or any triggers for the incident. This meant the provider could not be assured that appropriate measures were in place to reduce the risk of incidents recurring or that learning from incidents had taken place.

People spoke positively about how staff supported them to transition between services, including when they moved to or from hospital. One person told us about their experience when they moved to Deepdene Court, they said, “I was given information on what support the home could provide me with.” People described being supported to access health and social care services. One person told us, “The staff support me with appointments, they do this well.” Some people described their aspirations to move on from the service. One person said, “I will be home at some point.” Another person said, “If I wanted help with moving forward, I would discuss this with the manager.”

Staff described how they had developed positive working relationships with partner agencies including mental health, physical health and social care services. One staff member described how they ensured smooth transitions between services. They were kept informed of changes with a person’s mental health needs by attending the hospital ward round when a person was admitted to hospital. They explained how this would aid a smooth transfer home when the person was well enough to leave hospital.

The local authority told us the Provider had engaged with them through their Operational Framework for Managing Provider Concerns.

When people came to Deepdene Court an initial assessment was undertaken to ensure the service could meet their needs. Systems included a regular review of risk assessments and care plans to update them when people’s needs changed. This process was not always effective in ensuring that risk assessments and care plans reflected people’s needs and the care provided. For example, not all risks had been identified and assessed including health care needs. Care plans did not always provide staff with the guidance they needed. This increased risks to people of not receiving the care they needed in the way they preferred. Systems to support people with their mental health recovery were not always evident. There was a lack of planning to support people to progress on their journey to improve mental health and wellbeing. Consideration was not always given to how people could achieve their goals and aspirations. There was a lack of consistent planning for activities that could provide structure and enrichment in people’s daily lives. Some people told us they hoped to move on from the service to achieve more independence but there was no clear plan in place to support this aspiration.

People had mixed views about whether they felt safe living at Deepdene Court. Some people said there were times when they did not feel safe. One person said, “I feel safe living here most of the time but some of the residents have challenging behaviours, this has caused me to become anxious”. Another person told us of an incident when a staff member had shouted at them and they had not felt safe. Daily records showed incidents of distressed behaviour were frequent and included altercations between people who lived at the home or with staff. One person told us, “I do feel safe living here, the staff would make sure I was safe and look after me well.”

Staff had received training in safeguarding people and were able to demonstrate an understanding of their responsibilities. However, some staff told us they were aware that potential safeguarding incidents were not always reported. They said there was, “No point, because nothing changes.” Other staff lacked a clear understanding about when incidents should be recorded and reported. One staff member told us, “Verbal altercations and physical threats should be recorded as incidents and safeguarding should be considered, but oversight of this has slipped.” This meant the provider could not be assured that all incidents were recorded, reported and that appropriate actions had been taken to ensure people were safeguarded. Some staff told us they had witnessed staff members shouting at service users, but this had not been reported or documented. They told us staff were, “burnt out” due to the high number of incidents that occurred at the service. One staff member described how some staff responded to incidents of distressed behaviour, saying, “Sometimes staff interactions in response are not always as respectful as they should be.” We spoke with the person in charge of the home who said they were not aware of any incidents of this nature.

The atmosphere was calm and staff were supporting people in communal areas. When a person was showing signs of distress and frustration a staff member spoke with them quietly to resolve the issue and defuse the situation.

Incidents had not been consistently reported in line with the provider’s safeguarding policy. Systems were not effective in identifying incidents that were potential safeguarding events. This meant not all safeguarding incidents were escalated and reported to the local authority and the Care Quality Commission. There was a failure to ensure that people were always safeguarded from risks of abuse and the provider could not be assured of external scrutiny, because not all incidents had been identified and reported. Where Deprivation of Liberty Safeguards (DoLS) were in place there was a system for recording any conditions.

People were not consistently involved in assessing and managing risks. Some care plans included people’s views and preferences but this was not consistent. People told us they were not always involved. One person said, “I don't know if I have a care plan, I have never been consulted about this.” Another person said, “I have never seen my care plan and never been consulted.” A third person said, “I have a care plan, but have not seen it for around 6 years.” Risk assessments were not well personalised. For example, some people smoked cigarettes and general smoking risk assessments had been completed but these did not always include individual risks such as a history of falling asleep when smoking or use of emollient cream containing flammable ingredients. This meant there were not always robust measures in place to mitigate individual risks.

Staff did not always know people well and were not always informed about risks to people. For example, a staff member was aware of some people’s needs including a person who was at risk of choking and a person who had diabetes. However, they were not aware that other people had diabetes, or that some people were being assessed for risks of choking. Staff were not accessing care plans regularly. One regular staff member told us, “People do have care plans but I’m not sure who writes them, and I have not seen one in a long time.” Another staff member said, “You need to be logged on (to the electronic system) to see care plans, and we don’t have the time or staff numbers to do that.” Another staff member said, “Staff lack understanding of care planning, they should be updated monthly as well as risk assessments, but staff didn’t write them and rarely get to see them as they are all stored electronically.” Staff said they were not aware of positive behaviour support plans for people who had complex needs. One staff member said, “I’ve never seen a plan like that. Although we don’t really get time to see the care plans etc so they maybe there and we have just not been told.” This meant the provider could not be assured that staff had the information they needed to provide care safely and in the way people preferred. Following the assessment the provider confirmed additional support had been put in place to ensure staff were able to access the information they needed in care plans.

We observed staff supporting people at meal time, including a person who was at risk of choking. The member of staff was aware of these risks and was attentive to the person.

People had a range of physical and mental health needs. Some people had complex mental health needs and required support to manage distressed behaviour, which at times, posed a risk to themselves or others. Staff did not always have clear guidance to ensure people were supported appropriately. The provider’s policy required there to be a clear personalised care plan to advise staff in how to manage these risks, including appropriate distraction techniques, de-escalation strategies and where needed a behaviour support plan. Care plans did not always provide clear information and behaviour support plans were not in place for all people who needed them. This meant staff did not have all the information they needed to provide safe care and support to manage these risks effectively. Some people had risks associated with health conditions including diabetes, but not all people had a risk assessment and care plan to ensure staff knew about the level of risk and how to support them to manage the condition. Staff did not always know people well and this increased the risk that they would not receive the support they needed. One person was identified as having high risks associated with skin integrity. They had a skin wound but there was no care plan in place to guide staff in how to support them and no body map to identify the location of the wound. Some people had been referred to a Speech and Language Therapist as they were observed to have difficulties with swallowing. There were no risk assessments or care plans in place to guide staff in how to support them whilst they waited for the SaLT assessment. This meant staff were not all aware of these risks and did not have guidance in how to support people to mitigate risks of choking.

People told us they were satisfied with the environment and considered it to be homely and comfortable. One person told us, “I would say it feels like a home, it’s well decorated and furnished.” Another person said, “It feels homely, it’s nicely decorated, my bedroom is comfortable and I am satisfied with this.” Another person told us, “I am happy with my room and have been able to personalise it.” One person told us their bed was not comfortable. The bed was not suitable for the person’s needs but staff told us a specialist bed had now been ordered. People were aware of the provider’s policy about not smoking in the home to maintain a safe environment. One person told us, “The staff do check, i have smoked in my room in the past and received a warning letter from the home.”

Staff said the provider’s policy was not effective in preventing people from smoking in their rooms. One staff member told us, “Smoking is still happening in bedrooms, people are verbally warned and staff speak with them about this, but what more can we do? They keep doing it, although posters are up warning them they could have to leave if caught, that’s never happened and they know that.” Staff described the environment as needing refurbishment. One staff member said, “It just looks so run down.” They explained how challenges with maintaining the environment made it more difficult to keep the place clean. One staff member told us it was not clear who was responsible for supporting people to keep their bedrooms clean. They said it should be care staff supporting people but they don’t have time so it is left to domestic staff and sometimes gets missed.

We noted there were indications that people were smoking in the rooms contrary to the provider’s policy. Ash and burn marks were evident in some rooms, including bedding with burn holes, and there was a smell of smoke in some areas of the home. Some areas of the home were in need of refurbishment

Daily records showed staff were checking when they suspected people were smoking in the home, but they consistently found people were ignoring the policy, including those who had already receiving warnings from the provider. There was no record kept when people left the building, this meant staff could not be sure who was in the building in the event of a fire or other emergency. Systems were in place to monitor environmental safety, including audits and maintenance action plans, fire safety checks and Personal Emergency Evacuation Plans for people who might need support in the event of an emergency.

People spoke positively about the care staff and domestic staff at Deepdene Court and said they were kind and caring. One person said, “The staff do their best.” People described a high turnover of staff and spoke about the impact this had on their care. One person said, “They (staff) keep leaving.” Another person said, “Sometimes they don’t tell us if a staff member leaves, I think they should inform us.” One person told us the regular staff were well trained, saying, “They know what they are doing and they are experienced.” People told us agency workers were not always familiar with their needs and preferences. One person described the impact of this, they said, “I do feel not listened to and feel disconnected because of my difficulties with hearing.” Another person told us, “I feel they don’t understand my needs.” Another person told us, “I feel my psychological needs are too difficult for the staff here to support me.” People said they felt concerned about the high turnover of managers, one person described feeling worried that the home might close. Another person said, “The managers never stay too long.”

Staff told us they did not feel there were enough staff on duty. One staff member said, “It is stressful at times and there are not enough of us in my opinion, which is why we can’t even read care plans etc as we don’t have the time.” Another staff member told us, “I don’t feel there is enough staff to give resident’s quality time.” They explained this meant people were not being supported with activities or social interests. One staff member said, “There are times I don’t feel safe when working alone.” They explained communication systems were not always effective and said, “Other staff would come if you needed help, but we are told just to lock ourselves behind a door if we feel threatened or at risk of harm.” Staff described a lack of leadership and support due to frequent management changes. One staff member said, “It’s been tough, but we just had to get on with it and crack on.” Staff had different opinions about how they were supported. Some staff told us they were supported with supervision meetings although these had not been frequent and regular. Other staff had not received supervision. One staff member said, “I’ve not had any supervision since I’ve been here.”

We observed there were enough staff on duty to support people’s physical needs but there was a lack of engagement and interactions between staff and people were limited. During meal-time some people ate in the dining area and staff were on hand to support them, but there was little conversation between staff and people. Staff were observed to ask people if they needed to go and see the nurse for medication and informed them when lunch was ready. We did not observe staff supporting people with activities to provide enrichment.

There continued to be concerns about staffing at Deepdene Court. The service was without a registered manager and recruitment was in progress. There had been an improvement in the consistency of nursing staff and records showed a nurse was on duty every day. However, there remained a heavy reliance on agency staff who were not all familiar with people’s needs and the lack of nurses at night increased risks for some people with needs that required clinical judgements to be made. There were safe systems in place for the recruitment of staff.

People spoke positively about the cleanliness of the service and described receiving regular support from domestic staff to keep their room clean. One person told us, “Day to day I keep my bedroom tidy the staff clean my room once/twice a week.”

Staff had received training in infection control procedures and told us they had the equipment they needed. There was an expectation that care staff would support people to keep their personal space clean and tidy. However, staff told us they rarely had time to complete this task and left it to the domestic staff to ensure the cleanliness of people’s rooms. Staff told us the service was in need of refurbishment and redecoration, one staff member said, “A refurbishment is needed, everything looks unclean and it is hard to clean, but we do try our best.”

Communual areas appeared clean, the general fabric of the building was in need of redecoration.

An external infection control consultant had undertaken an audit at Deepdene Court and the resulting action plan was in place to ensure improvements were made across the service. Regular internal audits were conducted to ensure that progress was being made. Staff told us they used a checklist to ensure all areas were cleaned regularly.

People were not all aware of the medicines they were taking. One person told us, “The staff don't discuss medication with me, I don't know what medication I take.” People said they would ask the nurse if they had questions about their medicines. One person told us, “I am supported with medication, the nurse would inform me if I asked what the medication is for.” Another person said, “I am supported with taking my medication by a nurse, any changes that have been made would be discussed with me.” People told us staff reminded them when they needed to have medicines. One person said, “They remind me to go to the clinical room.”

Care staff told us they had received online medicines training. However some staff had not received refresher training in line with the provider’s policy. Staff told us they had not received additional training, to enable them to meet the needs of all people within the service including people with diabetes, epilepsy and those prescribed high risk medicines. Staff described the impact of inconsistent leadership at the service. One staff member described how some people would like a level of involvement in administering their medicines, but the lack of management oversight meant no risk assessments had been undertaken to support people with full or partial self-administration. Staff described a lack of robust systems for monitoring people on high risk medicines and for sharing information when transferring care settings. This meant the provider could not be assured that up to date medicines information was sent with the person. A staff member described how they had developed their own system for scheduling when people on high risk medicines required routine blood monitoring. Another staff member had their own system for sharing information. Whilst this helped to reduce risks to people, these systems were not embedded within practice at the service. Staff said they had developed a good relationship with the GP surgery and pharmacy.

We were not assured that medicines were administered as the prescriber intended. For example, one person prescribed a variable dose medicine which depended on their physical health monitoring, did not receive the correct dose on four separate occasions. Physical health monitoring was not consistently undertaken according to the care plan. There was not a robust process for the oversight and monitoring of high-risk medicines. Staff were not using body maps or topical administration records for the application of creams and ointments. This meant the provider could not be assured that creams were being applied as the prescriber intended. Some people were prescribed PRN, or “as required” medicines. PRN protocols were in place and accessible at the point of administration for PRN medicines. However, these did not contain enough information to support staff in administering consistently, as intended. Some people had been prescribed medicines that required a clinical judgement to be made about when to administer the medicines. There was not always a nurse on duty and there was no protocol in place to ensure a clinical judgement could be made if the person’s condition changed. This meant there was a risk Information in care plans was not always detailed enough or accurate. For example, for one person the interval for monitoring a specific medicine, differed throughout the care plan. For another person, there was a diagnosis of a long-term condition recorded in one section, then stated there wasn’t a diagnosis in another section. Medicines related incidents were recorded. However, there was no evidence of shared learning or actions taken to prevent reoccurrence. Records showed medicines training had expired for some staff and a refresher was not undertaken in line with the provider’s policy. The provider had medicines related policies in place. However, these were not comprehensive enough to ensure the safe use and management of medicines.