Deepdene Court

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified two breaches of legal regulations. There were continued failures in the governance and management of the service. Whilst some improvements in management of medicines and in staffing had been achieved, there remained concerns about the lack of management oversight and a failure to sustain and embed improvements. The provider’s systems were not effective in providing a recovery model for people’s mental health needs or in supporting the needs of people who also had learning disabilities or autism. Systems had failed to identify shortfalls in risk assessments and care plans. Records were inconsistent, lacked personalisation, and did not include detailed strategies for staff to provide effective support. Governance systems had failed to identify shortfalls and inconsistencies in the management of incidents. Incidents, including potential safeguarding events, were not always recorded, reported or analysed to ensure learning and improve outcomes for people. Systems for monitoring the administration of medicines had failed to identify shortfalls and omissions. The Provider was required to notify the Care Quality Commission of some incidents but notifications had not always been submitted. Staff described a lack of leadership and said they felt unsupported in their roles. They described a negative culture due to a failure to address risks and challenges that staff were facing daily.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff meetings were usually held regularly but had not been happening due to the change in management at the home. One staff member said, “Staff meetings should be once a month but have not been happening.” Some staff did not feel able to speak up and raise concerns. One member of staff told us, “There is no point, nothing changes.” Another staff member said, “Nothing gets done about it and we don’t get told anymore about what they have done, so it seems pointless reporting anything.” One staff member told us they had spoken up about concerns, they said, “I did not feel supported during the process and felt like I was causing trouble as opposed to feeling heard.” However, another staff member said they were confident that they could speak up and would be heard. They said, “If I feel I need to speak up then I could.” Another staff member said, “They are trying to make them (staff meetings) a bit more regular.” Following the assessment the provider confirmed staff meetings were now happening on a regular basis.

The provider had systems in place to enable people, their relatives and staff to express their opinions on the service. People told us they knew how to make a complaint and would speak to a staff member if they had any concerns. The provider described providing opportunities for staff to tell them about any concerns. They confirmed that this process had not always been successful because staff had not informed them of concerns they had about the management of the service. The provider explained how they were making improvements to ensure staff felt able to speak up when they had concerns.

Staff described a negative impact from inconsistent leadership at the home. Staff did not feel consistently supported and some staff said they did not always feel safe at work. One staff member said, “I don’t feel valued or listened to. There is a huge turnover of staff, we don’t know whether we are coming or going.” Another staff member said, “There have been so many changes with managers and so no one has been here long enough to make any changes that positively impact or help us.” Staff told us the person in day to day charge of the service was usually a senior care worker and spoke highly of the support they had provided. Staff said they were aware that a deputy manager had recently started and that a new manager had been recruited.

The service was without a registered manager at the time of the assessment. The provider had undertaken recruitment and had appointed a new manager who was not yet in post. Senior care workers had often been in day-to-day charge of the service in the absence of a manager. Operational managers visited the service to provide support and a deputy manager had been recently recruited and was having their induction at the time of this assessment.

Staff meetings were usually held regularly but had not been happening due to the change in management at the service. One staff member said, “Staff meetings should be once a month but have not been happening.” Some staff did not feel able to speak up and raise concerns. One member of staff told us, “There is no point, nothing changes.” Another staff member said, “Nothing gets done about it and we don’t get told anymore about what they have done, so it seems pointless reporting anything.” One staff member told us they had spoken up about concerns, they said, “I did not feel supported during the process and felt like I was causing trouble as opposed to feeling heard.” However, another staff member said they were confident that they could speak up and would be heard. They said, “If I feel I need to speak up then I could.” Another staff member said, “They are trying to make them (staff meetings) a bit more regular.” Following the assessment the provider confirmed staff meetings were now happening on a regular basis.

The provider had systems in place to enable people, their relatives and staff to express their opinions on the service. People told us they knew how to make a complaint and would speak to a staff member if they had any concerns. The provider described providing opportunities for staff to tell them about any concerns. They confirmed that this process had not always been successful because staff had not informed them of concerns they had about the management of the service. The provider explained how they were making improvements to ensure staff felt able to speak up when they had concerns.

Staff described being exposed to incidents of verbal abuse, including racial abuse. They told us, “It’s not nice being yelled at.” Staff described a negative impact from regular exposure to verbal abuse and threats. Some staff told us they had received training in how to keep themselves safe at work including break-away techniques. However not all staff had completed this training. This meant they were not always supported effectively in line with the provider’s policy to keep them safe at work. These concerns were fed back to the provider to address.

The provider had recruited a diverse workforce. Staff had completed equality and diversity training. The provider’s policy on managing violence and aggression includes that all staff should receive appropriate training in how to keep themselves safe at work, for example in situations where they may experience verbal or physical aggression or abuse. Systems for debrief and learning from incidents was not embedded within practice and this meant the provider could not be assured that staff were always supported effectively.

Staff told us they were aware management systems were not always effective. One staff member said, “Systems need improving, incident reporting, safeguarding, audits, care plans and risk assessments all need some work.” Another staff member said, “Morale is low. I am just doing the best I can and hoping that we get a stable manager soon and can build the team back up.”

The provider’s management systems had failed to identify shortfalls including when incidents were not being recorded. Lack of oversight and governance meant there was a failure to identify and report safeguarding alerts and concerns. Notifications for some incidents had not been submitted to the Care Quality Commission by the provider. Systems for clinical governance, including the monitoring of high-risk medicines and oversight of medicine use were not robust. Systems for assessing and monitoring risks were not effective, care plans were inconsistent, poorly personalised and lacked the detail staff needed to provide safe and effective care to people. Although regular reviews of care plans were recorded, information had not always been updated. Governance systems had failed to identify shortfalls in providing support for people with learning disabilities in line with the principles and values of Right support, right care, right culture. Where audits had identified shortfalls, for example in environmental risks, these were included in a service improvement plan.

People said staff supported them with appointments in the community, including with mental health professionals. One person said, “The staff support me with all my medical appointments.” Some people told us they were able to go out and access the community independently. One person said, “I do go out in the local area, sometimes I go further and visit Bognor Regis.” Another person said, “I go out shopping and sometimes visit the cafe and have attended clubs or groups.” Not all people were able to go out independently and relied on staff to support them. This meant they were restricted in how often they were able to go out because there were not always enough staff on duty to accommodate outings.

Staff described effective working relationships with mental health professionals. Staff said they sought advice and support when people needed additional support to manage their mental health needs.

The local authority told us staff were engaging with their provider concerns process to make improvements in safeguarding people at the service.

Some people’s mental health needs meant they were at increased risk of discrimination and were vulnerable to abuse when out in the community. Incident reports included occasions when some people had been the target of criminal activity or abuse when they were out in the local community. There was a lack of strategies in care plans to address these risks and support people to remain safe. The provider’s policy included that people should have behaviour support plans to ensure staff had guidance in how to support people to remain safe. These were not in place and care plans did not provide clear guidance or strategies for staff to support people both at home and when out in the community.

Staff described an inconsistent approach to incidents and a lack of learning. Some staff said there was rarely a debrief following an incident so there was a missed opportunity to identify triggers or share learning about strategies for supporting people. One staff member said, “Incidents should also be discussed in handovers,” however, this was not happening consistently. Staff said they tried to support each other and were hopeful of improvements when a new manager was in post.

Lack of management oversight had a negative impact on continuous learning and improvements at the service. There was a high number of incidents, including altercations between people and staff or other people who lived at the service. Evaluation of incidents was not consistent and opportunities for learning were missed. Medicines related incidents were recorded. However, there was no evidence of shared learning or actions taken to prevent reoccurrence.