Background to this inspection
Updated
19 December 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 15 and 17 November 2017 and was unannounced.
The inspection was carried out by one inspector and an expert-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.
Prior to the inspection we gathered information we held about the service, for example information from members of the public, healthcare professionals and notifications. Statutory notifications are information about important events which the service is required to tell us about by law. We used this information to plan the inspection.
During the inspection we spoke with seven sisters of the sacred heart (people), seven staff members, one health care professional, the registered manager and the provincial. A provincial is an officer who ensures that orders are properly carried out. We reviewed five care plans, five medicine administration records, two staff files and other records relating to the management of the service.
Updated
19 December 2017
This inspection took place on 15 and 17 November 2017 and was unannounced.
Duchesne House is a Catholic care home, providing personal care to sisters of the Society of the Sacred Heart religious order, in the London Borough of Wandsworth. The home is registered to for 22 people some of whom may have dementia. At the time of the inspection there were 13 people using the service.
The service was last inspected on 10 November 2015 and was rated ‘Good’.
The service had a registered manager in place. 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.
People were not always supported by staff that had undergone regular training to effectively meet their needs. Training in some mandatory areas was not up to date. We shared our concerns with the registered manager who took action to address our concerns. We were satisfied with the action taken by the registered manager.
People received their medicines as prescribed. Records management of medicines was not always accurate. We shared our concerns with the registered manager. After the inspection the registered manager put systems and processes in place to address our concerns. We were satisfied with the action taken.
People continued to be protected against the risk of harm, abuse and identified risks. The service had embedded systems and process in place that gave staff clear guidance on how to mitigate identified risks. Staff were aware of how to identify, report and escalate suspected abuse. Staff received safeguarding training.
People were supported by sufficient numbers of staff to keep them safe. Rotas were flexible to ensure people’s changing needs were reflected in staffing levels.
People were protected against the risk of cross contamination because the service had implemented systems and processes to ensure infection control was managed safely.
People are supported to have maximum choice and control of their lives and staff do support them in the least restrictive way possible; the policies and systems in the service do support this practice. Staff had an adequate understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
People’s dietary needs and requirements were met. People continued to be supported to make healthy choices and were given access to a wide range of healthcare professionals.
The service ensured people’s needs were being met by the design and adaption of the premises. Changes to the environment were done in consultation with people as far as practicably possible.
People continued to be treated with compassion and kindness. The service employed Pastoral officers to ensure people’s spiritual and emotional needs were catered to. People had their right to privacy and dignity maintained. The service placed emphasis on ensuring people’s end of life care was delivered in a way they chose. People receiving end of life care were treated with the upmost dignity and kindness.
Staff supported people to make decisions about their care and support. People were given information in a manner they understood to enable them to make decisions. People were able to raise their concerns and complaints, systems in place ensured those who may find it difficult to speak up, had a voice.
People received person centred care that was tailored to their needs. People were encouraged to be involved in the development of their care plans, which were reviewed regularly to reflect their changing needs.
People views about the service continued to be sought through regular house meetings, keyworker sessions and pastoral discussions. Issues identified through feedback received was then acted on in a timely manner.
People received care and support from a service that actively encouraged partnership working with other healthcare professionals. A healthcare professional told us any recommendations given to the service were implemented into the delivery of care.