Denville Hall

We found the following examples of good practice.

The registered manager and staff team worked with local health professionals to minimise the spread of COVID-19. Staff retention was good which meant there were minimal staffing pressures. Regular agency staff and management team members back filled gaps in rotas.

There were numerous PPE work stations throughout the building for staff to easily utilise PPE. Staff received training in infection control and were using PPE safely and effectively.

Visiting by family and friends was taking place in line with national guidelines, given there was a small outbreak of COVID-19. People who were receiving end of life care were being given full visiting access.

We were assured that this service met good infection prevention and control guidelines.

Denville Hall is a care home providing personal and nursing care for up to 40 people from the acting profession aged 65 and over. At the time of the inspection, 33 people were using the service. Accommodation was provided on two floors and there was a separate unit which specialised in providing care for up to 15 people living with dementia.

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

The provider had effective systems to help ensure people who used the service were safe from avoidable harm. Where there were risks to people, these had been assessed and management plans included clear guidelines to help reduce risk. People received their medicines safely and as prescribed. Staff received training in the administration of medicines and had their competency at managing medicines safely checked.

Lessons were learned when things went wrong. The provider had processes for recording and investigating incidents and accidents.

Appropriate recruitment checks were carried out before staff started working for the service. People were supported by staff who were suitably trained, supervised and appraised.

People were protected by the provider’s arrangements in relation to the prevention and control of infection. The home was clean, tidy and well maintained throughout.

People’s nutritional and healthcare needs were met and we saw that staff took appropriate action when concerns were identified.

The provider acted in accordance with the Mental Capacity Act 2005. People had their mental capacity assessed before they moved into the home. Where necessary, people were being deprived of their liberty lawfully. 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.

The environment was tailored to the individual needs of people who used the service, including those living with the experience of dementia.

The registered manager led a caring and dedicated team. Together, they met people’s individual needs and maintained their quality of life.

Care plans were developed from initial assessments and contained relevant and up to date information about people’s needs and preferences, so staff knew how to care for and support them. Where possible, people had an end of life care plan in place which stated their individual wishes when they reached the end of their lives.

People were engaged in meaningful activities according to their interests and background. People reported they were very happy with the activities on offer. Staff were responsive to people’s individual needs and knew them well. They ensured that each person felt included and valued as an individual.

The provider had robust systems in place to monitor the quality of the service and put action plans in place where concerns were identified. People’s care records were reviewed and updated monthly or more often if their needs changed.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 July 2018). At this inspection we found improvements had been made and the provider was now rated good.

Why we inspected

This was a planned inspection based on the previous rating.

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.

Denville Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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 is registered to accommodate up to 40 older adults. At the time of our inspection 30 people were living at the service, with one person in hospital. Accommodation was provided on two floors and there was a separate unit which specialised in providing care for up to 15 people living with dementia.

There was a registered manager in post. 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.

The last inspection of the service was on 5 and 11 September 2017 when we rated the service Requires Improvement for the key questions, ‘Is the service safe, effective, responsive and well led?’ and we rated the service overall as Requires Improvement. At the last inspection, we had found four breaches of Regulations which related to safe care and treatment, staffing, person centred care and good governance. We asked the provider to complete an action plan to tell us what improvements they would make at the service to improve the key questions to at least good. They told us they would make the necessary improvements by 31 January 2018.

At this inspection on 30 and 31 May 2018 we found that there had been some improvements. However, the service remained Requires Improvement in two key questions, ‘Is the service safe and well led?’ and overall.

We saw many improvements with how medicines were being managed. However, staff needed to be more vigilant in ensuring they recorded when they applied prescribed creams to people during personal care. The provider did not also have effective arrangements to review and address safety alerts that are communicated to care services via the national patient safety alerts. Where the provider had noted that appropriate window restrictors were not in place to help reduce the risk of falling from height, they had not always acted in a prompt manner to resolve the issue. We saw food items in the fridge with no dates of opening to help protect people from the risk of eating unsafe food. The registered manager addressed these issues promptly after we pointed these out to them.

The registered manager had introduced a number of audits and checks on various aspects of the service. We saw for the most part action was taken when areas for improvement were identified. However, when quality assurance processes were not robust enough which led to issues not being dealt with in a timely manner. Although people and relatives could give feedback about the quality of the service, there was no evidence that a formal satisfaction survey had recently been carried out.

Feedback on the service from people using the service, relatives and professionals was positive. We observed staff were caring and treated people with dignity, compassion and respect. Staff were knowledgeable about people’s interests and needs.

People’s care records had improved and, other than one detail which was inconsistent for one person and was addressed during the inspection, the information about people was up to date. Risks had been identified and ways to minimise harm to people had been recorded. Where possible people contributed their views on the service and gave feedback on how they wanted to be supported.

The staff told us they felt well supported. They had the information and training they needed to care for people. The staff felt the service was well managed and had opportunities to discuss their work and any concerns they had with the registered manager. There was an open culture within the service and people and staff were supported to raise concerns and make suggestions about where improvements could be made.

People and relatives were aware of their right to make a complaint if they had any concerns.

The service continued to have an accreditation from Dementia Care Matters who had set up the 'Butterfly project'. This had been introduced and implemented the unit where people living with dementia resided. This project encouraged staff to help people using the service to express themselves and for staff to reflect on how to support people and see them as an individual.

The provider was acting in accordance with the Mental Capacity Act 2005. People's mental capacity was assessed when their care was planned. People had been asked to consent to their care and treatment and the staff understood their responsibilities under the Act. Processes had been followed to ensure that, when necessary, people were deprived of their liberty lawfully.

People were protected by the provider's arrangements in relation to the prevention and control of infection. The environment was clean and free of hazards and staff had specific training in this area.

People's health and nutritional needs had been assessed, recorded and were being monitored. People had access to healthcare professionals as they needed, and their visits were recorded in people's care plans.

People had access to a range of social and leisure activities. There were a range of organised events and people had opportunities to participate in these as well as individual and small group activities. Visitors were welcome at the home at any time and told us they were kept

informed about changes to their family member’s health or wellbeing.

There were enough staff to meet people's needs and keep them safe, and they had been recruited in a suitable way.

Denville Hall provides support and accommodation for up to 40 older people. Some people using the service were living with dementia. There were 26 people using the service at the time of this inspection.

There was a new manager in post since June 2017 and they had applied to the Care Quality Commission (CQC) to become the registered manager. Prior to this there had been two other managers in post since the last inspection in 2015 but they had not registered as a manager with the CQC.

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.

On the first day of the inspection we identified several areas where improvements needed to be made. When we carried out the second day of the inspection we found the manager had addressed some of the shortfalls and had put action plans in place and documents to start making the improvements to the service. This showed that some of the systems within the service had not been effective in assessing the quality of the service to ensure that areas for improvements were identified and addressed.

Several audits and checks had not been carried out prior to our inspection. For example, medicines, other than controlled medicines, had not been checked and counted regularly to identify any discrepancies so these could be addressed. Accidents and incidents had not been checked to see if there were any trends in these occurring so action could be taken to prevent these from these reoccurring. By the second day of the inspection the manager had carried out some audits and addressed some of the issues we had identified during the first day of the inspection.

Some records were not being maintained appropriately. Records in the kitchen were not filed appropriately and therefore finding information was not easy. There were gaps in the Medicine Administration Records. There was no written evidence of any checks the provider had carried out.

Since earlier in 2017 there was an electronic system to record people’s care needs, information about them and risks. This was being used by many staff but was difficult to navigate and therefore information was not always fully recorded for staff to see. This issue had been recognised and staff were due to receive support and guidance in October 2017 from the IT organisation.

There was a lack of evidence that people had been involved in the development of their care plan. Although their personal preferences and likes and dislikes were noted it was not evident that they had agreed to the contents of their care plan or that they were a part of any review.

There were some good systems in place to manage medicines but there were recording issues when medicines had been administered and pain assessment tools and protocols for medicines to be given as and when required were not in place for everyone. Nurses had not received medicines management training since working at the service. This was arranged after the inspection.

There was a lack of evidence that staff had received a formal induction, had been offered the chance to study for the Care Certificate or that staff had received regular supervision. Under the new management this had started to be addressed. Training was also being booked for those staff who needed to complete this to ensure they could support people appropriately.

There were sufficient numbers of staff working to meet people’s needs but at times agency staff were used to cover shortages of staff. People and staff told us that the use of agency staff was not ideal, especially if they were new to the service. Recruitment checks were carried out to make sure staff were suitable to work with people using the service.

Most staff had received training on safeguarding adults from abuse and there were policies and procedures in place. There had been one safeguarding concern since the last inspection which had been dealt with appropriately.

Through feedback and our observations, the care people received was good. Staff were attentive and friendly with the people using the service. People had access to the health care services they needed and their nutritional needs were being met.

The service had an accreditation from Dementia Care Matters who had set up the ‘Butterfly project’. This had been introduced and implemented to people using the service and staff in the dementia unit. This encouraged staff to help people using the service to express themselves and for staff to reflect on how to support people and see them as an individual.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The systems in the service supported this practice.

There was a complaints procedure available and people said they would talk with staff or their relatives if they had a concern. The provider arranged for meetings to be held for people to share their views and hear updates on the service.

We found four breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to safe care and treatment, staffing, person centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on the 27 and 28 October 2015 and the first day was unannounced.

During the last inspection which took place on the 25 and 26 November 2014 the provider was not meeting the legal requirements in relation to ensuring there were clear procedures in place to report any safeguarding concerns, records were not detailed and accurate to ensure staff cared for people using the service safely and appropriately. Staff were not being supported regularly and effectively and the service did not have systems in place to assess and monitor the quality of service provision. At this inspection we found the provider had made improvements and was now meeting the legal requirements.

There was a new registered manager in post. 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 and their relatives were positive about the care and support provided at Denville Hall. Staff knew people well and understood how to meet their individual needs. We observed positive relationships between staff and people at the service and their relatives. Visitors were welcomed and people were supported to maintain relationships with those who were important to them.

Risk assessments were in place that reflected current risks for people at the service and ways to try and reduce these. Care plans were being regularly reviewed to ensure the care provided met people’s changing needs.

The service had re-introduced the Butterfly project in the dementia unit and staff were receiving information and training on how to implement the principles of this. This encouraged staff to help people using the service to express themselves and for staff to reflect on how to support people and see them as an individual.

Activities were designed to meet people's interests and previous occupations, such as showing live theatre shows and films. These were promoted in the service and people could take part in whatever they wanted to.

Staff received training to help them undertake their role and were supported through regular supervision and appraisal. Staff had training in working with the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People’s capacity had also been considered and assessed to ensure staff supported people where possible to make daily choices and decisions.

There were recruitment procedures and checks in place to ensure staff were suitably vetted before working with people. There were enough staff to meet the needs of people using the service.

The staff we spoke with were able to tell us the action they would take to ensure that people were protected from abuse.

People told us that they felt able to raise any issues or concerns and these were dealt with promptly and satisfactorily.

People had a choice of meals and staff were available to provide support and assistance with meals.

Staff referred people for input from healthcare professionals when required.

There were systems in place to monitor the quality of the service being provided and staff met regularly as a team to look at what was working well and where improvements could be made.

This is a summary of what we found-

We found the service was not safe because people were not always protected against the risks associated with medicines.

At our last inspection in July 2014 we found a number of issues with the way medicines were managed which meant that safe and effective arrangements were not in place to ensure that people were receiving their medicines as prescribed.

The provider wrote to us stating that they had taken action and had made the necessary improvements. During this inspection we looked at recording and storage of medicines. We found that there were still some omissions in records and our audits of stock did not always evidence the accuracy of the records.

We observed medicines given to two people at lunchtime and saw that they were given with patience and gentle encouragement and the medication administration record was signed after the medicines were seen to have been given.

Staff in the home had received training to manage medication safely and we saw the assessments of their competency when tested. Training was on going with another session planned in October 2014 for new nurses recently employed.

Feedback from people living at the home and the staff was positive with a healthcare professional confirming that staff had a good understanding of people’s individual needs and worked effectively to meet these. Comments from people using the service included, “I am happy with the move to this home”, and “I am getting used to the staff”. People also confirmed that there was plenty to do in the home and that the staff respected their wishes.

People’s needs were assessed, where possible, prior to their move to the home. This was to ensure the staff could appropriately meet people’s needs. The majority of the care records we viewed contained current information and had recently been reviewed. These included information on people’s preferences, routines and provided staff with details on how to safely support people.

Staff were aware of reporting safeguarding concerns to the manager and knew of external agencies they could also talk to if they were worried about a person’s welfare. We saw a sample of training certificates which evidenced that staff received training on this subject. Safeguarding and whistle blowing policies and procedures were in place to inform staff what action to take where they had an issue or concern.

Staff received ongoing and regular training on medicines management. However, we found poor practice in the recording of the administration of medicines. Furthermore, the medicines policy and procedures were not always followed prior to the administration of medicines, which could place people at risk of poor care.

People said they were satisfied with the support and care they received. Where people were unable to make choices for themselves, protocols were in place to ensure decisions were made on their behalf in their best interest.

Medicines were managed and records were up to date.

Required checks were carried out prior to employing new staff and they received an induction training to prepare them for caring for people.

A complaints procedure was in place and people were encouraged to express any concerns so they could be addressed.

Comments from people who use the service included, “it’s wonderful, really”, “second to none, I have never experienced anything like it” and “I think it is a wonderful place, the staff are really excellent”. Comments from relatives and friends included, “really excellent” and “a lovely place with such good all round care”.

People were provided with information about the home and encouraged to visit prior to admission, to see if it was somewhere they would like to live. People and their representatives were involved in planning care so their needs could be understood and met. Care records were comprehensive and kept under review, so any changes in people’s needs were identified. People expressed satisfaction with the care they received. One person said “the staff help us whenever they are asked. I think they are wonderful”. Another person told us “they look after us beautifully.”

People said there was always someone to talk to if they were worried about anything. Staff understood safeguarding and whistle blowing procedures and knew about the need to report any concerns. Staff said they had received a lot of training in recent months, to keep their skills and knowledge updated. They demonstrated they understood people’s needs and how to meet them effectively. One person said the staff were “very helpful and kind.”

Systems were in place for monitoring the quality of the service and action was taken to address any shortfalls identified. Concerns raised regarding the quality of the food provided had been addressed in a timely and effective way. Comments on surveys carried out in 2012 included “my relative could not be in a better place” and “excellent staff…..they all treat my relative with great care and compassion.”