Dene Park House

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

Effective safeguarding procedures were in place to protect people from the risk of abuse. Staff had received safeguarding training and demonstrated a good understanding of how to protect people from harm or abuse. Staff effectively assessed, monitored and managed risks to people’s personal safety and wellbeing. Care plans were in place to mitigate risks and were regularly reviewed. Equipment was safe and well maintained. The registered manager ensured staff were trained to use equipment and understand how to check items were safe to use. The premises were safe and mostly well-maintained, but some areas of the home needed redecoration to ensure effective cleaning. Staff followed appropriate infection control procedures. Fire safety was well-managed, and arrangements were in place to support people in the event of an emergency. Systems were in place to ensure incidents and accidents were reported, recorded, investigated and any lessons learnt were used to reduce risk of re-occurrence. The provider and registered manager understood their responsibility under the duty of candour and how to respond. Staff recruitment was undertaken safely and significant improvements had been made to the recruitment records of new staff. Staff received an induction and training relevant to their roles and responsibilities. They were supported through regular supervision and appraisal. Staffing levels and deployment received mixed reviews from people, relatives and staff. We shared this with the registered manager to consider when determining their staffing levels and skills mix to ensure people received consistently safe, person-centred care. Medicines were better managed, although further improvements were needed to records. Staff were knowledgeable about people’s medicines and were suitably trained. Staff worked closely with external professionals to ensure people had safe transitions between services.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People found the care and support provided met their needs. They felt involved in all aspects of the design of their care and how it was delivered. People were regularly consulted about the care they received. They found most staff were competent, caring and treated people in a dignified manner. A person told us, "It’s first rate really, I’m safe and they [staff] look after me."

The provider and registered manager understood their responsibility under the duty of candour and how to respond. They promoted an open and honest culture throughout the service. Staff responded appropriately when accidents and incidents occurred. Records were analysed for patterns or trends and incidents were used as a learning opportunity. The provider critically reviewed the operation of the service and actively made changes as and when these were needed. A staff member said, “When I raise a concern it does get listened to and appropriate actions are taken.”

The provider regularly reviewed the systems and processes in the service to determine if improvements could be made. Action plans were used to identify and monitor where changes were required and how these could improve the service. The provider used feedback to assist them improve the quality of care. The registered manager monitored the quality and safety of the service to ensure people achieved positive outcomes.

People told us they felt safe, and they experienced a smooth transition into the service. People were only admitted when the registered manager and staff were confident the person’s needs could be met. One person said, “I am so secure and happy here.”

The registered manager and staff worked with health and social care professionals to ensure people’s care and support needs were met. Staff understood when people required support to reduce the risk of avoidable harm.

Staff worked in partnership with other agencies to improve people's opportunities and wellbeing. They acted appropriately to facilitate referrals for people requiring care and support on discharge from hospital. Professionals reported they had no concerns about the service and they found, overall, it had the right processes in place. A professional told us, “Staff conduct a professional pre-assessment with the person and the ward making it person-centred. They ensure Dene Park House can meet the needs of the person to the best of their ability. Staff ensure they have all the necessary paperwork delivered to them prior to discharge, ensuring the person’s needs and support requirements are clearly set out.”

Systems were in place to ensure people transitioned to the service in a safe manner and there was continuity of care. The provider had a range of policies and procedures to manage risk and monitor the safety of both people and staff. The registered manager ensured care plans contained information about people’s needs and preferences to enable staff to provide appropriate care. Risk assessments were in place and assisted staff to identify and mitigate risks.

People told us they felt safe living at Dene Park House and with the staff who supported them. One person told us, “I am safe here” and a relative said, “I am sure [Name] is safe enough, they have company and there are good carers.”

Staff demonstrated a good understanding of how to protect people from harm or abuse and told us they had received safeguarding training. One staff member said, “If I suspected abuse, I would report it straight to my manager.” Another staff member told us, “I am 100% happy to raise safeguarding concerns with my manager, who is brilliant.”

Staff were observed to be treating people with dignity and respect.

Effective safeguarding systems were in place to protect people from the risk of abuse. Safeguarding concerns were reported to external agencies when required. A professional told us, “I have always had positive outcomes when discussing safeguarding concerns and staff respond to concerns in an acceptable timeframe.”

People felt involved in all aspects of their care planning and were supported to do the things that were important to them and manage any associated risks. They felt their views were closely listened to and their suggestions acted upon.

Staff effectively assessed, monitored and managed risks to people’s personal safety and well-being. They knew people well and understood when people required support to reduce the risk of avoidable harm. People had detailed risk assessments in place and staff found the assessments effectively assisted them to safely mitigate risks.

We observed some issues with safety of premises that could impact on people's safety. This included, a frayed carpet around a person’s bedroom door, which presented an obvious trip hazard, a loose and moving toilet seat and a razor stored in a communal bathroom.

The registered manager had an effective system in place to monitor the quality and safety of the service and ensure people achieved positive outcomes. Care plans were in place and were reviewed regularly. Care records contained information on known risks to people and plans to reduce them. For example, where people had limited mobility, plans contained information on how they could safely mobilise.

People lived in a safe environment with access to well-maintained, assistive equipment which was suitable for their needs. People told us they felt safe and were confident the staff carried out their role safely and competently. One person told us, “This place is very nice.” One relative said, “The place is fantastic, I can’t praise it enough, we’re really happy with it.”

Staff told us they had received training in safe working practices including fire safety, health and safety and safe people handling. They felt safe working at the service. Staff said there was appropriate equipment to mobilise people safely and they had received training in how to use it. Staff completed health and safety checks of the environment to mitigate risks as far as possible. One staff member told us, “Equipment to support people with their care is readily available and well maintained.”

We observed some issues which had the potential to impact people’s safety including, a frayed carpet, loose toilet seat and a razor stored in a communal bathroom. The provider said these would be reviewed.

The provider had effective policies and procedures in place to ensure the environment was safe and well maintained. Detailed records were maintained of all checks and servicing. Fire safety was well managed, with regular fire drills and routine alarm tests. Effective processes were in place to support people in the event of an emergency. The provider had a business continuity plan in place and each person had a Personal Emergency Evacuation Plan (PEEP) which contained information about how best to support them during an evacuation.

People and relatives told us they felt safe with the care and support provided by staff. They told us staff worked hard but some said they were not always visible or responsive. One person told us, “They [staff] are nice enough, but they could come a bit faster, you wait ages.” Another person said, “They [staff] come if you call, even at night.” One relative commented, “I do see staff, well sort of, but I can find someone [staff] if I need them.” People and relatives were confident most staff had the right skills to provide their care. One relative told us, “There are some [staff] who are well trained but not all.”

Staff told us they effectively worked together to provide safe care to meet people’s individual needs but provided mixed feedback about the levels and deployment of staff. Their comments included, “Sometimes there is not enough staff but residents get the best care we can give” and “If there are enough staff on duty, the residents don’t only get the care and support they deserve but also feel safe and it makes the staff happier too.” Staff felt they had the skills and knowledge to carry out their role effectively. They spoke positively about the training and support they received as part of their job roles. One staff member commented, “I’ve had face-to-face and online training. These were very valuable I learnt a lot.” Staff also confirmed they had been involved in providing an induction for new staff and had ensured they understood exactly how to meet people's needs.

We observed staff were visible throughout the day and people were attended to in a fairly timely way. Staff appeared to be very busy, in some cases not always alert to people's support needs and often gathered in groups or consulting their phones for ‘task’ reminders. Most staff were seen occasionally chatting to people, showing appropriate affectionate contact with gentle reminders and prompts. Some were observed passing by people’s rooms without looking in or interacting with people. We shared our findings and observations with the provider and registered manager to consider when determining their staffing levels. They confirmed they were investing in staff recruitment and aiming to reduce the reliance on agency staff. They advised they would continue to review the deployment and skill mix of staff to meet people’s needs.

At the last inspection of the service, we had made a breach of regulation 17, as staff recruitment records were not accurate and up to date. At this inspection we found there had been significant improvements made to the recruitment records of new staff and the service was no longer in breach of the regulation 17, good governance. The provider and registered manager followed safe and effective recruitment practices. Staff received the support and training they needed to carry out their role effectively and deliver safe care. This included a comprehensive induction, supervision, appraisal and where needed, professional revalidation. Staff completed training around all aspects of care including condition specific and had their performance routinely monitored. The registered manager used a dependency tool to set staffing levels, based on people's assessed care and support needs, along with ensuring there was an appropriate skill mix on duty. People, relatives and staff provided mixed views about the staffing levels and skill mix.

Most people and their relatives found staff followed infection control practices. One relative told us, “I do see staff using their gloves and aprons.” Another relative said, “They [staff] don’t wear their PPE, I see they have got it on now you are here but they don’t normally.” People’s rooms were personalised, appropriately furnished, warm and comfortable. One person told us, “I’m very safe, very comfy”.

Staff confirmed they received training in infection control procedures and had the protective equipment they needed to reduce the risk of spreading infections. They were observed using personal protective equipment effectively and safely. Staff also completed practical competencies and these were monitored regularly by the registered manager during walk arounds. One staff member told us, “There is always enough personal protective equipment available.”

We observed some people’s equipment needed cleaning, for example, bed rails and mattresses. Some areas of the home needed redecoration to ensure effective cleaning, for example, handrails, skirting boards and doorframes. The provider and registered manager were responsive to our feedback and said a programme of redecoration would start in November 2024.

The provider had systems in place to mitigate the risks to people and staff from catching and spreading infections. These included regular cleaning and audits. Staff worked closely with external health care professionals to ensure infection control remained at an appropriate standard such as, the infection control team and the care home support team. Both teams worked closely with Dene Park House, they visited when required and if the home needed any additional support. The service had been awarded a “5 Very Good” Food Hygiene Rating by the Food Standards Agency on 16 September 2024. The provider’s infection prevention and control policy was easily accessible to staff for reference.

People told us their medicines were well managed and they were administered on time. A person said, “I see the doctor a lot and I get my meds. I had a lot of pain one night and they [staff] rang the doctor at 2am and someone went to get my medicines. That was great.”

The registered manager told us about the improvements they had made since our last inspection including addressing issues identified with agency nurses, and the range of medicines audits they completed to ensure medicines had been given as prescribed and records were accurate. Staff were knowledgeable about people’s medicines needs. Staff told us they had completed training in medicines administration and their practice was subject to routine competency assessments. The provider’s medicines policy was readily available for staff.

Processes were in place for the safe administration of medicines, however we identified shortfalls in medicines records. Care plans for medicines were in place, however these were not always sufficiently detailed or up to date. Protocols for the administration and monitoring of ‘when required’ medicines were not always in place and the administration of creams was not always fully recorded. We found some people had gaps in the administration of their medicines, however there had been no impact on people’s health. Comprehensive policies and procedures were in place to support the administration of medicines. Medicines were stored securely and safely including controlled drugs. Further development and embedding of processes was needed. We discussed the concerns we had found in relation to medicines records and the management team agreed the concerns should have been identified in audits. This was an area for improvement.