Danmor Lodge Limited

Updated 17 June 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Danmor Lodge Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection, this included notifications made by the service and concerns raised with CQC. We sought feedback from the local authority and health professionals who work with the service. We used all of this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

Inspection activity started on 18 May 2022 and ended on 26 May 2022. We visited the service location on 18 May 2022.

We spoke with three people who used the service to ask about their experience of the care provided and with one visiting relative who was also a volunteer. We spoke with nine members of staff including the registered manager, deputy manager, senior care workers, care workers and domiciliary staff. As most people were living with dementia, we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included elements of three people's care plans and care records and Deprivation of Liberty Safeguards authorisations. We looked at a variety of records relating to the management of the service.

We also held remote video calls with the registered manager and deputy manager to discuss the governance arrangements at the service and also to give inspection feedback to the registered manager and deputy manager.

After the inspection visit

We continued to seek clarification from the registered manager to validate evidence found. We looked at further records in related to oversight, audits, complaints and compliments.

We asked the provider to share a poster asking staff and family and friends to contribute to our inspection. We received feedback from eight relatives and three staff. We subsequently spoke with one of the relatives and shared the information with the service to act upon. We received feedback via our website until 27 May 2022.

Updated 17 June 2022

About the service

Danmor Lodge Limited is a residential care home providing personal care to up to 25 people. The service provides support to older people and older people living with dementia. At the time of our inspection there were 22 people using the service.

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

People were happy with the care and support they received. Comments included; “We know all the staff and they’re all very friendly and helpful. I have nothing to worry about as they all look after us”, “I’m being looked after beautifully”, “It’s very good here”, “I’ve got lots going to keep me busy” and “There always something going on and something to do.”

People were supported by staff who understood the risks they faced and how best to reduce these risks. Any risks to people were fully assessed, planned for and mitigated.

Medicines were managed safely. People received their medicines when needed and appropriate records had been completed. We saw people had access to healthcare professionals.

Staff were trained in safeguarding. Staff were confident that any concerns they had about a person’s welfare would be acted on and they knew how to contact safeguarding agencies if this was appropriate.

Staff were recruited safely and there was a very stable core staff team. Staff received a comprehensive induction and completed a variety of training courses to enable them to carry out their roles competently. Staff told us they felt well supported and they knew people as individuals and spoke passionately about the people they cared for.

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. People were able to make choices about all aspects of their day to day lives and were encouraged to continue to follow their interests.

There was a happy relaxed atmosphere with a variety of activities that people had been consulted about and there were meaningful activities for people living with dementia or being cared for in their bedrooms. Whilst one of the lifts was not working staff had ensured they spent additional time with people in their bedrooms to reduce their social isolation.

People lived in a home that was kept clean and infection prevention and control measures were in place to reduce the risks associated with Covid-19.

There was an open and positive culture within the home and people, their relatives, staff and professionals told us the registered manager and management team were approachable and helpful.

There were governance arrangements in place and systems to monitor and improve the quality and safety of the service provided. The registered manager and deputy manager were open and transparent and acted on any feedback given throughout the inspection.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (29 March 2019).

Why we inspected

We received concerns in relation to risk management for people whilst one of the lifts was out of order. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed following this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern/ incident. Please see the Safe and Well-led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Danmor Lodge Limited on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.