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

During our assessment of this key question there remained concerns about the management and governance of the service, this was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems to ensure fit and proper persons were employed were not robust. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were clear about the model of care at the home as being a recovery model. They gave examples of working with people to support them to regain skills and confidence. One staff member said, “That’s why I do this job, to help people get their life back of track.” Staff described positive team work and spoke of the staff team working together to support people. One staff member said, “It’s a strong team, we look out for each other.” Staff expressed some concerns regarding the culture of the service. One staff member said, “The last Manager tried to make improvements, but head office would say no, there’s a culture of not listening to the manager or staff on the ground.” Another staff member told us when they raised concerns they did not feel supported or listened too, "Staff have felt bullied, we've been told, ”If you don’t like it you can leave.” Some staff members described raising concerns about safety at the home and felt the needs and challenges faced by people were not well understood or considered by the provider. They said, " They are not interested in what people need- for example with the lack of nurses, they (provider) seem content to have a nurse come in just to give the injections a couple of times a week, that's not what's needed, people need the expertise, of nurses that's why they are in a nursing home." Another staff member said, "When we had someone with really complex needs, there were lots of incidents and it didn't feel safe, but we weren't listened to, what staff said was disregarded. "

People's care plans reflected their needs and were consistent with the recovery model. Incidents were recorded and reported. Systems had not identified the level of risk to people from a lack of suitable staff or where there was a change in a person's needs that required additional staffing,

Staff described the negative impact of not having consistent leadership at the home. One staff member said, “ We have had 4 or 5 managers in the last few years, that’s not been good.” Staff said the lack of permanent nursing staff at the home also had a negative impact on the management and leadership of the home. One staff member described how shifts were made more difficult without regular nursing staff in duty. They said, "Without the manager and a nurse, sometimes there is not a senior member of staff on duty in the unit, it puts more pressure on the care staff." One staff member said, "Some people here have very complex needs and they need the support and experience of staff with the right skills. The care staff are very good and do their best but this is a nursing home, without having nurses this doesn't work." The provider told us they were using a consultant to provide management support and leadership at Deepdene Court. The provider confirmed they had not seen all the required recruitment checks including a valid DBS check, before the person started work. This meant they could not be assured of the integrity of the person. The provider had taken immediate action on becoming aware of concerns raised and said future appointments would be subject to robust scrutiny.

Recruitment checks were not robust and the provider could not be assured that all leaders had honesty, openness and integrity and were fit for their role. DBS checks had not been viewed to confirm a person was suitable for the role and there had been a failure to ensure all relevant background information was scrutinised, with appropriate risk assessments completed.

The provider had a whistleblowing policy and staff were aware of the policy and knew how to raise concerns. The provider had not always taken action to address the concerns raised by whistleblowers. There was a complaints policy in place and people said they would feel comfortable to talk to staff about any concerns they had.

Staff said they felt able to raise their views but did not feel their views were always listened to and acted upon. Their comments included, “Head office don’t listen to us, they don’t care about what it’s like on the ground, if we say anything then, ‘If you don’t like it you can leave,’ that’s what we get told, ‘you can go and get another job.’” Another staff member said, “We have been asking for nurses but we haven’t been listened to, but it was head office not the local manager.” One staff member said, “The manager tried to make improvements but head office would say no, not listening to the manager or staff on the ground. “

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff understood their roles and responsibilities but confirmed there were not always clear systems of accountability and governance. For example, one staff member explained there was no system in place to monitor insulin or depot injections since the last employed nurse left in October 2023. Staff described difficulties in accessing nurses to cover vacant posts and confirmed there were no contingency plans in place to provide cover if needed. Staff demonstrated how they recorded incidents on the provider’s electronic system and described the process for monitoring incidents. The provider told us the most recent audit of the service had been undertaken in November 2022 and an action plan was developed following the audit. The provider described working with the local authority following safeguarding concerns that had been raised, and confirmed they had undertaken relevant investigations regarding the management of the service.

Systems for ensuring the rota was covered with suitable staff were not always effective. There was a lack of systems to assess risks to people from not having suitably qualified staff on duty, including qualified nurses. There was a lack of governance to ensure oversight of clinical needs, including for depot injections and administration of insulin, these shortfalls had not been identified through the provider’s systems for auditing medicines. A partner agency had taken back responsibility for administering depot injections for some people due to concerns about poor management of depot injections at the home. The Provider’s medication policy includes guidance for staff regarding refusal of medication but this had not been followed consistently. Staff were not consistently offering depot injections after a refusal, effectively monitoring non-compliance or contacting the original prescriber in line with the provider’s policy. The provider’s medicine policy lacked guidance for clinical staff. For example, it did not identify clearly how delegated tasks should be managed to ensure adequate oversight, supervision and competency of staff. The provider’s systems had not ensured records were accurate, complete and contemporaneous. Records of administration of depot injections and insulin were not always accurate and complete. The provider had undertaken an audit of the service dated November 2022 and produced an action plan following this audit. This had identified issues that were still current at this inspection, including the need to assess risks to people when nursing staff were not available and that CTO conditions were not clear in people’s care plans. This meant the provider had failed to act and make improvements to the quality and safety of the service. There was a system in place to ensure incident reports made by support workers were followed up and how patterns and trends were identified.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.