Background to this inspection
Updated
12 August 2021
The inspection
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 Care Act 2014.
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 completed by two inspectors. One inspector completed the on-site inspection and another inspector made telephone calls to staff and relatives.
Service and service type
Duncote Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 had a manager registered with the Care Quality Commission. 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.
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. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service and three relatives about their experience of the care provided. We spoke with seven members of staff including registered manager and care workers.
We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data, cleaning data and staffing rotas.
Updated
12 August 2021
About the service
Duncote Hall is a residential care home that can provide long and short-term residential nursing care for up to 40 older people, including people living with dementia. At the time of inspection 13 people were using the
service.
People’s experience of using this service and what we found
Improvements had been made since the last inspection. However, these needed to be fully embedded.
Systems and processes to ensure oversight of the service and the care people received was in place but required embedding and reviewing to ensure all information was captured and all risks reduced.
People were protected from harm. Known risks to people had been assessed and mitigating strategies implemented. However, we found a few areas required further improvements. Most unexplained injuries had been investigated, followed up and recorded appropriately.
People received their medicines safely and by trained staff. However, we found not all prescribed medicines had been recorded appropriately. However, we found no evidence of harm to people.
People told us activities were not offered at weekends, and staff at times were slower at responding to needs than expected.
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.
Staff were seen wearing appropriate PPE, COVID-19 testing was in place and the service followed government guidance throughout the COVID-19 pandemic.
People were supported by staff who had been recruited safely and who had received the necessary training to complete their roles.
People told us staff were kind, caring and knew them well. Staff respected people’s privacy, dignity and independence. People were involved in their care planning and preferences had been recorded.
People were supported with aspects of food and fluids as required. People had a choice of meals and drinks throughout the day.
Staff worked closely with other professionals such as speech and language therapists, GP’s, commissioners and other health professional.
People, staff and relatives knew how to complain. The management team had requested feedback on the service from people, their relatives, staff and other professionals.
People's communication needs were documented and met. The registered manager had information available in different accessible formats such as easy read, large print or in a different language.
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 Inadequate (published 9 April 2020) and there were multiple breaches of regulation. The provider completed action plans after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Exiting special measures
This service has been in Special Measures since 9 September 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
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.
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.