Durnsford Lodge Residential Home

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• 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

We identified 5 breaches of legal regulations. People were not consistently protected from the risk of abuse and/or improper treatment. Staff did not always identify allegations of abuse, poor practice or make referrals in line with the providers policy and procedures. People continued to be exposed to the risk of avoidable harm as the provider failed to take adequate steps to address concerns relating to the management and mitigation of risks. People were not protected by safe recruitment practices. We were not assured that the provider was storing and managing people’s medicines safely. People and their relatives were not involved in a meaningful way in the development of their care. There was limited information to demonstrate how staff were engaging with people in understanding their rights, supporting them to have increased opportunities or enabling them to make informed decisions. The provider failed to ensure the premises were properly maintained. However, people told us they felt safe living at Durnsford Lodge, and most relatives felt confident with the care and support provided and told us they would recommend the service. Other risks to people’s health and wellbeing were being managed well. Staff had received training relevant to their role. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who were able to share their views, told us they felt safe. One person said, “I like all the staff and they are kind and I have no concerns.” Most relatives told us they were able to raise concerns if something was not right and felt these would be listened to and acted upon. However, 2 relatives did not feel, staff listened or acted on their concerns. We found there was little information to show how staff were actively engaging with people using the service or seeking their feedback with a view to drive service improvements in a meaningful way. There was limited information to demonstrate how staff were engaging with people in understanding their rights, supporting them to have increased opportunities, enabling them to make informed decisions, or involving people and their relatives in the development of their care and support. For example, 4 relatives told us they had not seen or been involved in the development of their loved one’s care plans; 4 relatives said they were not aware of any accidents or incidents that may have taken place and 4 relatives told us they had not taken part in best interests’ discussions. We observed people spent prolonged periods of time without any meaningful activities. We received mixed feedback from relatives regarding the levels of activities provided. Comments included, “Staff are really friendly and supportive and involve [person’s name] in the exercises and quizzes,” “There are no activities, Mum doesn't want to vegetate in a chair.” And “I have seen a list of activities but have never seen any of them take place.”

The nominated individual and registered manager told us they used information from accidents, incidents, safeguarding and complaints to learn lessons. Outcomes were used to make service improvements and shared with the staff team via team meetings as well as relatives and other healthcare professionals if appropriate. The registered manager described the process for dealing with complaints and assured us that all concerns were taken seriously and investigated. We saw evidence of where issues had been raised, these had been investigated in line with the provider’s policy and procedures. The registered manager explained how regular staff meetings enabled the sharing of information and provided an opportunity for staff to get involved in the running of the service, share their views, and raise concerns. Most staff said they felt able to raise concerns and were confident the registered manager would listen and take action. However, staff consistently told us concerns about staffing levels, and activities were not listened to or taken seriously by the provider. One staff member said, “I have spoken to [Nominated individuals name] myself and explained that we don’t have time to do activities or spend time with people. The response I got, was that staff were sitting down having breaks.” Another said, “We don’t get enough time to spend with people, it is a bone of contention, something needs to be put in place for activities. But it is convincing the provider.” Following the inspection the provider confirmed they provided a range of activities daily. For example, staff supported people daily to take part in a range of games, arts and craft sessions and themed days. In addition, the service purchased music sessions from an external provider.

The provider had systems and processes in place to seek people’s, relative’s, and staff’s views, analyse incidents, investigate concerns, and learn lessons. The registered manager and the nominated individual told us each month they carried out a range of spot checks and audits at all levels to monitor the quality and safety of the service, which helped to ensure compliance with the regulations and learn lessons. However, we found audits were not undertaken robustly; they were not effective in identifying concerns and they did not drive or sustain improvement. For example, accidents and incidents were recorded and reviewed by the registered manager to identify any learning which may help to prevent a reoccurrence. This information was shared with the provider through regular monthly meetings and audits. However, we found safety concerns were not being identified by either the registered manager or the provider and where they had been identified action had not been taken to reduce and/or mitigate risks. The provider had not developed a proactive and positive learning culture in which concerns about safety and quality were identified: listened to and responded to promptly and robustly. There was limited information to indicate that the provider had learnt lessons from previous inspections or embedded good practice. For example, in relation to the management of risk, safeguarding, mental capacity, recruitment, and governance. The failure to effectively operate systems to assess, monitor, and mitigate risks to the health, safety and welfare of people using the service, placed people at an increased risk of avoidable harm. This was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People who were able to share their views with us, told us they felt safe and were happy living at Durnsford Lodge. Comments included, “I like all the staff, they are kind and I have no concerns,” “Yes, I feel safe - no concerns with any staff or other residents,” and “I absolutely feel very safe here, they are so caring and patient which is important.” Most relatives we spoke with did not raise any concerns about people’s safety. Comments included, “The staff are really good, as far as we are aware [person’s name] appears to be well cared for,” “We feel [person’s name] is safe, yes,” “Happy with the home and [person’s name] is looked after well,” and “I know [person’s name] feels safe and we feel the same.” However, 3 relatives raised concerns about staffs’ approach, quality of personal care, laundry, communication, activities, and the environment.

The registered manager described how the service protected people from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. All of which was under pinned by the service’s policies and procedures in relation to complaints, safeguarding, whistleblowing, mental capacity, and deprivation of liberty safeguards. The nominated individual explained that each month in addition to the auditing process they held a governance and risk management meeting with the registered and deputy managers to discuss and review any information of concern to ensure the correct action had been taken. Staff had received training in safeguarding adults and were able to tell us the correct action to take if they suspected people were at risk of abuse and/or avoidable harm. One member of staff said, “If I witnessed any abuse, I would raise it with my manager unless it was the manager, and I would go to [nominated individuals name] or go through to the safeguarding team so I would not hesitate to whistle blow as I love my residents.” Another said, “I would go to the manager first and then if I did not get satisfaction, I would put in a safeguarding myself to the local authority.” However, we found whilst staff were able to tell us the correct action to take if they suspected people were at risk of avoidable harm or abuse. They failed to recognise or escalate their concerns within the organisation or to Plymouth City Council’s safeguarding team in line with the provider’s safeguarding policy.

During the inspection we observed many positive interactions between people and staff. For example, we saw some lovely person-centred interactions, it was clear that staff cared about the people they were supporting. We saw staff offering choice, asking people how they were and engaging people in everyday conversation. And we saw how staff sensitively comforted and redirected people when they became emotionally distressed.

There were systems in place to protect people from abuse, including policies and procedures and training for all staff. However, we found the registered manager and provider had not always recognised when information of concern needed to be shared with the local authority and the Care Quality Commission for further investigation / follow up in line with their own safeguarding policy. For example, incident report forms identified there had been nine recorded incidents involving people hitting each other between 15 October 2023 and 26 February 2024. Staff failed to recognise and report when people had potentially placed themselves at risk of sexual abuse and/or exploitation by their own actions. All these incidents had been reviewed by the registered manager and the nominated individual as part of the services auditing process and had been signed off as not requiring any further action. The failure to effectively establish and operate systems to investigate and report allegations of abuse placed people at an increased risk of harm. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). The registered manager told us that some people living at the service would be prevented from leaving as it would not be safe for them to do so. We found there was no legal basis or framework in place to support these restrictions. The failure to provide care and support in line with the Deprivation of Liberty Safeguards code of practice was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People we spoke with told us they were happy, they felt safe and liked the staff supporting them. One person said, “I absolutely feel very safe here.” Most people living at the service were not aware of their care plans or associated risk assessments. 5 relatives told us they had not been involved in or had access to people’s care plans or risk assessments. Comments included, “I don't think I have seen a care plan, and we haven't had any discussions about [person’s name] capacity,” “A care plan was done a long time ago, no reviews since,” “There has been no meetings about [person’s name] care and no care plan I am aware of for years.” However, one relative said, “We were involved with [person’s name] care plan. No reviews yet.”

The registered manager described how the service assessed people’s needs before offering a placement. Assessments were used to develop person centred care plans and risk assessments, which were reviewed on a regular basis. Staff told us they knew people well and had a good understanding of their needs. staff were aware of people's individual risks, potential triggers and signs that might show the person was becoming unwell or anxious. Staff described how they supported people to manage their emotional distress or anxieties. However, we received mixed feedback from staff about the accuracy of people’s care plans. For example, one member of staff said, “Care plans are updated by the registered and deputy managers, I have all the information about any special dietary requirements. When any new residents come in, l have a look at their care plan.” However, other staff said care plans were not always reflective of people’s needs. For example, another member of staff said, “So, I would say the care plans are not updated enough – like [person’s name], it says they need a hoist when I looked yesterday but they use a handling belt.”

It was clear from our observations that staff had developed good relationships with people. Staff we spoke with had a good understanding of people’s needs. We saw how staff were anticipating people’s needs and identifying triggers and redirecting, preventing people experiencing emotional distress and or increased anxieties. For example, we saw how staff took time to explain to people what they were doing and allowed people time to process information. We also saw how staff used reassurance, humour, and singing as a way of effectively engaging with people

At our last inspection we found the provider was failing to effectively manage and mitigate risks. At this assessment we found not enough improvement had been made and the provider was still in breach of regulation 12. The registered manager and nominated individual described how the service assessed people’s needs, developed care plans and risk assessments. These were reviewed on a regular basis with the involvement of people, relatives, and staff, and audited monthly in conjunction with the nominated individual as part of the providers governance processes. However, we found your ongoing failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people continued to be exposed to the risk of avoidable harm. For example, one person had been assessed at high risk of falling from bed and required the use of bedrails to maintain their safety. Records showed, between 19 October 2023 and 28 February 2024 staff had recorded 3 entrapment risks and 2 safety concerns relating to the use of bedrails. The registered manager confirmed, no action had been taken to further investigate these incidents or to mitigate, reduce or prevent reoccurrence. Following the inspection the provider told us action had been taken, but acknowledged more should have been done. Another person’s care record indicated that they had potentially been placing themselves and others at risk of sexual abuse and/or exploitation by their actions. None of these risks had been assessed by the service or formed part of this person’s risk management plan. Your failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm and was a continued breach of regulation 12 of the Health and Social Care Act 2008.

People who were able to share their views with us, did not raise any concerns about their living environment. Comments included: “Yes, it is always clean around the house, and everything is changed, and they are always coming here and mopping the floor and they are always changing my bedsheets,” “Yes, the place is quite clean, they come in and clean and hoover.” Most relatives we spoke with did not raise any concerns about people’s living environment and told us they would recommend the service to others. Comments included. “[Person’s name] has a lovely room it’s clean and tidy, they put a bird box outside to enjoy the birds,” “It is clean, I'd live there.” “Her room is cleaned every day; her clothes and bedding are washed.” However, one relative said. “We bought new towels and bedding. I checked the quilt, and it was really thin and poor quality, so I replaced it and the pillows.”

The registered manager told us there had been several improvements with regards to the environment since the last inspection. For example, redecoration of some people’s bedrooms, new flooring to lower and upper floors along with new fire doors and emergency work being carried out on the services electrics. The registered manager said a lack of investment by the provider in the right areas, and urgency to recruit a maintenance person had impacted on people’s living environment and their ability to stay up to date with everyday maintenance tasks. The registered manager said they were chasing the provider but accepted that many of the actions had been outstanding for some months with no expected date for completion. The nominated individual told us they were aware that some aspects of Durnsford Lodge needed to be upgraded and assured us there was a plan in place to address these concerns. They told us they had recently employed a new part time maintenance person and there was a plan in place to refurbish the top floor bathroom, but this had been delayed due to contractors. A staff member said, “We need someone here to do maintenance at least part time, but if we had someone here full-time things would get sorted quicker.” Another said, “No, there is not enough done to maintain the building. The provider spent a fortune on lampshades and curtains, but it is the tables and chairs that need replacing.” Following the inspection the provider told us they had invested £75,000 since June 2023 on repairs and maintenance to improve people’s living environment.

We toured the service with the registered and deputy managers and found some areas of the service still needed significant attention. Some hallway carpets were worn, heavily stained and looked grubby. Some areas of the home were not clean. For example, some walls were dirty and in need of cleaning, people’s bedrooms and corridors needed painting and some equipment used to support people with their continence needs were damaged, cracked and not hygienic. We noted one person’s room which had recently been redecorated, had damp coming through the walls. At our last inspection, April 2023, we found the bathroom on the top floor within the main house and the toilet on the ground floor were out of action awaiting repair. At this inspection, we found no action had been taken. The registered manager told us they did not have a date or timescale for the work to be carried out. Following the inspection the nominated individual told us the registered manager was aware of this information. We also noted some people’s bedrooms did not have sufficient plug sockets to run electrical equipment. This had led to the practice of ‘daisy chaining’ (The use of multiple extension leads being plugged into each other to allow more appliances to be plugged into a single wall socket). This is considered poor practice, as it presents a risk that the wall socket could be overloaded. The registered manager showed us a bedroom, which was vacant and ready for allocation. We noted the bedding, towels, and face cloths looked threadbare and grubby. The walls were stained and marked, and the window needed to be repaired and painted, this had been outstanding since April 2023.

At our last inspection we found the provider failed to ensure the premises were clean; suitable for the purpose for which they are used and properly maintained. This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this assessment we found not enough improvement had been made and the provider was still in breach of regulation 15. We cannot be assured the provider is doing all that is reasonably practicable to mitigate risks to the people using the service in relation to the environment. During the assessment we found several concerns regarding the general state of disrepair to the premises. Whilst environmental checks and audits were in place. These did not drive improvement within a timely manner. The providers continued failure to ensure the premises were clean; suitable for the purpose for which they were being used and properly maintained was a continued breach of regulation 15 (Premises and Equipment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following our site visit the provider confirmed that the downstairs toilet had been fixed and work had started on the top floor bathroom.

People who were able to share their views with us did not raise any concerns about staffing levels. Comments included, “The staff do help, and when I ring the bell, I do not have to wait too long.” “The staff are ok. I do not usually ring the bell but there seems to be enough staff,” “If I need anything, I just go downstairs,” and “When I ring, they are here very quickly. The girls are always popping in and seeing if I want anything, and they are always nice, they are the best.” Relatives did not raise any concerns with us about staffing levels. One relative said, “I think there's enough of them [meaning staff] about, I haven't overly noticed the call bells ringing.” Another said, “Seems to be enough staff, I haven't noticed any variation at the weekend or evenings.”

The manager told us there were enough staff to meet people’s needs safely. However, staff consistently said there were not enough staff to meet people’s needs and spend time with people or do activities. Comments included, “No we don’t have the staff,” “No, not enough staff and definitely not enough in the afternoons. I think 4 in the morning would be sufficient if we had an activities person on the floor. After 4pm we only have 3 staff. If we had more staff, we could spend more time to sit with people,” “We don’t get enough time to spend with people, it is a bone of contention, so something needs to put in place for activities,” and “In the evenings we go down to 3 and we are running around. I have spoken about this several times with nominated individual and the response I got was staff were sitting down having breaks.” The deputy manager and nominated individual told us there had been some delays in providing staff supervision, but they now had a system in place, and they were confident this was getting better. Staff confirmed they attended training and received regular supervision. One member of staff said, “My last supervision was 2-3 weeks ago, and I think they happen every 3-6 months.” Another said, “I do have regular supervision, we have them I think every 6 months. Yeah, we get feedback about how we are doing, and it is just a chance to air any concerns and all these kinds of things.”

It was not obvious during our inspection that there were not enough staff to meet people’s assessed needs. There always appeared to be staff within the main lounge / dining area and we did not hear people’s call bell’s ringing for long periods of time, which might indicate that people were waiting for assistance. However, we noted that most people were in their bedrooms and not sat in communal areas.

At our last inspection we recommended the provider undertook a review of staffing arrangements and skill mix at night. At this assessment, we found improvements were still needed. We looked at the recruitment information for 3 staff and found recruitment checks had not been carried out safely. For example, one member of staff appears to have been employed before their recruitment checks had been completed. We found information of concern contained within the reference provided by this person’s previous employer. Neither the registered manager nor the nominated individual was able to tell us if this information had been followed up with staff member's previous employer. Another staff members file contained discrepancies. As the dates given on the application form did not match dates confirmed by referees. The third staff file contained conflicting information about the reason for leaving a previous employer. This meant the provider was unable to demonstrate they had followed a thorough recruitment process in accordance with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The providers failure to ensure staff were recruited safely and in accordance with Schedule 3 placed people at an increased risk of avoidable harm. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At the previous inspection, the registered manager was not able to provide assurance that night staff had the skills and competencies to meet people’s needs in a timely way. At this assessment we found this had not changed. The provider monitored staff training on a training matrix. This showed staff had received training in a variety of subjects. However, we found training did not always determine practice. The failure to provide sufficient numbers of skilled staff to meet people's needs, is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People who were able to share their views with us did not raise any concerns about the way in which they received their medicines. One person said, “Yes, they give me medication. They give me the right ones I think, and when I need them.” Another said, “They give me 3 pills every day. The doctor said I have to have them with water now, I can no longer have them with coffee or milk. So that’s annoying.” Most relatives we spoke with were confident that people had good access to their GPs and received their medicines correctly. One relative said, “Staff administer all mum’s medicines and they let me know of any changes like antibiotics etc.” Another said, “Mum takes medicine for her Dementia, her blood, and tablets to calm her. We get told if there are any changes and an annual review is done by the doctor.” However, one relative said [person’s name] is meant to take her [name of medicine] every morning. One of the staff upset her by saying you need to take your brain tablet, [person’s name] was so upset she stopped taking it and the staff never noticed.”

The registered manager told us there was a system in place for recording, reporting, and investigating any medicines errors or incidents. They described how they had worked with staff to reduce medicine errors and felt this area of practice had much improved. Regular medicines audits identified areas for improvement and recorded when actions had been completed. However, we found medicines audits had not been undertaken robustly and did not identify the concerns we found at this inspection. Staff told us they felt medicines systems generally worked well and they had supplies of medicines when they needed to be given. Staff were trained in medicines administration and had competency assessments. Staff we spoke with were mostly knowledgeable about people’s needs and their medicines.

At our last inspection we found the provider had failed to store and manage people’s medicines safely. This was a breach of regulation 12. At this assessment, whilst improvements had been made, the provider was still in breach of regulation 12. People’s medicines were not always managed or stored safely. For example, on the first day of the inspection we found the medicines room had been left unlocked. Upon entering, we found medicine cabinets had been left unlocked and medicines due to be returned to the pharmacy for safe disposal had been left in a box on the floor, allowing access to unauthorised staff. Records relating to medicines requiring additional security were not accurate. For example, one person’s medicine administration record (MAR) indicated there were several medicines held in stock. However, these medicines had been returned for disposal in August 2023. Audits conducted by staff, the registered manager and nominated individual had failed to identify these discrepancies and could not be relied upon. This meant you failed to ensure medicines requiring extra security were stored safely and securely and to keep accurate records of the disposal and transfer in accordance with the Misuse of Drugs Regulations 2001. One person received their medicines covertly, staff administering this medicine told us they administered the medicine in yogurt. However, we noted the prescribing instruction guided staff to mix or dissolve in water. The failure to follow prescribing instructions could have had an adverse impact on this person’s health and wellbeing. Your failure to store and manage people’s medicines safely, and to keep accurate records of the disposal and transfer of medicines held by Durnsford Lodge was a continued breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Other medicines were administered safely and staff had received training in the safe administration of medicines.