Durnsford Lodge Residential Home

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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

We identified 2 breaches of legal regulations. People who were able to share their views with us and their relatives spoke positively about the service, the staff and the care and support they received. However, we found the service was not operating in accordance with the regulations. Governance processes were not effective in keeping people safe, protecting people's rights, providing good quality care and support or driving improvements. Throughout the assessment, the registered manager and nominated individual was open, transparent, acknowledged any areas for improvement and was keen to address any areas of concern. Staff felt able to speak up and raise concerns with the registered manager and/ or nominated individual. But they did not always feel their concerns were being heard or their views would bring about change. 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 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and staff understood what was expected from them and had good understanding of their roles and responsibilities. Staff we spoke with did not have a clear understanding of the providers values, but it was clear that staff knew people well and care about the people they supported. 5 of the 6 staff we spoke with told us they felt valued and supported by the registered manager. One staff member said, “Yes, I think it is an open culture here, staff can speak up. [manager’s name] and [deputy’s name] are very approachable and always have time to listen.” Following the inspection the provider sent the Commission additional feedback from 7 staff which confirmed what staff had told us. The manager told us they were aware that improvements were needed to develop shared direction and positive culture within the service. They described how daily spot checks help to identify concerns and poor practice. Where concerns had been identified, these had been addressed through staff supervision and shared with staff through team meetings.

All staff were required to complete an induction and attend regular training, which included equality, diversity, and inclusion training. In addition, the provider was working with the service’s management team to raise standards within the service and develop a shared direction and positive culture. The provider employed the services of an external quality team to provide an independent view of the service and provide feedback. Records showed staff were receiving regular supervisions and appraisals. Staff meetings allowed opportunities for areas of improvement to be discussed and implemented.

Staff spoke positively about the leadership and management of the service and told us they felt valued, appreciated and supported by the registered manager. One member of staff said, “[managers name] is a very supportive and approachable manager.” Another said, “The managers [ meaning registered and deputy] are brilliant, they work on the floor when were short. Yes, very supportive,” Throughout the inspection, the registered manager was open, honest and recognised that improvements were needed. The nominated individual accepted that some concerns had been a direct result of the lack of oversight of the service. Whilst they had not been fully aware of all the concerns we identified, they were aware of the need to improve and told us they were keen to make those improvements. They had developed a service improvement plan and had made several positive changes to the home’s environment but acknowledged the failure to employ a maintenance person was impacting on people’s living environment.

The registered manager and nominated individual understood their responsibilities in relation to duty of candour. Duty of candour requires that providers are open and transparent with people who use services and other people acting lawfully on their behalf in relation to care and treatment. We found systems had not been effectively operated to identify and report significant events. This had led to the provider not notifying the Care Quality Commission of 19 significant events in line with their legal responsibilities, which occurred between 1 October 2023, and 20 March 2024. This was a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (part 4). The registered manager and nominated individual did not demonstrate sufficient oversight of the service to ensure people received care and support that promoted their wellbeing and protected them from harm. Poor judgements and decision making, potentially placed people at the risk of harm or risked compromising their human rights. For example, in relation to safeguarding people from the risk of abuse, or avoidable harm; working in line with the principals of the Mental Capacity Act 2005 (MCA) or through safe recruitment practices. The provider was unable to assure themselves that learning took place from accidents and incidents. The registered manager told us they shared information with external agencies such as healthcare professional's when things had gone wrong as well as liaising with families where appropriate to do so. However, we found this was not consistent practice. Complaints received by the service were documented, investigated by the registered manager; reviewed and followed up by the provider.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The registered manager and nominated individual described the systems and processes to monitor the service and ensure compliance with the regulations. Each month the registered manager and nominated individual carried out a range of spot checks and audits to monitor the quality and safety of the service and ensure compliance with the regulations. Audits included, care plans, medicines, safeguarding, accident and incidents, recruitment, health and safety etc. In addition to the auditing process, the nominated individual told us they held quality, risk, and governance meetings with the registered and deputy managers to discuss findings, identify concerns and agree actions. However, we found these were not effective in identifying concerns or driving improvements. The management and staff structure provided clear lines of accountability and responsibility, which helped ensure staff at the right level made decisions about the day-to-day running of the service. People's personal records were kept secured and confidential. Staff understood the need to respect people's privacy including information held about them in accordance with their human rights. The registered manager told us that regular handover meetings helped to ensure essential information about people's care needs were shared within the staff team and / or escalated if needed.

At our last inspection we found systems were either not in place or robust enough to demonstrate the service was being effectively managed. At this assessment we found not enough improvement had been made and the provider was still in breach of regulation 17. Governance processes were not effective in keeping people safe, protecting people's rights and providing good quality care and support. This meant they were not always effective, did not drive improvement and did not identify the issues we found at this assessment. Issues included concerns with regards to leadership, safeguarding, management of risk, management and storage of people’s medicines, staffing, recruitment, mental capacity, DoLS, and the environment. For example, care plan audits and reviews failed to identify concerns we found in relation to the management of risk, mental capacity, restrictive practice, or best interests. Medicines audits failed to identify the concerns we found with the safe storage and management of people’s medicines. Safeguarding audits did not identify safeguarding incidents that should have been reported to the local authority and the Care Quality Commission. Governance systems failed to identify that staff were not following the providers policies in relation to safeguarding, medicines, mental capacity and recruitment. Systems were not fully embedded into practice or robust enough to demonstrate that accidents or incidents were effectively monitored. Quality, Risk and Governance meetings undertaken by the nominated individual and registered manager to monitor the service were not effective in ensuring compliance with the regulations. The providers failure to act upon feedback from previous inspections and enforcement action taken by the Commission, meant that you were not compliant with the regulations. This was a continued breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us the registered manager and staff team were approachable; kept them informed when things changed, and they felt confident in raising concerns if something was not right. One person said, “I am not sure who is in charge, but I would just talk to any of the staff, and they would sort it out.” Another said, “Yes, I do know who is in charge and she has a little dog. If I had any concerns, I think I would speak to the staff.” We received mixed feedback from relatives. Most relatives we spoke with said they were happy with the care provided and felt the staff communicated well. Comments included, “The head carer rings me at home, I'm kept informed about every little thing.” “[Registered manager and deputy managers names] are in charge, their approachable ladies, friendly and keep us informed.” “They let me know if the doctor’s been in and if anything has changed. Someone came in had a chat with Dad and asked if he was happy and his thoughts on the place.” However, some relatives were not so positive. One relative said, “You can’t trust them, there is no communication at all.” Another said, “We are very unhappy, I would move [person’s name] out today if I could.” We found some relatives were not aware of people’s care plans or risk assessments; did not remember taking part in mental capacity or best interests’ decisions and could not recall being told about any accidents or incidents. Following the inspection the provider confirmed the action they had taken to engage with relatives this included Friends and Family Surveys, Email updates and Feedback forms.

The registered manager told us they recognised the importance of joint working with partner agencies to improve people’s outcomes. They described how they worked in close partnership with the district nurses who supported people with skin conditions such as pressure ulcers. The SALT team, [speech and language therapist] to support people who may be experiencing eating and drinking difficulties, and the older person’s mental health team [OPMHT] who provided support for some people living at the service who had advancing Dementia. Staff told us they felt appreciated by the registered manager and could contribute their ideas for the running of the service. One member of staff said. “[Registered managers name] does listen if you go to her, she is very understanding and supportive.” However, some staff told us the provider did not always hear their ideas. For example, one member of staff said, “Everyone knows we need an activities person, but it’s about convincing the provider.” Staff were aware of the value of working in partnership with people, their families and other healthcare professionals. However, we found staff had been slow to raise / escalate concerns or seek advice in a timely manner. This impacted on the quality-of-care people received and placed them at an increased risk of avoidable harm as documented within the safe section of this assessment.

We received no specific feedback from partner agencies prior to this assessment taking place, but we saw examples of how the provider was working in partnership with some health and social care professionals. Following the assessment, we received feedback from a representative from the local authority who told us they had confidence in the provider and the improvements they had made following our assessment. The provider was engaging well with healthcare professionals and local authority representatives who were supporting the services continued improvement.

The provider had a variety of systems and processes in place to demonstrate how they worked in partnership with key stakeholders. Systems were in place to gather people's, relatives, and staff’s feedback on the quality of the service. Care plans evidence that staff had engaged with some people’s families, and relevant professionals to seek support. Regular meetings and handovers helped to ensure information was shared with staff at the right levels.

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.