Archived: Dearne Hall

We carried out this inspection on 16 August 2018. The inspection was unannounced. This meant no-one at the service knew we would be visiting.

Dearne Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Dearne Hall is registered to accommodate 48 older people. At the time of the inspection 44 people were living at the home. The home has three floors. The middle floor is for people living with dementia, the ground and top floor is for people who require personal care, some of whom are living with dementia.

Our last inspection at Dearne Hall took place on 5 and 15 June 2017. The service was rated Requires Improvement overall. We found the service was in breach of three of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. Regulation 12, Safe care and treatment, Regulation 19, Fit and proper persons employed and Regulation 17, Good governance.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions asking if the service was safe, effective, responsive and well led, to at least good. The registered provider sent us an action plan detailing how they were going to make improvements. At this inspection we checked the improvements the registered provider had made. We found sufficient improvements had been made to meet the requirements of the Regulations.

There was a manager at the service who was registered with the CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People living at Dearne Hall told us they felt safe and they liked the staff. Relatives we spoke with felt their family member was in a safe place and did not have any concerns about their family member’s safety.

Regular checks of the building were carried out to keep people safe and the service well maintained.

Staff confirmed they had been provided with safeguarding vulnerable adults training, so they understood their responsibilities to protect people from harm.

There were sufficient staff to meet people’s needs safely and effectively.

The service used effective recruitment procedures which helped to keep people safe.

We found systems were in place to make sure people received their medicines safely.

Staff were provided with relevant training and supervision to make sure they had the right skills and knowledge to support people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People enjoyed the food provided and were supported to receive adequate food and drink to remain healthy.

We found the home was clean, bright and well maintained.

People had access to a range of health care professionals to help maintain their health.

People were treated with dignity and respect and their privacy was protected. People, their relatives and health professionals we spoke with made positive comments about the care provided by staff.

A range of activities were available both inside and outside the home to provide people with leisure opportunities.

People living at the home and their relatives said they could speak with the registered manager or staff if they had any worries or concerns and they would be listened to.

There were effective systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to.

Staff told us they felt they had a very good team. Staff, people and relatives said the registered manager was approachable and communication was good within the service.

Dearne Hall is a residential care home registered to accommodate 48 older people. At the time of the inspection 45 people were living at the home. The home has three floors. The middle floor is for people living with dementia, the ground and top floor is for people who require personal care, some of whom are living with dementia.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

On 5 July 2016 the Care Quality Commission carried out an inspection and found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we checked and found that whilst some improvements had been made, further work was required to fully comply with the regulations.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Systems were in place to manage risks to people and the service to ensure people, others and the environment were safe. The registered provider had not always been effective in managing risks to people, such as people’s nutrition, moving and handling and pressure area care.

Health professionals were contacted in relation to people’s health care needs such as doctors and community health teams. However, improvement was required to ensure staff carried out any changes that were made and that this was recorded accurately in people’s care files.

Improvement was required so that medicines were stored safely and that better systems and processes were in place to monitor the recording and administration of topical medicines.

Information and documents in the recruitment of staff did not include all the required information to support a robust recruitment process.

There were systems in place to assess and monitor the quality of service provided, but these had not always been effective in ensuring compliance with regulations and keeping people safe.

Staffing levels were sufficient to meet people’s needs, although some people felt more staff were required as staff were always busy and did not always respond to their needs in the time they felt appropriate.

There was a system in place for staff to receive training and supervision so they had appropriate skills to carry out their roles, but the implementation of the registered provider’s annual appraisal procedures required embedding.

There were systems in place to make sure people were protected from abuse and avoidable harm.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. However, we found policies and systems in the service did not always ensure the service complied with the Mental Capacity Act.

Meal times were a positive experience for people, with choices available.

Staff had developed positive relationships with people. They provided not only the physical care people needed, but also considered the quality of life of each individual.

Some people and their families felt there could be more and a better variety of activities.

People and relatives told us staff were caring and treated them or their family member with respect.

People were confident in reporting concerns to the manager and registered provider and felt they would be listened to.

Dearne Hall is a residential care home registered to accommodate 48 older people. At the time of the inspection 48 people were living at the home. The home has three floors. The middle floor is for people living with dementia, the ground and top floor is for people who require personal care, some of whom are living with dementia.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The person managing the home was not present during the inspection, but the area manager was able to confirm an application to register had been submitted.

Feedback from people, relatives, staff and other stakeholders was that the manager provided effective leadership to the service and provided opportunities for people and staff to express their opinions on the quality of the service provided and the running of the home.

On 24 February 2015 the Care Quality Commission carried out an inspection and found a breach with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we checked and found that improvements had been made to meet that breach of regulation, but found a further breach of four regulations. You can see what action we told the provider to take at the back of the full version of the report.

When we spoke with people who used the service they all told us they felt safe. Relatives spoken with did not raise any concerns about mistreatment or inappropriate care provision of their family member. Staff had received safeguarding training and were confident the manager would act on any concerns.

We found staffing levels were sufficient to meet people’s needs, but that recruitment of staff did not include all the relevant information and documents required to ensure staff were suitable to work with vulnerable people.

Systems and processes were in place for the safe administration of medicines.

Systems were in place to manage risks to people and the service to ensure people, others and the environment were safe. The registered provider had not always been effective in managing those risks, such as people losing weight and fire safety.

Staff received induction, training, supervision and appraisal relevant to their role and responsibilities.

The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who lacked capacity to make important decisions themselves.

Meal times were a positive experience for people, with choices available.

Staff had developed positive relationships with people, providing not only the physical care people needed, but also considering the quality of life of each individual person.

People and relatives told us staff were caring and treated them or their family member with respect.

Health professionals were contacted in relation to people’s health care needs such as doctors and community health teams.

People were confident in reporting concerns to the manager and registered provider and felt they would be listened to.

There were systems in place to assess and monitor the quality of service provided, but these had not always been effective in identifying improvements needed and to ensure improvement to achieve compliance with regulations.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Observations showed that people were given choice and consent was sought from people for making decisions.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Comments included, 'It's nice here, I've got a decent room with a good view and the staff are very helpful' and 'I like living here. I've got a few friends and we have a laugh.'

People were protected from the risk of infection because appropriate guidance had been followed. Staff were trained in infection control and regular audits were undertaken.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. The home had an appropriate recruitment procedure in place.

There was an effective complaints system available. People we spoke told us that if they ever did have a complaint they would speak to the manager, or one of the care workers. They felt complaints would be dealt with appropriately.