Delves Court Care Home

Updated 25 April 2023

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 Health and Social Care Act 2008.

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 team consisted of 2 inspectors, a pharmacist specialist and a nurse specialist advisor.

Service and service type

Delves Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Delves Court Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there were two registered managers in post, who managed the service together.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since registration. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to 9 people and 8 relatives about their experience of the care provided. We spoke with 5 professionals who have contact with the service. We spoke with 12 members of staff including the registered managers, the unit manager, an activity coordinator, a housekeeper, a cook and 6 members of staff. We reviewed a range of records. This included 14 people's care plans, a range of medicine administration records (MAR) and 4 staff recruitment files. We viewed a variety of records relating to the management of the service including audit systems. We spent time observing the care that people received within the home.

Updated 25 April 2023

About the service

Delves Court Care Home is a nursing home providing personal and nursing care to up to 64 people, including people with dementia. At the time of our inspection there were 55 people using the service.

People’s experience of using this service and what we found

People were not always protected from the risk of harm; systems were not effective in assessing, monitoring and mitigating risks to people’s health, safety and welfare. People weren’t always supported by registered nurses for their nursing care needs. There weren’t always sufficient numbers of staff available to help people. This meant people were sometimes left at risk of harm or without timely care.

People didn’t always receive the support they needed to manage weight loss, however people reported they were given meal choices and drinks as required. People were supported by trained staff but had varied experiences of staff skills and practice.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People did not always receive support that was caring and maintained their dignity. Whilst many people found the staff caring and compassionate, a lack of staff sometimes led to shortfalls in people’s experiences. People didn’t always receive adequate support to maintain their independence.

People’s person-centred needs weren’t always at the forefront of their support. However, people were supported with a range of meaningful activities and staff were attentive to people’s emotional and social needs.

Quality assurance systems were not always effective for people. This meant the action taken by the provider had not always ensured people received consistent, good quality and safe care. However, people and relatives spoke positively about the management of the service. Systems were in place to seek feedback and resolve people’s complaints.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 15 May 2020 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about end of life care and the staffing and safety of the service. A decision was made for us to inspect and examine those risks.

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.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to how people’s safety was managed, the staffing of the home, how people’s rights were promoted, people’s person-centred needs and how the service was run at this inspection.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.