Archived: Danes Lea - Care Home

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service Safe?

We found that the provider had taken sufficient steps to improve infection control systems and practices to ensure people that used the service were safe from the risks of infection. Audits and cleaning schedules had improved, care plans contained improved details about peoples' infection risks, the environment and equipment had been deep cleaned and some furnishings had been replaced. The laundry and sluice rooms had been reorganised so they presented less infection risk to people that used the service and staff.

Below is a summary of what we found. We used a number of different methods to help us understand the experiences of people who used the service, because some of the people who used the service had complex needs which meant they were not able to tell us their experiences. The summary is based on our observations during the inspection, speaking with people who used the service, visitors, the staff who supported them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us that they were consulted about their care and were able to make their own decisions about life in the home. People felt staff respected their privacy and dignity. We found people were being looked after by friendly, supportive staff within a warm and homely environment.

The registered provider set the staff rotas and took people's care needs into account when making decisions about numbers, qualifications, skills and experience required. This helped to ensure that people's needs were always met.

Our observation of the premises found that although most areas were superficially clean and tidy, some aspects of the environment needed a deep clean and some furnishings and fixtures needed repair or replacement to ensure that facilities managed the prevention and control of infections.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the prevention and control of infections.

Is the service effective?

People's health and care needs had been assessed and care plans were in place. People and relatives told us they were able to discuss their care needs and make decisions using the care review process and on a daily basis with the manager or staff.

Specialist dietary, mobility and equipment needs had been identified in the care plans where required. Input from health care professionals was sought when concerns about a person's care were identified.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with cognitive and physical disabilities.

Is the service caring?

We saw that staff acted in a friendly and supportive manner, whilst being professional and courteous when speaking to people and visitors to the service. People who we spoke with were well dressed and some were waiting to be seen by the hairdresser. Individuals told us 'I like it here, they treat you right', 'I am well looked after' and 'There is nothing wrong with the care here, I have no complaints.'

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

Is the service responsive?

People said they could make a complaint if they wanted to. One person said that they had spoken to the manager in the past and they felt the manager had responded appropriately. They were satisfied with the outcome of their complaint. We looked at the complaints investigations completed by the manager in the last six months. These were completed in line with the complaints policy.

Is the service well led?

The service had an effective quality assurance system, which indicated the quality of the service was continually monitored. The records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continually improving.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Feedback from these individuals was obtained through the use of satisfaction questionnaires, meetings and one to one sessions. This information was analysed by the provider and where necessary action was taken to make changes or improvements to the service.

The service had an open door policy so staff were able to discuss any concerns with the manager. Regular staff meetings were held so that people could talk about any work issues. This meant that staff were able to provide feedback to their managers and their knowledge and experience was recognised and taken into account.

Efforts were made to involve people who used the service and their relatives in issues relating to the management of the service.

People who used the service who we spoke with told us they were satisfied with their care and treatment. One person told us 'I am very satisfied'.

Staff at the service were able to recognise and act where they suspected any abuse. Safeguarding documentation showed appropriate action was taken where there were safeguarding concerns.

The provider had addressed concerns from our previous visit and systems were in place to ensure staff who worked at the service were recruited and pre-employment checks were completed to ensure the safety of people who used the service.

The provider had a robust quality assurance procedure that ensured the quality of the service provided was regularly monitored and reviewed.

They told us they could make day to day decisions about their lives and said they were generally happy with the support they received from staff. One person told us, 'I am comfortable at the home and staff take the time to explain things to me. They are friendly and very pleasant'.

We saw that best interest meetings had taken place when people lacked the capacity to make important decisions for themselves.

We noted that staff were provided with sufficient and up to date information to enable them to support people in the way that they had chosen. Health care professionals had been consulted about a person's welfare when this had been deemed necessary.

Medication had been received into the home and then stored securely. Medication had been returned to the pharmacy when not needed. Recording was accurate with a minor concern about administration that managers told us would be addressed on the day of the inspection.

The home was maintained in a satisfactory state of repair.

We checked the recruitment records for two members of staff and found that both had started work before all information had been received to confirm that they were considered suitable to work with vulnerable people. This left people who lived at the home at risk of harm.

There were satisfactory quality monitoring systems in place.