We carried out a review of the data available to us about Douglas Court on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Douglas Court, you can give feedback on this service.
We found the following examples of good practice.
The provider assessed all visitors for symptoms of acute respiratory infection before being allowed to enter the home. For example, all staff and the visitors had their temperature checked automatically upon entering the building by using Hikvision’s Temperature Screening Thermographic Cameras. People who use the service had their temperatures checked and recorded twice a day.
The provider had installed PPE stations in the reception and all around the building, including an automatic hand sanitising station. The staff worn correct PPE in accordance with the government’s guidance.
All visitors were required to take a Lateral Flow Test (LFT) and worn full personal protective equipment (PPE), including a mask, an apron and gloves in order to reduce the risk of catching and spreading infections.
During the active outbreak of COVID-19, the provider put measures in place to reduce the spread of the infection. For example, isolation and cohorting of staff.
The home looked cleaned and hygienic and there were enhanced cleaning scheduled in place.
The provider had installed a visitor’s pod in the garden which meant that families could have a comfortable, relaxed visit without risk. They had also made provision in the conservatory for visitors to have a safe space to visit.
Douglas Court can accommodate up to 43 people. At the time of our inspection there were 33 people living at the service. The home is a two story building with lounges, dining rooms and a conservatory situated on the ground floor.
We found the following examples of good practice.
¿ The provider had installed a visitors pod in the garden which meant that families could have a comfortable, relaxed visit without risk. They had also made provision in the conservatory for visitors to have a safe space to visit.
¿ Staff had received training in donning and doffing personal protective equipment (PPE), and we saw this was accessible throughout the home and staff used it in accordance with the most up to date guidance. Staff had received further training in Covid-19 and infection control.
¿ The registered manager told us that they had removed chairs in the lounges to maintain social distancing.
¿ The infection control policy was up to date. We reviewed audits which reflected actions had been taken to maintain the standards within the home. There was a Coronavirus Policy and Procedure, Management of Personal Protective Equipment (PPE), Coronavirus Uniform Policy and Social Distancing in the Home Policy. All of this helped to guide staff to manage the pandemic.
¿ Only essential medical professionals had entered the home during the outbreak unless someone was at the end of their life; then their family were able to visit.
¿ White boards had been purchased for communication both in the home and in the visiting area. People had found communication difficult with face masks on, but the whiteboards had helped to support this.
¿ During the outbreak they had installed additional PPE stations so that staff had easy access to PPE. They also had a separate area to change their clothing and put on uniform when starting work. This helped to reduce cross contamination from clothing they had worn to work.
Douglas Court is a residential care home, registered to provide accommodation for up to 43 older people, younger adults and or people living with dementia. Douglas Court accommodates people across two floors. On the day of our visit 42 people were using the service.
People’s experience of using this service and what we found
Improvements had been made to the deployment of staff in communal areas. However a few people felt staffing levels were not always fully effective.
Improvements identified in internal audits were not always actioned. For example, action from the infection control audit had not been implemented.
People told us they felt safe at Douglas Court. People were supported by staff who had a good knowledge of how to protect them from abuse and harm.
Risk assessments were in place, providing guidance for staff in how to mitigate risks and keep people safe from harm. People's medicines were administered as prescribed. People were protected from the risk of infection.
Staff supported people with their dietary needs. People were supported to access healthcare services as required.
People were supported by staff who promoted their privacy and dignity. Staff had a good understanding of people, their likes and dislikes. Staff encouraged people to be independent.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The provider’s complaints policy and procedure were accessible to people who used the service and their representatives. People knew how to make a complaint.
People had opportunities to participate in activities and social events organised by staff.
The registered manager understood their legal responsibilities and had shared information with us and others when they needed to. People and their relatives told us the service was well-led. Staff told us they enjoyed working at the service and worked well as a team.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 15 December 2016).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The service had a manager who was in the process of becoming registered with the CQC and had submitted an application. 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 2008 and associated Regulations about how the service is run.
At our last inspection on 21 January 2014 we found that the service was in breach of Regulation 13 management of medicines and regulation 21 requirements relating to workers of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2010 which following legislative changes of 1 April 2015 corresponds to Regulation 12 safe care and treatment and Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to make improvements. We received an action plan from the provider in which they explained how they would make improvements. At this inspection we found that improvements had been made and the service was meeting these requirements.
We have made a recommendation about the deployment of staff. Some people said that at times staff were not visible in one of the lounges and we saw that this was the case for part of the morning in one of the lounges. One person said that this had recently improved. For the previous three months there had been an average of 10 accidents or incidents a month. Many of these were un-witnessed falls.
People were protected from the risk of harm at the service because staff knew how to recognise abuse and what action to take if they suspected abuse or had a concern. Risks to people's well-being had been assessed and action plans were in place. Pre- employment checks had been carried out to assess staff character and suitability to work at the service.
Routine maintenance and safety checks were carried out on the building and equipment used. Staff knew what action to take in the event of an emergency such as a fire or an accident.
People's medicines were managed safely and were given to them in accordance with their prescriptions.
Staff received appropriate support through training and supervision and had their practice observed and assessed. There was an on-going training programme to provide and update staff on safe ways of working.
There was a choice at each meal time and people had enough to eat and drink. People were supported to maintain a balanced diet and risk of malnutrition was assessed and managed. People had access to healthcare services and could see a doctor, community nurse or other professional as required.
People were supported in line with the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). We found that appropriate assessments of capacity had been completed and DoLS applications had been made. People were asked for their consent before receiving care and support.
Staff supported people in a kind and compassionate way. People had their dignity and privacy protected. Staff knew the things that were important to people and their individual preferences. People were supported to be as independent as they could be.
People said they would feel comfortable making a complaint and felt sure they would be listened to and action would be taken.
People had confidence in the manager and said they were approachable. Staff felt supported by the management team. People and their relatives were asked for their feedback about the day to day running of the service. Changes were made as a result of what people said.
Regular checks known as audits were carried out to check the quality of service provision. Changes were made where shortfalls were identified.
People using the service and their visitors told us that they were happy with the care and services provided at Douglas Court. Comments included 'It can't be faulted here, the staff, the food and everything is good" and 'It's got a homely atmosphere, we know all the staff and there's good communication between staff and residents.'
During the inspection visit we observed that staff were responsive to people's needs and wishes.
We saw that people's needs were assessed, and care plans were in place. This meant people received support in a way that met their needs.
The majority of the people we spoke with told us they enjoyed their meals. People also said that they received enough to eat and drink.
People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.
Robust recruitment procedures were not in place to safeguard people who used the service.
Procedures were in place for managing complaints about the service. People, who use the service, told us they had no complaints about the service and felt safe at Douglas Court.
Visitors said they were happy with the service provided. One visitor told us 'so far I am pleased with the support my relative receives, the staff have been marvellous.'
Visitors told us they are contacted by the home if there have been any changes in their relatives health needs.
We spoke with four people living at the service. They all told us they were being supported well by the staff and they enjoyed living at Douglas Court. Comments included 'it's great here, I'm not going no where' and 'I like living here, it's not as good as being at home, but its close.'
People told us they enjoyed the meals provided and there was always plenty to eat. People stated 'the food is very good,' 'meals are varied' and 'I like the food.'
People told us the entertainment provided was excellent. Comments included 'there is always something happening', 'it's the Halloween party tomorrow, we always have a party', 'singers come to the home and I like to take part.'
People told us they were able to raise concerns about care and support with the staff team. Comments included 'I have no reason to complain, but would speak to the manager if anything was bothering me.'
People who used the service and their relatives, told us that they were encouraged to participate in a good range of social activities within the home.
People told us that they felt safe in the homes environment. They also thought the staff had the right qualifications, skills and knowledge to perform their duties safely.
People who used the service and their relatives told us that they were provided with the opportunity to comment on the quality of service provision at residents meetings and within quality assurance processes.
The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate.