Durnsford Lodge Residential Home

Updated 30 June 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 was made up of one inspector and two Experts by Experience who had consent to phone and /or speak to gain feedback on the care provided by the service from people's and their relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Durnsford Lodge 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.

Durnsford Lodge is a care home without 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 was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed the information, we held about the service, including notifications we had received. Notifications are changes, events or incidents the provider is legally required to tell us about within required timescales. We sought feedback from the local authority and 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 this information to plan the inspection and took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spent time with and spoke with 16 people living at the service, 9 relatives, 3 members of staff, and the registered manager. To help us assess and understand how people's care needs were being met we reviewed 5 people's care records. We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems. After the inspection we continued to seek clarification from the provider to validate evidence found

Updated 30 June 2023

About the service

Durnsford Lodge is a 'care home' that provides care and support for a maximum of 28 older people, some of whom may be living with a dementia and/or physical frailty. At the time of the inspection 24 people were living at the service.

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

People told us they were happy; they felt safe and the staff were kind and caring. However, we received mixed feedback from relatives about the care provided.

We found whilst the provider and new registered manager had made a number of positive changes since the last inspection, more work was needed to ensure the service was operating in accordance with the regulations and best practice guidance.

People were not always protected from the risk of harm associated with their complex care needs or the environment. We asked the provider to take immediate action to address those concerns. Following the inspection the provider confirmed they had taken action to address concerns identified in relation to people’s living environment and fire safety.

People were not always supported to have maximum choice and control of their lives and staff were not always supporting people in the least restrictive way possible. The service could not always demonstrate they were acting in people’s best interests.

People’s medicines were administered and disposed of safely. However, medicines needing extra security were not being stored safely or securely.

Staff were recruited and employed in sufficient numbers to meet people's needs. However, we have made recommendations about the use of agency, students, and the deployment of staff.

Poor judgements and decision making did not always demonstrate a culture where people were valued and respected consistently.

Governance systems were either not embedded into practice or not undertaken robustly enough to identify and monitor the quality of the service and effectively drive improvements.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 March 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe Effective and Well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Durnsford Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, need for consent, dignity and respect, premises and equipment and good governance at this inspection. We have also made recommendations in relation to recruitment and the deployment of staff at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.