Archived: Derwent Lodge Care Centre

Updated 8 January 2015

This report was written during the testing phase of our new approach to regulating adult social care services. After this testing phase, inspection of consent to care and treatment, restraint, and practice under the Mental Capacity Act 2005 (MCA) was moved from the key question ‘Is the service safe?’ to ‘Is the service effective?’

The ratings for this location were awarded in October 2014. They can be directly compared with any other service we have rated since then, including in relation to consent, restraint, and the MCA under the ‘Effective’ section. Our written findings in relation to these topics, however, can be read in the ‘Is the service safe’ sections of this report.

The inspection team consisted of two inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, we reviewed the information we held about the service including the Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection, we viewed a variety of records including six people’s care records, four staff records, complaint records, a sample of audits for monitoring purposes and a selection of policies and procedure documents. We observed the mealtime experiences for people and interaction between staff and people and their relatives/visitors. Following the inspection we requested and received copies of the staff rosters for July 2014.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We spoke with seven people using the service, eight relatives, two other visitors, two volunteers, the Director of Quality and Audit for the provider, the deputy manager, five registered nurses, nine care staff, the activities coordinator and four healthcare professionals who provided input for people the service. Following the inspection, we also spoke with the registered manager, who was on leave at the time of inspection.

Updated 8 January 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection. During the last inspection on 18 March 2014 the provider was meeting the regulations we checked.

Derwent Lodge Care Centre is registered to provide nursing care to a maximum of 62 people with nursing care needs and/or dementia care needs, and those with physical disabilities. The service is arranged over three floors in single bedroom accommodation. At the time of inspection there were 54 people living at the service.

The registered manager has been in post since November 2011. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People and their relatives were happy with the care provided and told us they felt safe and staff treated them with dignity and respect. People and their relatives were involved with the planning and review of their care, so their preferences and wishes were known.

The service was meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Concerns were raised by people, relatives and staff about the service being short of staff on occasions, leading to delays in care being provided. Staff felt they were not kept informed about any action being taken to address this. The manager and deputy manager said there was ongoing recruitment of new staff taking place to address shortages.

We identified some shortfalls in the standard of records keeping particularly for risk management and wound care. This could place people at risk of not receiving the care and treatment they needed.

Staff understood safeguarding and whistleblowing procedures and knew to report concerns to the manager. Records we saw confirmed the provider followed recruitment and training procedures. Staff demonstrated an understanding of people’s individual needs and wishes and how to meet them.

Systems were in place to monitor the quality of the service, however these were not always effective in identifying shortfalls, for example, with care records. People and relatives said they would express any concerns they might have, so these could be addressed.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.