Background to this inspection
Updated
17 May 2022
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 first day of inspection was carried out by three inspectors. An expert by experience worked remotely. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day of inspection was carried out by four inspectors, a medicines inspector and an Expert by Experience onsite. The third day of inspection was carried out by two inspectors.
Service and service type
Duchess Gardens Care Centre 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. Duchess Gardens Care Centre is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced on the first two days and announced on the third day.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 13 people who used the service and nine relatives about their experience of the care provided. We looked around the building and observed people being supported in communal areas. We spoke with 10 staff members including the registered manager, clinical lead, nurses, care workers, agency staff and receptionist.
After the inspection
We continued to seek clarification from the provider to validate evidence found. Where we had concerns about people, we made referrals to the local safeguarding authority. We also met with the provider and local authority to discuss the most urgent concerns and were assured immediate action had taken place.
Updated
17 May 2022
About the service
Duchess Gardens Care Centre is a residential and nursing care home providing personal and nursing care to 45 people at the time of our inspection. The service can support up to 131 people. At the time of our inspection, some units in the home were not in use.
People’s experience of using this service and what we found
Some of the concerns we found at this inspection related to issues found at our previous inspection, meaning action needed to achieve the necessary improvements had not been taken.
The provider was unable to demonstrate robust governance arrangements and learning had not taken place. Systems and processes designed to identify shortfalls and drive improvement were not effective and had not identified the concerns we found.
Care plans and good governance were areas of concern identified in our inspection of July 2021 when we took enforcement action. These concerns remained at this inspection.
The provider had not assessed and mitigated risks to people, and people did not have accurate and complete care records. This included hazards in the home's living environment as well as risks associated with people's health, safety and wellbeing. Procedures failed to safeguard people from the risk of abuse.
People did not always receive their medicines in a safe way. The systems in place and management oversight had failed to identify shortfalls.
Staff were non-compliant in following government guidance on wearing personal protective equipment correctly.
Privacy and dignity were not always promoted. Staff were not always observed to be being respectful and caring and at times we observed a lack of interaction between staff and people.
Safe recruitment practises were not followed as the required background checks had not been undertaken before staff started work at the home.
Most people and relatives told us they felt safe, and most of the feedback from people was positive for the service.
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 inadequate (published 16 September 2021), when there were breaches of regulation. 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. This service has been rated requires improvement for three consecutive inspections and inadequate for the last consecutive three inspections, including this inspection.
Why we inspected
This was a planned inspection based on the previous rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Duchess Gardens Care Centre on our website at www.cqc.org.uk.
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, caring and well led sections of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches of relation to, safe care and treatment, safeguarding, medicines, ensuring the premises are safe, infection prevention and control, staffing, dignity and respect and good governance.
Please see the action we have told the provider to take at the end of this full report.
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 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 return sooner.
Special Measures:
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.