We carried out a review of the data available to us about Dene Grange Care Home 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 Dene Grange Care Home, you can give feedback on this service.
Dene Grange Care Home is a residential care home providing personal and nursing care to up to 50 people, some of whom live with dementia. At the time of our inspection 30 people were using the service, living in three units within the home. One unit was not currently being used.
People’s experience of using this service and what we found
Improvements following our last inspection had been made. Risks had been identified and regularly reviewed.
People felt safe and medicines were managed well. People and their relatives said staff were kind and looked after them very well.
The home was well-led, and the registered manager had improved governance and quality assurance systems. Lessons were learnt when things went wrong.
The home was still in the process of refurbishment, but this was expected to be completed in the next few months. The home and surrounding gardens had been made safe and ongoing monitoring took place.
There were enough staff to meet people’s needs, although there was a lack of domestic staff and the registered manager had already gained agreement for domestic staff to be increased. Staff were recruited safely and were inducted into the service and received suitable ongoing training.
The home was clean and tidy, although due to a lack of domestic staff, touch points were not cleaned as often as they should have been. There were some inconsistencies with staff around the use of PPE. These issues were addressed immediately by the registered manager.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were supported with foods and drinks they enjoyed. People were supported to access healthcare services and staff had good working relationships with external professionals.
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 22 September 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 improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended the provider review their medicines procedures. At this inspection we found recommendations had been addressed.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dene Grange Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
People’s experience of using this service and what we found
Safety procedures were not robust, including those in connection with fire procedures and maintenance of the premises. Risk assessments were not always in place.
The premises did not always provide a stimulating environment for some people, and in places required redecoration and further maintenance to be completed.
The providers quality assurance systems were not always effective and had not found issues, including those identified during the inspection. People’s care records, including monitoring charts, needed to be improved.
People were supported to have maximum choice and control of their lives and staff always support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, a review of mealtimes was to take place to ensure people were always offered a choice and to ensure food was well presented.
Medicines were managed well. We have made a recommendation to review procedures to ensure best practice was always followed.
We were somewhat assured with infection control procedures and have signposted the provider to additional support to enhance their procedures.
We received mixed responses about the management team and some staff said morale was not good. Staff support systems were not up to date as programmed by the provider. Improvements were planned to take place.
Safe recruitment procedures were followed, and an ongoing recruitment drive was in place. Enough staff were in place. There were some gaps in staff training, but the provider took immediate action to address this.
Despite the issues we found, people felt safe and relatives confirmed this. Staff were kind and compassionate.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 1 June 2020 and this is the first comprehensive inspection. We carried out a focussed inspection on 28 January 2022 which only reviewed infection control procedures and therefore the service was not rated at that time. The last rating for the service under the previous provider was good, published on 1st May 2018.
Why we inspected
We undertook this inspection because the service had not been previously fully inspected since registering with the CQC under the new provider. We also wanted to follow up on concerns shared with us via the local authority regarding safety at the service.
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. You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We have identified breaches in relation to safety, the premises and governance of the service at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider, local authority and Northumberland Fire and Rescue Service to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
There were enough staff at the service to meet people’s needs. The provider had a recruitment drive in place to fill any gaps. New staff had been appointed.
Visitors to the service were admitted safely. There were specified visiting areas which were cleaned after every visit. When visitors could not attend the service for whatever reason, other methods were used to help minimise social isolation for people, including video or audio calls.
Visiting professionals had not always been asked for their vaccination status. This was addressed immediately.
The service was clean and odour free. Additional cleaning was being carried out on frequent touch points such as grab rails and door handles. However, some areas needed repainting to cover bare wood which cannot be cleaned effectively. The provider was going to address this immediately.
People were encouraged to social distance. Lounges and dining rooms had been set out with space between people. Staff worked on specific units to help minimise the transmission of infection.
Staff wore their PPE correctly and had received infection control training. Staff were to receive refresher training in donning and doffing (on and off) of PPE.