Deepdene Court

We identified two breaches of the legal regulations.

People were not consistently protected from the risk of harm and abuse. Staff did not always identify allegations of abuse or make safeguarding referrals in line with safeguarding policy. People told us they did not always feel safe. One person described how they felt anxious when other people had incidents of distress or became angry and emotional.

Incidents were not always recorded and reported in line with the provider’s policy. This meant there was a lack of scrutiny and missed opportunities for staff to learn from incidents and to ensure risks were appropriately managed.

Risks to people were still not consistently identified, assessed and managed. Care plans did not always provide the guidance staff needed to support people’s needs and manage risks. People and their relatives were not consistently involved in planning care and in managing risks. Staff were not referring to care plans consistently and not all staff were familiar with people’s needs. This increased the risk that people’s needs might not be met.

It remained that medicines were not managed safely. Some medicines required clinical oversight. Nurses were not on duty at night-time, this meant there was not always a nurse available to provide clinical oversight or to make clinical decisions when needed. Records were not always clear and accurate and this meant staff did not have all the information they needed to administer medicines safely and in line with prescriber’s instructions.

However, there were now enough suitable staff to provide care safely and improved systems for the safe recruitment of staff. There were effective systems to manage infection prevention and control. People were satisfied with their accommodation although some environmental risks were not consistently managed.

We identified two breaches of legal regulations.

There were continued failures in the governance and management of the service. Whilst some improvements in management of medicines and in staffing had been achieved, there remained concerns about the lack of management oversight and a failure to sustain and embed improvements.

The provider’s systems were not effective in providing a recovery model for people’s mental health needs or in supporting the needs of people who also had learning disabilities or autism. Systems had failed to identify shortfalls in risk assessments and care plans. Records were inconsistent, lacked personalisation, and did not include detailed strategies for staff to provide effective support.

Governance systems had failed to identify shortfalls and inconsistencies in the management of incidents. Incidents, including potential safeguarding events, were not always recorded, reported or analysed to ensure learning and improve outcomes for people. Systems for monitoring the administration of medicines had failed to identify shortfalls and omissions. The Provider was required to notify the Care Quality Commission of some incidents but notifications had not always been submitted. Staff described a lack of leadership and said they felt unsupported in their roles. They described a negative culture due to a failure to address risks and challenges that staff were facing daily.