This inspection took place on 14, 15 and 16 May 2018 and was unannounced. The Dean Neurological Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Dean Neurological Centre provides accommodation for 60 people who require personal care with nursing. There were 47 people living in the centre at the time of our inspection. The centre provides personal care and support to people with complex long term neurological conditions, brain or spinal injuries and people who require on-going support and assistance to maximise their functional ability. The centre is purpose built and set over two floors, each floor comprising of 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is a therapy department, sensory room and people have access to several decked areas in the garden.

Following our last inspection in June 2017, we met with the provider and asked the provider to complete an action plan to show what they would do and by when to improve the key questions in the domains of safe, effective, responsive and well-led. At this inspection we found that progress had been made in the recording of people’s care needs, the delivery of personalised care and the monitoring of the service to drive improvement. However further improvement was still needed as people’s care records were not always current and some people did not always receive personalised care.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However an interim manager had been allocated to the home by the provider to support the registered manager to drive improvement across the home. The centre was also being supported by specialist internal and external advisors as well as representatives from the provider.

Systems and initiatives to monitor the service were being implemented. Through their own quality assurance assessments, the provider had identified concerns in the running of the home and was acting on these shortfalls. However we found that their systems had not always identified gaps in the recording of people’s current needs and the delivery of personalised care. We have recommended that the service seeks advice in designing and reviewing people’s support to ensure that it reflects their needs and preferences.

Systems were being put into place to gain the views of relatives and staff and improve communication and assess the quality of the service being provided.

Relatives and staff had been concerned that people had not always been supported by staff who were familiar with their needs. A high turnover had resulted in people being supported by agency and/or new staff who may not have a sufficient understanding of their care requirements. The centre was actively recruiting new staff and plans were in place to implement an effective management structure and keyworker system to help to assist with the monitoring of people’s needs and care records.

People were supported to access health care services when their medical needs had changed and received their medicines as prescribed. We received mixed comments about the quality of food people received, however we found that people’s dietary needs and choices were catered for.

We found the centre was clean and free from offensive odours. The provider was in the process of employing additional housekeeping staff to maintain the level of cleanliness on a daily basis and reduce the risks of cross contamination.

People and their relatives were positive about the staff

This inspection took place on 26 and 27 June 2017 and was unannounced. The Dean Neurological Centre provides accommodation for 60 people who require personal care with nursing. There were 54 people living in the centre at the time of our inspection. The centre provides personal care and support to people with complex long term neurological conditions, brain or spinal injuries and people who require on-going support and assistance to maximise their functional ability.

The centre is purpose built and set over two floors, each floor comprising 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is therapy department and people have access to several decked areas in the garden.

There was registered manager in place as required by their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and their relatives were mainly positive about the caring nature of staff; however people’s care plans and daily care records did not support the safe delivery of care. Not all people had recorded guidance or care planning which reflected their support requirements and risk management. Staff did not always follow safe infection control practices. People were not continually informed of the care being provided.

People benefited from a new medicines management system to ensure they received their medicines as prescribed.

Staff enjoyed working at the centre. There were suitable numbers of staff to support people; however the registered manager was reviewing the deployment of staff across the centre to ensure people received care and support in a timely manner. Effective recruitment systems were in place to ensure people were cared for by staff with good character. Staff understood their responsibility to report any accidents, incidents or safeguarding concerns.

Systems to monitor staff training and support had generally improved. Staff told us they felt trained; however their work based skills were not regularly assessed to ensure they were competent to support people with complex skills. A series of competency assessments were being developed to evaluate the skills and knowledge of staff. Not all staff training was mandatory which meant some staff were at risk of having gaps in the knowledge to care for people. A clear frame work to monitor the specialist clinical skills that nurses required to carry out their role was not in place other than the nurse’s professional registration requirement. Not all staff had supervision records which highlight their professional development or act on any concerns.

Staff and people’s their relatives felt communication across the centre needed to improve. A quality improvement lead was helping to recognise shortfalls in the service and drive improvement in the centre. The provider had different means to regularly audit and check on the quality of the service being delivered, although the system had not always been effective in driving improvement across the service.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

This inspection took place on 14 and 15 December 2016 and was unannounced. The Dean Neurological Centre provides accommodation for 60 people who require personal care with nursing. There were 53 people living in the centre at the time of our inspection. The centre provides personal care and support to people with complex long term neurological conditions, brain or spinal injuries and requires on-going support and assistance to maximise functional ability.

The centre is purpose built and set over two floors, each floor comprising 30 individual bedrooms, communal lounges and dining rooms. On the ground floor there is therapy department and people have access to several decked areas in the garden.

There was registered manager in place as required by their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and their relatives were mainly positive about the care they received however we found people’s safety and well-being was compromised in a number of areas.

There were inconsistencies in the detail and information in people’s care records. Information was not always accessible or consistently recorded to provide staff with guidance. There was an irregular approach to the monitoring of people’s risks and well-being. There was limited evidence that people’s mental and social well-being had been addressed. Staff supported people who lacked mental capacity in their best interest and knew their preferences well; however assessments of people’s mental capacity had not been consistently carried out. Protocols were not in place for people who required their medicines ‘as required’.

Staff were confident in their role and said they felt trained and supported. However their skills and care practices had not been continuously checked or updated. Staff had not received regular private support meetings to discuss their development and performance.

People were supported by staff who were kind and compassionate and knew people well. Staff interactions were positive and caring. They respected people’s dignity and privacy when supporting people with their personal care. Staff understood their responsibility to safeguard people and report any concerns.

People enjoyed the meals provided. Those who had specific dietary needs were catered for. People’s medicines were mainly managed well, although accurate stock levels of medicines were not always kept. People were supported to access a variety of health care services as required.

The centre was adequately maintained and clean. Staff demonstrated good infection control practices.

The manager dealt with any issues from people and their families on a day to day basis and had acted on people’s concerns. Their views were sought but not always acted on. Systems to monitor and improve the quality of service people received and the training of staff were in place. However these systems were not effective in driving improvements within the service. The registered manager and provider were aware of concerns found during this inspection, and were formulating actions to improve the service.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

The inspection was unannounced.   A full inspection of the service was last completed in June 2013.  We found  breaches of legal requirements in the following areas: respecting and involving people, consent to care and treatment and the management of medicines.  A follow up inspection was completed in December 2013 and the required improvements had been achieved.

The Dean is registered to care for up to 60 people who have complex neurological or spinal related disease or injury.  People may have long-term physical and/or cognitive impairment, which may not improve over time and which may also require long-term medical support.  The service provides specialised 24 hour nursing care and therapy services for adults over the age of 18.  There were 45 people receiving care at The Dean when we visited. 

There was a registered manager in post at the service.  A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’.  Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act and associated Regulations about how the service is run.

All staff ensured that people were kept safe and safeguarded from harm. They all received safeguarding adults training and understood their role and responsibilities to protect people from harm.  Appropriate actions had been taken when safeguarding concerns had been raised.  Information was available for staff to say what they had to do if safeguarding concerns were raised and who they had to contact. 

There were good risk assessments and management plans in place to ensure that any risks in respect of people’s daily lives or their health needs were properly managed.  The plans ensured that those risks were reduced or eliminated. Staffing numbers on each shift were sufficient to ensure that each person was kept safe and their care needs were met.

All staff were provided with the training they needed to do their jobs and had further training opportunities to develop their skills.  Staff had the specific clinical skills they needed to meet people’s individual and complex care needs.  People were provided with sufficient food and drink, or dietary supplements to meet their requirements.  Where people were at risk of poor nutrition or hydration, measures were in place to monitor how things were going.  Arrangements were made for people to see their GP and other healthcare professionals as and when they needed to do so.

There were positive working relationships between the staff and people who lived in the home and people were well cared for.  Where possible people were involved in making decisions about how they wanted to be looked after and how they spent their time.  Families were involved in the decision making process where they needed and acted as an advocate on behalf of their relative.  People’s privacy and dignity was maintained at all times.

People  were encouraged to have a say and to express their views and opinions about their care and each person was looked after in a person-centred way.  They had a say about the way the home was run, meals and activities.  Staff listened to what they had to say and acted upon any concerns to improve the service they provided.

The registered manager provided good leadership and had a committed staff team who provided the best possible service to each person who lived there.  The quality of service provision and care was continually monitored and where shortfalls were identified actions were taken to address the issues. 

We used a number of different methods to help us understand the experiences of people using the service. This was because some people using the service had complex needs which meant they were not all able to tell us their experiences. We observed some staff interacting with people and spoke with staff about aspects of people's needs and examined their care records. The purpose of this inspection was to follow up on some areas of non-compliance we found at previous inspections. Because of this we did not speak with any people.

Changes had been made to the activities provided. People were able to join in group activities or have one to one time. All staff were involved in providing activities for people.

People had access to external health and social care professionals to help the service meet their assessed needs.

Suitable arrangements were in place for obtaining and recording people's consent to treatment and care.

Improvements had been made to the management of medications that were administered via percutaneous endoscopic gastrostomy tubes (PEG).

People said there were activities provided each day if they wished to join in.

People told us they were happy with the care they received and they made comments such as, “I have no complaints” and “some staff are excellent”. One person said “the physiotherapy has worked wonders” and that they had therapy daily.

People said the food was good and they had a choice about what to eat.

People said they would talk to staff, managers or their relatives if they had concerns.

People we talked to on the day of our visit said they did not have any complaints.

One relative and one health care professional raised concerns with us prior to this inspection. These concerns were considered during this inspection and relevant findings have been included in this report.

We also considered the many compliments that have been received by the service.

To be noted- There was a time laspe between this report being witten and the company being able to respond to the report due to correspondence being sent to the incorrect email box within the company. The company wish it known that during this time completion to some of the management restructuring, mentioned in outcome 24 of this report, was achieved. This has resulted in a new nursing manager (Matron) being appointed for this service. This person also intends to be the services registered manager. Progress therefore, in relation to the one compliance action in this report, will be reported on in our follow up review.

People who use the service and their relatives expressed both negative and positive comments about their experiences. Some people were able to express their views independently, others needed varying degrees of support to do this and others are totally dependent on an advocate to speak on their behalf.

Some people said they did not feel they had been involved in the planning of their care and that staff did not always acknowledge their personal preferences. All those spoken to however confirmed that regular review meetings are held and in these they are able to discuss their care and treatment.

Some people expressed general unhappiness and dissatisfaction with the care provided. Others spoke of having a positive experience all round.

Some people have expressed particular dissatisfaction with their respite care (care for a short and planned period of time). Several complaints about this have been received by the local Primary Care Trust and a few people have chosen not to return.

People were very satisfied with their therapy treatment.

People had mixed views about the activities provided. They told us they would like more opportunities to get out.

We could see that the purpose built building and equipment was helping to promote independence and maintain a quality of life.

People said the staff were friendly and helpful but that there are not enough of them to always assist them in a way they would prefer. They said they do not have to wait long if they ring their call bell. Relatives have expressed frustration in not being able to find staff when they want them and in staff not getting back to them when they said they would.

Several relatives, including some people who use the service, have felt that staff have not taken their concerns or complaints seriously when they have initially raised them. They have also remained unhappy with the services formal response. Although, this has not been everyone's experience.

We were told that senior managers are not very accessible.

People who use the service said communication between staff groups was poor and that this sometimes has a direct impact on them. They said their records are not always well maintained and some felt they were not monitored as well as they should be.

We were not able to speak with all people at The Dean Neurological Centre because of their complex needs as people had severe physical, communicative and cognitive issues. We spoke with or communicated with 13 people and 11 relatives. We also examined in detail the care of five people and all gave positive indications that they were happy with their care and support. Nine relatives all said they were happy with the care and support their relatives received. Two relatives told us about some concerns they had.

Nearly all people we spoke with told us they were bored because of a lack of activities. We found there was a lack of activities for people. The registered manager told us after the inspection that all staff provided activities as part of people's treatment and rehabilitation, but their recording of this was not very clear.

We found care staff demonstrated good knowledge of people's needs, especially those who required one to one care. All staff had access to on-going training and competency assessments were in place for care staff that used specialist equipment.

We found that further work was needed to ensure that people using this service were fully protected against the risks associated with medicines.

A compliance action issued at the last inspection had been addressed in relation to recruitment of new staff. A system was in place to monitor the service provision and obtain the views of people and their relatives.