Dormy House

The home used references and Disclosure and Barring Service checks when recruiting staff.

“The provider operated effective and safe recruitment practices when employing new staff.” from the report

People could access health care, and the home worked with several health professionals. Assessments were completed before people moved in.

“We saw evidence of visits from various health care professional including opticians, community nurses, hospice nurse, physios and occupational therapists.” from the report

Although care was inconsistent, inspectors saw staff greeting people warmly and protecting privacy during personal care.

“When personal care was being delivered staff always ensured the bedroom or bathroom door was closed to protect the person's dignity.” from the report

Inspectors saw staff supporting repositioning, checking blood sugar levels and using hoists safely in the examples reviewed.

“We observed where people required to hoisted, staff were undertaking this in a safe way to reduce risk of harm to the person.” from the report

Choking, falls, fluid restrictions and accidents were not managed consistently. Records did not always explain what had happened or what would prevent further harm.

“The failure to ensure risks to people's safety were robustly assessed was breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Some medicines lacked clear instructions, stock counts were inaccurate, records had gaps and equipment was dirty. This created a risk that people could receive the wrong medicine or miss doses.

“The failure to ensure medicines were managed in a safe way was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

People were sometimes left without the support they needed, including during meals and when at risk of falling. Many staff had not received suitable supervision.

“The failure to ensure there were appropriate levels of staff deployed at the service was a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report

Allegations of people being hit were not always recognised, investigated or reported to safeguarding teams. Injuries were not always investigated to reduce further risks.

“The failure to ensure people were protected from the risk of abuse was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

People were not always supported with personal care, appearance, choices or meaningful activities. The broken lift also left some people isolated in their bedrooms.

“The provider had failed to ensure people were always treated with dignity and respect and were always given choices around their delivery of care this was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Audits and other checks failed to identify serious issues with medicines, choking risks, staffing and care quality. Complaints and feedback did not consistently lead to action.

“The failure to ensure quality assurance and governance systems were effective was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.” from the report