Dukeminster Court

The home was clean and did not have unpleasant smells. Inspectors found regular cleaning and enough housekeeping staff.

“The home was clean and free from malodour. Effective systems were in place to ensure all areas were regularly cleaned” from the report

Inspectors saw staff speaking respectfully, offering choices and building good relationships with people.

“Our observations of how staff interacted with people were positive. People were spoken to respectfully, and the staff offered them choices.” from the report

People were protected from abuse and avoidable harm. Staff knew how to report concerns and safeguarding referrals were made when needed.

“People were safeguarded from abuse and avoidable harm.” from the report

The report found that the home was working within the principles of the Mental Capacity Act and that required legal authorisations were in place.

“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report

Inspectors found signs that some people were not always supported with brushing teeth or cleaning dentures. Care plans did not always clearly record people's dental needs.

“These findings indicated increased oral health risks to people.” from the report

Some as-required calming or sedative medicines were given without a clear record of why. Protocols and records for some medicines were also incomplete.

“This meant the provider could not always review whether the administration of these medicines was justified or appropriate.” from the report

Care plans did not always contain current risk information. Inspectors also found unsafe window and balcony arrangements, unsecured furniture and incorrect mattress instructions.

“Systems had not always been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report

The provider's checks did not always identify problems with medicines, care plans or environmental safety. Complaints were not always recorded in line with the home's policy.

“The provider had failed to always operate effective systems to always ensure the quality and safety of the service.” from the report

Records showed that male staff sometimes provided personal care when people preferred or only wanted female staff.

“Systems were not always effective at ensuring people's staff gender preferences were always met.” from the report