Downhurst Residential Home Limited

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 8 quality statements in the safe key question. We found people’s medicines were managed safely. There were systems in place to monitor and manage accidents/incidents, and safeguarding concerns. People and relatives told us they felt safe and had no concerns regarding safety. Staff were recruited safely. The home was clean and well maintained. People were kept safe from avoidable harm as staff understood how to protect them from abuse.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us they were happy with the care they received in the home. Everyone we spoke with told us they had regular meetings with staff and discussed any issues for example activities and the food menu. Also, in a recent satisfaction survey given to people and relatives the results showed that people felt empowered to speak up if they had any concerns and felt confident concerns would be dealt with by the team. One person told us that following a fall they were given a new sensor mat, and this would alert staff if they moved around, they commented that the night staff would come to them very quickly if the alarm went off.

Staff and leaders told us they had regular meetings to discuss any incidents. The registered manager told us they made sure service records contained information about any lessons learned. The culture within the home was open and transparent. People could be assured that when things went wrong, the staff team would discuss ways to prevent further occurrences. This meant people could live in a safer environment.

The provider had a process in place for learning lessons when things went wrong. For example, following a number of medicines errors, staff moved the medicines cupboard to a more private space which meant staff would not easily be disturbed when administering medicines. This resulted in fewer errors. The team used reflective practices to explore ways to change practices or ways of working to improve the service and learn from mistakes.

In a recent survey given to people living in the home most people said they were happy with how a transfer between services was managed. For example, if a person was discharged from hospital. Evidence provided by the provider showed that people’s care needs were clearly documented, and changes to those needs were communicated to all relevant parties.

The registered manager explained the process for referrals and admissions to the home. The provider worked with the local authority and health care professionals to ensure there was a smooth transition for people moving between services.

Feedback from the local authority was positive about the progress the provider was making in areas of their improvement plans. However, they did not specifically feedback on people moving between services.

Assessments of care needs were carried out by the provider prior to admitting someone into the home. This was to ensure the person’s needs could be met. The registered manager told us they were in contact with health care professionals and the funding authority during the admission process. The provider had in place an referrals and admission policy in place. This meant there was clear guidance for staff to follow if needed.

People told us they felt safe living in the home. One person said, “Oh yes, it is safe. I feel safe here, anyway. Not sure about anyone else”. Results from a recent questionnaire showed that people stated they felt safe and well cared for.

The registered manager and staff had a good understating of the need to manage safeguarding issues or concerns. Staff we spoke with could explain the process for reporting abuse.

During our visit to the service, we observed good practices. Staff supported people in a safe way. During lunch people were supported safely to have their meal. Staff followed care pans and risk plans.

The provider had safeguarding policies and procedures in place. Staff had training in safeguarding and knew how to implement them. This meant people could feel confident that any concerns about their well-being would be addressed and investigated in a timely manner. Safeguarding logs showed actions and outcomes that were identified as a result of any safeguarding investigation. CQC and the funding authority had been notified of any safeguarding concerns in line with the providers policy.

People and relatives told us they were involved in care planning and reviews. In a recent survey given to people the results showed people felt empowered to manage their own care and make decisions.

The registered manager and staff were able to provide examples of how people managed risks to their health. Staff and leaders had a good understanding of risks to people’s health and wellbeing and how to manage them. This meant people could be assured that their health and wellbeing was a priority.

We observed that people were supported in an appropriate way throughout the day. We observed safe practices between staff and people. For example, when supporting people to move around the home safely.

There was a process in place to involve people in care planning. Risks of harm to people were identified, monitored, and managed. Information in care plans was in enough detail for staff to follow and mitigate risks as much as possible.

The home was well maintained and clean. People told us they were happy living in the home. Equipment was available for people when they needed it. There were good facilities for people to use, including a large outdoor space.

Everyone we spoke with told us they made sure the home was free from hazards. Staff explained how they always needed to check equipment before using it for example, if a person was using a hoist and sling. This meant that people could be confident they would be kept safe.

During our visits, we observed the environment was free from hazards. Staff were observant and vigilant when supporting people. Staff used equipment correctly for example when supporting people with walking aids.

The registered manager shared examples of several health and safety checks and audits completed on a regular basis. For example, regular fire safety checks were done. This meant people, staff and visitors could be assured that the home was safe in regarding to fire safety.

People and relatives told us the staff at the home were very good at their jobs. Everyone we spoke with told us that staff were caring and attentive.

The registered manager and staff told us they felt supported in their role. They had regular 1:1 meeting. This provided them with the opportunity to seek guidance and support when needed.

During our visit we observed staff supporting people. Staff demonstrated competence in their role. Staff were attentive and supported people in a way that showed they knew people well.

Effective systems were in place to recruit staff. Background checks including criminal record checks were carried out. This meant people could be confident that staff had been vetted before beginning their employment. Staff had full training in a range of topics to carry out their role. Staff competencies were checked in line with the company’s policy. This meant people could be assured that staff were competent in their role.

The home was clean and during our visit we observed staff using personal protective clothing such as aprons and gloves. People and relatives told us they were happy with the cleanliness of the home.

Staff were able to explain the importance of preventing the spread of infections. Staff had training in infection, prevention and control which meant people could be confident that risks of harm were reduced as much as possible.

The home was clean and there were no malodours. We observed staff cleaning and tidying up on a regular basis. Staff wore personal protective clothing when needed, such as gloves. There were hand washing facilities available for people, staff and visitors.

The provider had an effective system in place to prevent the spread of infections. For example, the provider had regular health and safety checks. Audits of infection, prevention and control measures were done regularly. Actions were followed up. This meant any concerns could be picked up and addressed quickly.

People’s medicines was administered in a safe way. People’s medicines were reviewed on a regular basis. This meant people could be confident that their health and well-being was a priority.

Staff and the registered manager understood the process for administering medicines in a safe way. This meant people could be confident that their medicines would be given as intended and this would help to reduce the risk of harm.

The service had safe systems for appropriate and safe storing and handling of medicines. The service had processes for ensuring that medicines administration records accurately showed how medicines were prescribed and administered. Governance requirements were in place for processes such as medicines audits and medicines risk assessments.