Downs House

Downs House is a residential care home which provides accommodation and support to up to 49 people, including people living with dementia. Care is provided in one adapted building and people have access to several communal spaces and an outdoor area. At the time of our inspection there were 35 people using the service.

People’s experience of using this service and what we found

The provider did not always manage medicines safely. Risks related to the premises were not always safely managed, this included risks related to fire safety, fire exits, window restrictors and storage of hazardous substances. There were enough staff in place to meet people’ needs. Staff recruitment checks were completed as required.

We found that the provider was not always following the principles of the Mental Capacity Act 2005, for example in relation to the use of bed rails. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Staff did not always receive training or training updates in line with their role. There were significant numbers of staff who required or were overdue updates in key areas such as medicines, mental capacity act, first aid, fire safety, infection control, safeguarding, food hygiene, diabetes and health and safety.

The leadership and governance of the home required improvement to ensure audits were effective in promoting improvement and identifying risks. The registered manager has acted upon feedback from this inspection and were putting plans in place to address the issues identified.

The home is spacious and light, suitable for people’s needs. There was a coffee bar in the dining room that provided a social area where people and their relatives could get drinks and snacks.

The staff were caring and supportive to people who used the service, observations showed their needs being met in a kind and caring way and people were treated with dignity and respect.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service was good (published on 7 September 2018).

Why we inspected

We received concerns in relation to the management of medicines and people’s specific medical needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downs House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have found breaches in relation to consent, safe care and treatment, good governance and staffing at this inspection.

You can see what action we have asked the provider to take at the end of the full version of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

We found the following examples of good practice.

The provider had considered the use of the environment to protect people from the risk of the spread of COVID-19. This included review of communal areas to support social distancing and implementing personal protective equipment stations throughout the home.

We reviewed information which provided assurances that the provider understood and implemented national guidance to support safe admissions to the home. This included implementing measures such as testing schedules and isolation schedules for new people entering or returning to the home.

People and staff were supported appropriately to have access to regular testing in line with national guidelines and staff were able to access the COVID-19 vaccination programme.

The provider had adapted an area of the home to facilitate screened visits for people and their loved ones. This meant people could have regular visits scheduled with their nominated friend or relative, whilst reducing the risk of transmission of viruses. The provider also ensured people were supported to keep in touch with their friends and relatives via alternative means such as telephone or online virtual calls.

The provider ensured there was ample supply of appropriate personal protective equipment, and we observed staff using this in line with national guidance.

Downs House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Downs House accommodates up to 49 older people, some of whom may be living with dementia in one adapted building. At the time of this inspection there were 39 people living in the home.

A registered manager was 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.

Managers and staff understood and acted on their responsibility to protect people from abuse. Staff supported people to manage risks to promote their safety. There were sufficient staff available to meet people’s needs.

The home provided a clean and comfortable environment for people. Procedures were in place and followed to manage the prevention and control of infections. People’s medicines were managed safely.

The provider and registered manager had worked with others to ensure that lessons were learnt when things went wrong. Improvements had been made in response to safety incidents to prevent a reoccurrence.

People were supported to have choice and control and staff supported them in the least restrictive way possible; However not all of the processes in the service supported this practice. Improvement was required to ensure the use of equipment which can restrict people’s freedom of movement and constitute a restraint, was assessed in line with the Mental Capacity Act (2005).

Not all of the protected characteristics of the Equality Act 2010 were considered as part of the needs assessment or person-centred care planning. We have made a recommendation about this.

People were supported by staff who were trained and supported to meet their needs effectively. People’s nutrition and hydration needs were known and met.

People told us staff provided respectful, dignified and compassionate care. Personal care was delivered in private and people’s decisions about their care were respected.

People’s care plans were person centred and people received care in line with their assessed needs and preferences. People were supported to participate in a range of activities to meet their needs for social activity and stimulation.

People’s complaints were investigated and responded to. People were aware of the complaints procedures and were confident the manager and staff would listen and act on complaints.

People were supported at the end of their life by staff who provided, sensitive, appropriate and compassionate care for people and their families. Plans were in place to improve end of life care planning and training for staff.

There were effective systems in place to monitor and improve the safety and quality of the service people received. Feedback from people, their families and staff was used to drive improvements to the service. The registered manager led by example and was committed to promoting a positive culture where the needs of people were prioritised and staff were valued.

Downs House provides accommodation and care for up to 37 older people, some of whom may also be living with dementia. At the time of the inspection, work was underway to complete an extension to the home. The extension, when completed, will provide 12 extra bedrooms with ensuite wet rooms, a new kitchen and an orangery. There were 33 people using the service at the time of the inspection and one bedroom was not in use due to the building work.

Downs House has 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.

People said they felt safe. Staff had received safeguarding training and were able to explain how to protect people from abuse and how to report suspected abuse.

People’s individual risks were appropriately assessed and care plans were in place to mitigate known risks. Staff were knowledgeable about risks to people and what actions needed to be taken to keep people safe.

There were sufficient staff on duty. People’s needs were met whether they were in the communal areas or being cared for in bed.

Staff recruitment and induction practices were safe. Relevant checks were carried out to ensure that suitable staff were recruited.

Medicines were stored and administered safely. Records in relation to medicines were accurate and staff had received training in medicines administration, and had their competency checked regularly.

Staff had received appropriate training to meet people’s needs. Records showed that staff had received training in key areas such as infection control, fire training, moving and handling, food hygiene and first aid. Staff were supported to study for health and social care vocational qualifications. Staff told us they felt supported in their role.

Staff were knowledgeable about people’s needs and how to support them. Staff said they knew about people’s needs from handovers, care plans, risk assessments, people themselves and their families. We saw that staff interacted with people appropriately and kindly, appearing to know them well as individuals, and treating them accordingly.

People were asked for their consent before care or treatment was provided and the provider acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA). People made their own decisions where they had the capacity to do this, and their decisions were respected.

People were supported to have sufficient to eat and drink and to maintain a balanced diet. Drinks were readily available throughout the day and staff encouraged people to drink. For lunch a main meal was offered, with alternatives available. The chef was knowledgeable about people’s individual requirements such as those people who required a pureed diet, a soft diet or a diabetic diet. We saw that staff maintained a presence in the dining room during lunch, checking that everyone was managing and offering support if needed.

People were supported to maintain good health through access to ongoing health support. Records showed that district nurses, speech and language therapists and the GP had been involved in people’s care and referrals were made where appropriate.

Staff were kind and patient with people, using gentle persuasion and encouragement to support them. They took time to listen to people and understand how they were feeling. People’s dignity was respected. People were supported to be as independent as possible.

People were involved in decisions about their care and were offered choices in all aspects of their daily life. Where they had capacity, people had signed their care plans showing that they agreed with the plan of care.

Staff were able to respond appropriately to people’s needs because they knew them well and understood their care needs. Staff had taken the trouble to get to know people personally so they could respond to their preferences, likes and dislikes and provided personalised care. Care plans were reviewed monthly and updated where necessary to ensure that staff were always aware of people’s needs.

People were able to engage in different activities, such as scrabble, yoga or listening to music. People being cared for in bed were included in activities and staff visited them in their room. Harp therapy was available for people as a soothing activity.

The provider had a complaints procedure which detailed how complaints should be dealt with. There were a small number of complaints and all had been dealt with appropriately.

The atmosphere in the home was friendly and easy going. The registered manager was passionate about the home and keen to make improvements. There was a family feeling amongst staff who were united and keen to ensure people were happy and well cared for. Staff felt valued and involved in decision-making and this reflected in the care delivered.

Feedback was sought regularly from people, staff and relatives and was responded to, ensuring continuous improvement to the home.

The registered manager demonstrated good management and leadership. She ensured she was visible ‘on the floor’ on a daily basis. People knew and trusted her.

Policies and management arrangements meant there was a clear structure within the home which ensured the service was effectively run and closely monitored.

The quality of the service was closely monitored through a series of audits including care plans, the kitchen, infection control, health and safety, falls and medicines.

During our visit we spoke with the registered manager, the deputy manager and three members of staff. We reviewed records of staff meetings and supervision sessions and observed staff working in the home. We found the provider had ensured adequate staffing structures and support was in place.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found-

Is the service caring?

People told us they were supported by kind and attentive staff. Staff treated people as individuals and provided care which was in line with their agreed plan of care. People told us staff were kind and responsive to their needs at all times. We saw that people's needs were supported in a calm, dignified and respectful way. This meant people were cared for in a kind and respectful manner.

Is the service responsive?

People's needs were assessed and reviewed regularly to ensure their needs were met. People and their representatives were encouraged to participate in care planning and review. The registered manager or deputy manager regularly spoke with people and their representatives to ensure their needs were being met. This meant that people were able to express their views of the care they received and have them acted upon.

Is the service safe?

People told us they felt safe in the home and when being cared for by staff. People were cared for by staff who had the appropriate skills and experience to ensure their safety and welfare. Staff had a good awareness of the needs of people who lived at the home. This meant people received care which ensured their safety and welfare.

Is the service effective?

We saw people received care which was individualised and planned in line with their needs. People told us they received the care they needed to maintain their independence and dignity.

Is the service well-led?

People told us the registered manager and provider for this service were very approachable. Staff told us they received adequate support from the management. However, staff told us there was a lack of clarity in staff roles which had led to low staff morale. Staff told us they had reported their concerns, however this had not improved. This meant that staff were not supported to raise concerns and have them dealt with. We have asked the provider to inform us of actions they will be taking to resolve this matter.

At our last inspection in March 2013 we had identified concerns in; care and welfare of people who use the service, management of medicines, supporting workers and the quality assessment of this service. The provider had sent us an action plan detailing how they would work to improve these areas.

At this inspection we reviewed the progress the provider and new manager had made in taking action to ensure compliance in the areas of concern or where improvements had been requested. We found that improvements had been made in all of these areas.

We saw that the home was clean and well maintained. Care was provided over three floors with single occupancy rooms available. Access to many areas of the home was via stairs and there were two lifts available for use.

People were able to personalise their rooms with their own possessions and could access their rooms whenever they chose. Few people chose to remain in their rooms throughout the day, as the communal lounge area was the hub of activity during the day. Quieter areas were available for people to use if they chose.

We saw that staff treated people in a kind and gentle manner respecting their dignity at all times.

However our findings also showed that as a result of non-compliance with the regulations or part of a regulation, improvements were required in relating to the service's care planning documentation, medicines management, staff training, staff supervision and appraisal. In addition we found that the service's quality assurance systems were ineffective as they provided little evidence as to how information was consistently monitored to identify risks and areas for improvement.