Archived: Downshaw Lodge

Downshaw Lodge is a purpose built, two storey nursing home. The service provides support for up to 45 people who are living with dementia or have mental health needs. The service is a single sex provision due to the complex needs of the people who use the service.

At the time of our inspection 30 people were residing in the home.

The service was last inspected in May 2016 at which time we found four breaches of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. We also made three recommendations that related to developing dementia friendly environments, ensuring systems support people’s dietary and nutritional needs to be met, and ensuring continuity of activity provision. This inspection was carried out to check sufficient improvements had been made to the service.

There was a manager in post at the time of our inspection. This person was not yet registered with the Care Quality Commission (CQC) but evidence was available to demonstrate that their application was being processed by CQC at the time of our visit. 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.

Staff understood their roles and responsibilities in keeping people safe and protecting them from harm.

People who spoke with us told us they felt the care and support they received was good and safe.

We found that medicines were managed safely and people received their medicines as prescribed by their doctor or other prescriber.

Sufficient numbers of appropriately trained care staff and qualified nursing staff were available to support people and help meet their assessed needs.

Staff meetings and formal staff supervision had been taking place on a regular basis since the last inspection of the service and this was confirmed by staff we spoke with and records seen.

People told us they liked the food offered. We saw meals were fresh and looked and smelled appetising. People were offered choices of various alternative foods and beverages and we observed that the atmosphere over the mealtimes were calm, sociable and unhurried.

We saw evidence that fluid and dietary intake was being recorded after meals to accurately record what people were eating and drinking. Any advice from healthcare professionals such as nutritionists was being recorded in relevant documentation.

Each person using the service had an up-to-date care plan, risk assessments and other associated documentation in place.

The range of organised activities for people to participate in had improved since our last inspection of the service. The service employed an activity co-ordinator who actively engaged with people individually or in groups.

We saw that the service had a written complaints policy which was included in the service user guide and was also displayed in the main hallway of the home.

Where people who used the service lacked capacity to consent to care and treatment the appropriate steps were taken to protect their rights.

Systems were in place to monitor the quality of service and to identify where improvements to the quality of care could be made.

At the last inspection in May 2016, we rated the well-led domain as ‘requires improvement’ as we found the management of the service was not, at that time, well-led and staff lacked clear management leadership. At this inspection we found the provider had taken action and was now meeting legal requirements.

Downshaw Lodge is a purpose built, two storey nursing home. The service provides support for up to 45 people who are living with dementia or have mental health needs. At the time of our inspection the service had three separate ‘units’. Each unit was single sex due to the complex needs of the people who used the service. The provider recognised that this created some difficulties and that the women only unit was no longer appropriate for the needs of the people who lived there. Consequently, the number of women living at the service had reduced and the provider was looking to create a male only service.

This was the first inspection we have undertaken of Downshaw Lodge, since MBi Social Care took over the running of the service from Four Seasons (Evedale) Limited in early 2016. At the time of our inspection there were 32 people living at Downshaw Lodge. Our last inspection of Downshaw Lodge, when it was being run by Four Seasons was on 27 June 2014 when we found the service to be meeting all standards inspected.

At this inspection we found breaches of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the safe management of medicines, training and supervision, safeguarding and governance. We are considering our options in relation to enforcement for some of these breaches of the regulations and will update the section at the back of this report once any action has been concluded.

We have made three recommendations. These relate to developing dementia friendly environments, ensuring systems support people’s dietary and nutritional needs to be met, and ensuring continuity of activity provision.

At the time of our inspection there was a registered manager employed by 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was off work at the time of the inspection and shortly after the inspection we received notice from the provider that they had been absent for 28 days. There were arrangements in place to cover the management of the service including a relief manager and support from quality development officer managers.

Downshaw Lodge provided support to people with a range of complex needs, including people who were living with dementia, people with physical support needs and people with mental health support needs. We received positive feedback from an external professional about the service’s effective management of people’s mental health and behaviours that challenge. However, we found there was limited training provided to staff in this area, and care plans were also limited in detail in relation to provision of support with people’s mental health.

The home advertised as providing support to people living with dementia. There were some limited adaptations to make the environment more accessible to people living with dementia and a refurbishment of the environment was being planned by the new provider. However, staff had received only basic dementia awareness training. We have made a recommendation that the service considers guidance in relation to developing dementia friendly environments as part of the planned refurbishment of the service.

Prior to the inspection we were made aware of concerns in relation to the safe management of medicines. We were aware the provider had taken steps to improve the way medicines were managed. However, we found some on-going issues. For example, we found records indicated one person had received their medicines later than required, and that the spacing between doses had been inadequate. If this medicine had been given at an inappropriate time there was a risk it could have had a negative impact on their wellbeing. Some records in relation to medicines also lacked clarity, and we could not be certain that one of the fridges being used to store some medicines had been maintained at an appropriate temperature to ensure medicines were kept in accordance with recommendations.

The provider was completing daily audits of medicines. However, these audits had not been entirely effective given the on-going issues we found. We received a notification from the provider shortly after our inspection that one person had run out of stock of one of their medicines and had gone without it for four days. This concern was shared with the safeguarding team by the provider.

The dependency of people living at the home was assessed. Despite this, managers told us there was no tool or other standard method to determine staffing requirements based on the combined needs of people living at the home. However, during our inspection we found the provider was staffing flexibly to meet people’s changing needs. We saw there were sufficient staff to provide support to people when they required it.

Risks to people’s health and well-being had been assessed and actions had been identified to reduce potential risks. This included involving health professionals such as GP’s and dieticians where appropriate.

We saw actions had been taken to investigate safeguarding concerns when directed to do so by the local authority. In one instance we found measures had been introduced to reduce risks in relation to a safeguarding incident between two people living at the home. However, the practicalities of implementing these measures, which included keeping the individuals apart from each other, had not been fully considered.

The provider had submitted applications to the supervisory body to request authority to deprive people of their liberty where they lacked capacity and this was in their best interests. However, we found the provider had not considered all aspects of care delivery that might amount to restrictive practice. It was not always evidenced that potentially restrictive practices were undertaken in the person’s best interests.

Staff had received training in physical intervention. We found there was a lack of detail in one person’s care plan about when and how physical intervention should be used. We were told physical intervention had only been used on one occasion, which was in 2016. However, the provider was unable to locate any record in relation to this, which meant they couldn’t demonstrate the intervention had been proportionate and in this person’s best interests.

Staff we spoke with demonstrated that they knew the people they supported very well. There had been a high use of agency staff, although the provider had recently recruited more permanent staff and told us there was only one vacancy at the time of our visit. People and relatives told us staff were kind and caring.

We found staff had not received regular supervision, and there were gaps in the provision of training, including training in safeguarding, infection control, falls prevention and training in nursing practices. The provider told us they had booked additional training prior to the end of our inspection. We saw these shortfalls had been identified prior to our inspection and were detailed in one of the service’s action plans.

People told us they enjoyed the food provided, and we saw accurate records of food and fluid intake were kept. There were multiple records relating to people’s dietary requirements that did not always match. We saw on one occasion a person had not received one of their build-up drinks as directed. This drink was provided to help ensure the person had a sufficient calorie intake as directed. Staff told us this was as the kitchen had been busy.

Care plans were complete and had been recently and regularly reviewed. We saw any changes to care plans were reflected in handover documents to help ensure all staff were aware. Information on preferences, social history and interests was recorded to varying degrees. The provider told us a new format for care plans was being introduced soon, which would help ensure such information was clearly captured. We have made a recommendation that the provider reviews systems in place to ensure people’s dietary and nutritional requirements are met.

The activity co-ordinator was off work at the time our inspection, and we saw limited activities taking place. Activity resources were not readily available to staff and we saw the provision of activities were dependent on the activity co-ordinator. Records of activities previously held showed good consideration had been paid as to how to effectively engage the people living at the home in activities they enjoyed and found meaningful. We have made a recommendation that the provider makes arrangements to ensure activities are available in the absence of dedicated activity staff.

Staff told us they enjoyed their jobs and thought the staff team worked well together. The provider told us the results of a staff survey undertaken shortly after they had taken over indicated a problem with low morale. We saw an action plan was in place in relation to staff development.

The provider had already identified many of the issues we brought up during the inspection and we could see action plans were in place to address these shortfalls. The action plans were at various stages of their implementation and had clearly defined time-scales.

There was evidence that the service had consulted with people living at the home and relatives in relation to planned improvements to the service, including a planned refurbishment.

Systems were in place to monitor and improve the quality and safety of the service provided. We saw a number of these audits were overdue, and actions identified in one audit to improve the meal-time experience had not been effectively implemented. Dai