Down House

Down House is a residential care home providing personal and nursing care to up to 49 people. The service provides support to older people with a range of support needs. At the time of our inspection there were 36 people using the service.

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

Since our last inspection improvements had been made in how risks to people were assessed, monitored and managed.

The provider, manager and staff were clear about their roles and responsibilities. Quality assurance checks were in place to monitor the quality of the service provided. Medicines were managed safely, and people received their medicines as prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People living at Down House told us they received safe care from staff who knew how to identify and report any concerns. The provider had safe recruitment and selection processes in place. There were sufficient staff deployed to meet people's needs and staff recruitment was on-going.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 2 May 2020) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an inspection of this service on 10 February 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve risk management, medicines management and governance arrangements.

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.

We undertook this focused inspection to check they had followed their action plan and to confirm they met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Down House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Down House is registered with us to accommodate up to 49 adults. Nursing care is provided to some people. The service supports people living with dementia, a learning or physical disability, and/ or people who may have a sensory impairment.

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

People’s risks were not always managed safely. People’s care plans and risk assessments did not always detail what support they needed or what staff could do to reduce risks. Staff did not always follow best practice to ensure people’s needs were consistently met in a safe way.

People’s medicines were not always managed safely or administered as prescribed. Staff did not always follow best practice regarding infection control. There were not always sufficient nursing staff on duty. This impacted on the care people received.

The provider had not ensured the governance arrangements in the service had effectively identified areas requiring improvement. There was no clear system in place for overseeing the quality of the care people received or the quality of records in the service. The audits and checks of the service had not identified all the concerns highlighted during the inspection. The provider had not ensured areas for improvement detailed at the last inspection now complied with regulations.

People felt safe living in the service. Staff understood how to recognise and report any concerns about people’s health or wellbeing. People told us staff monitored their health and contacted external professionals when necessary. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us staff treated them with care. People’s views and preferences were valued by staff. Staff knew people well and empowered them to make choices and maintain their independence. The registered manager had a clear focus on understanding and respecting people’s diverse needs. People knew how to complain. Complaints were recorded and responded to.

People told us they service was well managed, and staff provided positive feedback about the registered manager. The registered manager was increasing the opportunities for people and staff to be involved in the service.

People told us there was enough to do and the registered manager was implementing plans for people to be more involved in planning meaningful opportunities.

In addition to training, the registered manager had introduced further methods of increasing staff’s understanding of key areas of care.

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

Rating at last inspection (and update) The last rating for this service, following a focused inspection which reviewed the key questions of ‘Safe’ and ‘Well led’, was requires improvement (published 14 February 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection not enough improvement had been made and the provider was still in breach of regulations. This service has now been rated requires improvement for two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to providing safe care and treatment, staffing and how the service is run.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The inspection of Down House took place on the 16,17 and 18 January 2019 and was unannounced. We previously inspected and reported on Down House on the 18 and 19 January 2018 and rated the service as good in each key question and overall.

The inspection was a focused inspection. This inspection was completed to follow up on information of concern we had received. The team inspected the service against two of the five questions. The information we had received meant we looked at whether the service was safe and well-led. During the inspection, we did not find concerns to enquire further as to whether the service was effective, caring and responsive.

Down House is registered with us to accommodate up to 49 adults. Nursing care is provided. The service supports being living with dementia, a learning or physical disability, and or, people who may have a sensory impairment. When we inspected, on the first day, 24 people were living at the service. On the second day, two people returned from hospital increasing the number to 26.

A registered manager was employed to oversee the running of 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 had had a planned leave of absence from June 2018 and had returned on the 3 January 2019.

Prior to the inspection, we had been informed that there were concerns in respect of:

•People’s medicine administration and management was not safe.

•Poor staff practice meaning they were not meeting people’s individuals care needs.

•People living with diabetes were at risk of not having their needs met.

•People with or at risk of developing skin damage were not having their needs met.

•Meeting people’s needs where they were at risk of choking and/or malnutrition was concerning.

•There was a high number of people were being nursed in bed with little social interaction.

•Poor record keeping in respect of people’s medicine records and care plans

•Poor staffing levels.

•Poor manual handling practices in which people had been injured or were at risk of being injured.

•People were not having the assessed equipment available to meet their needs; records did not detail up to date manual handling needs.

•Equipment used by people was not always being safely maintained.

During our inspection we did find some concerns that reflected these issues. These related to, risks identified of people who had a diagnosis of diabetes, people who were at risk of their skin breaking down/had skin ulcers, people who had a history of seizures and who were at risk of choking.

In addition, poor record keeping by staff and lack of auditing of people’s care records meant gaps and potential risks to people were not being identified and/or followed through on. People’s medicines were administered safely but there were again concerns about some records not always being accurate and, following the providers medicines policy and national guidance.

We observed two incidences of poor manual handling practices, relating to the use of a hoist that caused us concerns. We requested the registered manager address this as a matter of urgency.

We were however satisfied that the equipment used to support people to mobilise and the mattresses people slept on were safe and had undergone qualified engineer checks within the previous six months.

Staffing levels were good during the inspection however, we received mixed feedback on this. We were also concerned that due to the layout of the building, staff were difficult to locate. This is something the local authority and we have spoken to the provider about on previous occasions.

In respect of people being cared for in their beds, we found that there were up to nine people using the lounge each day to sit and/or eat their meals. The rest, were in their rooms and/or beds; some people were very frail, but everyone who could communicate, told us this was their choice. The dining room was not used during this inspection. However, again the layout of the building made moving from the lounge to the dining room difficult as they are at polar ends of several long corridors.

We found breaches of regulations. You can see what action we told the provider to take at the back of the full version of the report.

Down 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.

A registered manager was employed to oversee the running of 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.

We last completed a comprehensive inspection of Down House in October 2016 where we raised concerns about how the service was ensuring people’s dignity and treating them with respect. We asked the provider for a report on what action they would take to put this right.

We were also found the provider and registered manager were not ensuring people’s social needs were planned and met. We served a warning notice in respect of this. Warning notices are part of our enforcement policy and tell providers what they need to put right.

This meant following the inspection in October 2016 the caring and responsive sections were requires improvement. We also made the well-led section requires improvement as although changes had been made, the provider needed to evidence the changes made to the service were sustained.

We went back to the service in March 2017 to ensure the service was now meeting the requirements of the warning notice. We found this had been met but the service remained requires improvement overall.

Rating at this inspection

At this inspection we found the service had improved to Good.

Why the service is rated Good

We found the concerns from the previous inspections had been resolved and people were now receiving care which was safe, effective, responsive to their needs and the service was well-led.

People felt safe at the home and with the staff who supported them. There were systems and processes in place to minimise risks to people. These included a recruitment process and making sure staff knew how to recognise and report abuse. There were adequate numbers of staff available to meet people’s needs in a timely manner.

People received effective care from staff who had the skills and knowledge to meet their needs. Staff monitored people’s health and well-being and made sure they had access to other healthcare professionals according to their individual needs. People’s medicines were administered and managed safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported by staff who were kind and caring. Where people found it difficult to express themselves, staff showed patience and understanding. People were treated with dignity and respect.

The service was responsive to people’s needs and they were able to make choices about their day to day routines. People now had had access to a range of organised and informal activities which provided them with mental and social stimulation.

People could be confident that at the end of their lives they would be cared for with kindness and compassion and their comfort would be maintained. The registered manager and provider were acting in a way that was inclusive to all people and staff; they aimed to review how this was made known to people and those commissioning their service.

People said they would be comfortable to make a complaint and were confident action would be taken to address their concerns. The registered manager and provider treated complaints as an opportunity to learn and improve.

The home was well led by an experienced registered manager and clinical lead. The provider had systems in place to monitor the quality of the service, seek people’s views and make on-going improvements. We have made a recommendation about reviewing navigating the building from the view of person living with dementia.

Further information is in the detailed findings below.

We undertook this focused inspection to check that they had met the requirements of the warning notice and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Down House) on our website at www.cqc.org.uk.

Down House is registered to care for 49 older or younger adults. Nursing care is provided. There were 26 people residing at the service when we inspected.

The service did not have a registered manager in place. However, there was a manager employed to run the service who was in the process of registering with us. 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.

We found people’s social needs were being planned in a personalised way. People were involved in deciding how they wanted to spend their time. An activities co-ordinator had been employed to provide dedicated time for people to have the opportunity to be active. People could choose to take part in group activities or have time with the activity co-ordinator and staff on their own. One member of staff said, the activities had been positive for people as, “People like the company; they stay awake longer and don’t just fall asleep or just watch TV.”

At our last inspection, the service was meeting all the other requirements in respect of being responsive to people’s needs. However, there were other breaches of the regulations in respect of Down House, which were not reviewed on this inspection. This means the service is judged as ‘Good’ in respect of responsiveness but remains ‘Requires improvement’ overall. We will review the service as a whole at our next inspection.

We last completed a comprehensive inspection of Down House on the 9 and 11 December 2015. We found regulations were not being met in respect of staffing and people’s care was not planned and delivered in a personalised way. We asked the provider to send us an action plan on how they were going to put this right. Also, people were not being assessed in line with the Mental Capacity Act (MCA) 2015, people’s care and treatment was not always safe and systems were not in place to ensure the service was well-led. We sent the provider warning notices in relation to these breaches of regulations. We returned on 19 and 20 April 2016 to check whether the requirements in the warning notices had been met and found they were not. Warning notices are part of our enforcement policy; they tell a provider they are not meeting a regulation.

Down House can accommodate up to 49 older and younger adults who may be living with dementia or have a physical disability, learning disability or sensory impairment. There were 20 people living at the service on the first day and 21 on the second day. Down House provides nursing and residential care.

Down House is registered with us to provide accommodation for persons who require nursing or personal care, diagnostic and screening procedures and treatment of disease, disorder or injury. Diagnostic and screening procedures were discussed on inspection to request it is removed as this activity is not in use.

A registered manager was registered to manage the service. However, they left on the 31 August 2016. 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. A new manager had been employed who aims to register with us.

Since our previous inspections we found improvements had been made at the service. However, we found not all staff treated people with kindness and respect. Also, people continued to not be provided with opportunities to remain socially, cognitively and physically active. When we reviewed people’s care records, we saw people’s emotional and social side was not being planned for. The new manager spoke with us about the values of good care they wished to instil in the service. They told us how they had identified that the culture of caring was not at the standard they would wish for people at all times. The manager planned to address this with staff.

A new manager had started in this role on 1 September 2016. Management of the service was by a senior management team established since our inspection in December 2015. By reviewing the service through a number of audits, activities had been identified as a need in the service. Staff had been given time on the rota to achieve this. This was due to start the week following the inspection and would be monitored. It was too early at this inspection to judge the new management had addressed all the areas of concern and brought about permanent change.

People’s initial assessment had been replaced by a model which ensured all the necessary details were collated. An initial care plan was developed so staff could understand how to meet people’s needs quickly. Care plans were in place to support people to have personalised care in respect of their health needs.

People’s medicines were administered safely. We have recommended the provider ensures staff know what action to take if the temperature of the medicine fridge goes out of the required range; reviews the disposal of medicines that require additional controls and reviews the process for recording, analysing and learning from medicines errors.

People’s nutritional and hydration needs were met. Where there were concerns identified, these were follow up on with referrals to relevant health professionals. People were offered choice on what they wanted to eat and drink. Snacks and hot drinks were available at any time.

People had their health needs met. People could see a range of health professionals as required. Health professionals were happy about how the service communicated with them and felt referrals were made at the right time.

Risk assessments were in place to mitigate risks people may face while living at the service. These were linked to their care plans. The inside and outside of the building were being risk assessed to keep people safe. We have recommended the provider reviews guidance in respect of risk assessing the premises inside and outside for people who may have mobility and sight needs. Personal evacuation plans were in place to support the evacuation of the building in the event of an emergency.

People were being assessed in line with the MCA 2005. The manager and nurses understood their responsibilities in respect of the MCA and associated Deprivation of Liberty Safeguards (DoLS). Staff in other roles did not understand their responsibilities. We have recommended the provider ensures all staff are informed on how the MCA impacts on their roles and responsibilities.

Staff were trained, supervised and had annual appraisals in order to ensure they could support people. There were sufficient staff to meet people’s needs safely and they were recruited safely. Staff understood how to identify abuse and would always pass on their concerns. They would also speak out if they were concerned about practice. Staff felt their concerns would be responded to appropriately by the manager. Staff followed safe infection control practices.

People and visitors spoke positively about the manager. People and visitors felt comfortable approaching the manager. They felt any issues would be heard and acted on. People were involved in contributing ideas on how the service could be run. Staff described the manager as approachable and supportive.

People’s complaints and concerns were acted on and feedback given to ensure people were happy with the outcome. The manager had put in a system of learning from these.

We found breaches of regulations. You can read at the back of the full report what action we have told the provider to take.

We undertook this focused inspection on the 19 and 20 April 2016 to check they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Down House on our website at www.cqc.org.uk

Down House is registered to provide residential and nursing care to up to 49 younger and older adults. People may be living with dementia, have a learning disability or autistic spectrum disorder or be physically disabled. They may also be living with a sensory impairment. Twenty-five people were living at the service during this inspection. Another person was in hospital at the time of our visit.

A registered manager was not in place to manage the service. The previous registered manager left on the 9 August 2015. 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. There was a manager in place to manage the service. The provider stated they were aiming for this manager to apply to become registered with us.

People’s care records were not personalised and did not always evidence whether people were involved in planning their own needs. The records of people’s care were incomplete and lacked essential details to ensure care given was appropriate and as desired by the person. People’s medicines were not always managed and administered safely.

People were not being assessed in line with the Mental Capacity Act 2005 (MCA) as required. No person’s records held an assessment of their capacity to consent to their own care and treatment. Staff did not understand the link between assessing someone in line with the MCA and ensuring they were not depriving someone of their liberty. However, applications to deprive a person of their liberty to keep them safe had been submitted and were awaiting authorisation.

People’s individual risk assessments were not reviewed regularly to ensure they reflected people’s current risk. People were not involved in planning how to mitigate the risks they faced while living at the service. People did not have risk assessments for individual health needs in place to inform staff how to recognise and meet this need should people become unwell. A risk assessment to mitigate environmental risks to people’s safety had not been completed to assess the inside and the outside of the service. This meant potential risks were not identified and people kept safer as a result.

People were not assured a quality service as robust quality assurance processes were not in place which identified the issues or concerns. Where audits had been put in place they lacked any analysis of the data and action plan to improve the service as a whole for everyone.

Resuscitation equipment had been serviced and was ready if required. The resuscitation policy required review to ensure staff understood their responsibilities.

Infection control measures had improved to ensure people were kept safe from infection. A risk assessment was to be developed to identify areas of potential risk. For example, the laundry had the clean and dirty areas in the same part of the room and this had not been identified by the provider as a specific area that needed reviewing.

People were protected by staff being clear about their own responsibilities. Staff understood the limits of their roles and felt the service was now better at ensuring there were clear lines of accountability.

We found continued breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report. The Commission is currently giving consideration to what enforcement action to take. We will report on this later.

This inspection was completed to ensure the concerns had been addressed. We found that improvements had been made.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring and responsive?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We spoke to seven people who used the service and they said they were all happy with the care provided. They agreed, when asked, that they were treated with respect and dignity by the staff. There were enough staff on duty to meet the needs of the people who received care at the home. One person said 'The staff are lovely and very kind'.

The provider told us that since we had issued warning notices they had put safety monitoring checks into place to ensure people had access to a call bell at all times. We saw people had access to call bells either in their own bedroom or in the lounge area where people were sat. This meant people were able to access help quickly when needed.

Is the service effective?

People's health and care needs were now being assessed with them where possible and a full assessment was completed before people moved into the home. One staff member confirmed that they asked people for their consent before any care was provided. The staff we spoke with had a clear understanding of the care and support needs of people living in the home. We saw that people had outside support from their GP and other services such as a tissue viability nurse when needed.

We discussed people's care needs with staff and they told us about people's needs and how they liked their care to be delivered. People who were newly admitted to the home had completed and up to date care plans in place. Additional work was still required to update other people's care plans who had resided at the home for some time.

Is the service caring?

During our observations and conversations we saw and heard examples of staff being respectful and treating people with dignity. They spoke kindly to people, were patient and when we spoke to staff they knew and understood people's individual needs. However staff were still leaving people without any interaction for long periods.

We saw that people responded positively to staff and that staff had the skills to communicate with people with a range of needs. Care was given in an unrushed manner and staff communicated well with people while care was being provided.

Is the service responsive?

Down House had undergone changes since our April 2014 inspection. We found that they had addressed some of the concerns following our inspection. Further improvements were required but the provider had plans in place to carry these improvements out.

We saw people newly admitted had their health needs assessed and their care and treatment was planned and delivered in line with their individual care plans. For example, we saw that one person had been given full details about the reason for admission and the care and treatment required. This helped the people to understand why they had been admitted to Down House. There was written information and evidence in people's daily records that this help had been given by staff. This recorded information provided a means of communication between staff.

We saw evidence that some of the care plans had been updated to ensure they were appropriate to people's current needs with further reviews planned. Further improvements still needed to be made on some care plans. The home was now responding to changes in people's needs. For example, care plans and assessments were reviewed regularly when changes in people's condition occurred.

We looked in detail at the care and treatment five people staying in Down House received. We spoke to staff about the care and treatment given to people. We looked at the records related to the five people and met with them.

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found-

Is the service safe?

There were enough staff on duty to meet the needs of the people receiving care at the home and a qualified nurse was available on each shift. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

People's care needs had not been appropriately assessed. People's safety and welfare was at risk.

Staff training records contained all mandatory courses as required, for example staff had completed training in safeguarding and manual handling. This meant the provider could demonstrate that the staff employed to work at the home had the skills and experience needed to support the people who received care in the home.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The DoLS apply to care homes and hospitals. No application had needed to be submitted at Down House.

Is the service effective?

People's health and care needs were assessed with them, but they were not always involved in writing their care plans. Some of the care plans had not been reviewed regularly. Care plans were therefore not able to support staff consistently to meet people's needs.

The people we spoke with told us that they felt staff were kind and caring. People told us that they were happy with the care and support that had been delivered and their needs had been met.

Is the service caring?

People's preferences, interests, aspirations and diverse needs had not always been recorded. Because of this, care and support could not always be provided in accordance with people's wishes. People's needs were not always appropriately assessed and their choices and preferences were not always respected.

The people who were able to said they were supported by kind staff. We saw that the staff showed patience when supporting people. However the staff did not always respect people. We observed staff showing little or no interaction with people when tasks were carried out. Other people told us they were able to do things at their own pace and were not rushed.

Is the service responsive?

There were few activities arranged within the home and so people had limited social and recreational activity. We looked at how complaints had been dealt with, and found that the responses had been open, thorough, and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision and service development.

The service had not adequately monitored people's care records or the risks this caused to people's safety and welfare.

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities.

We observed people's privacy and dignity being respected but one person told us this was not always the case. We observed the staff speaking to people in a way that demonstrated a good understanding of people's choices and preferences.

Care plans were not consistent in the information held and did not always reflect people's health and social care needs. People who lived in the home were not always informed about updates about their care needs. This meant that people living in the home care and welfare needs may not have been met.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. We spoke with most of the staff working during our visit and some agreed that the home had sufficient staff.

Not all staff were clear about the actions they should take if they had any concerns about people's safety.

We saw that Down House held records securely to protect people's confidentiality. However care plans and other records were poorly maintained.