We carried out a review of the data available to us about Downshaw Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Downshaw Lodge, you can give feedback on this service.
We found the following examples of good practice.
The home had policies and procedures to manage any risks associated with the COVID-19 pandemic. This included the management of risks for people who had tested positive for COVID-19.
There were enough stocks of personal protective equipment (PPE). We observed staff and management were using PPE correctly and there were procedures in place to support staff with its use.
The environment had been adapted to comply with guidance and ensure people and relatives were able to continue interacting safely.
The provider had implemented a regular programme of COVID-19 testing for people in the home, staff, and visitors. All visitors, including professionals, were subject to a range of screening procedures, including showing evidence of vaccination and a negative lateral flow test before entry into the home was allowed.
Staff had established good working relationships with relevant healthcare professionals and their support continued during the pandemic.
Workforce pressures were not currently having a detrimental impact on the delivery of the service.
Downshaw Lodge is a care home providing personal and nursing care to 44 male adults with a range of needs arising from their physical and mental health. People at Downshaw lodge are living with dementia and, as a result of their illness, may present with behaviours that challenge. The accommodation is split into two units, named Mason and Sheldon, situated over 2 floors and provides 45 bedrooms and a range of communal and activity areas. The service can support up to 45 people.
People’s experience of using this service and what we found
Medicines were managed safely, stored appropriately and administered by staff who received training. Infection control systems and audits were in place to ensure a clean environment. People were protected from the risk of abuse and harm by staff who understood how to respond to any concerns. Staff were recruited safely.
People were supported by well trained and supported staff who understood their support needs. People’s needs were assessed, and equipment and plans put in place to meet these needs. 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.
Staff were kind and caring. People felt they were well treated and supported. Independence was promoted, and staff respected people’s privacy and dignity.
People's had comprehensive plans of care based on individual need, which included communication needs. An activity coordinator was employed to ensure people were able to follow their interests and hobbies. People knew how they could raise concerns about the service and were confident complaints would be responded to in quickly.
The registered manager and staff were clear about their roles and provided care which focused on ensuring good outcomes for people. The service used a variety of methods to assess and monitor the quality of care they delivered. This included numerous audits which were used to drive improvement within the home. Staff worked in partnership with a variety of agencies to ensure people’s health and social needs were met.
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 23 January 2019) and there were two 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
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Downshaw Lodge 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.
Downshaw Lodge provides accommodation, nursing and personal care support to male adults with a range of needs arising from their physical and mental health. People living at the home have a dementia diagnosis and, as a result of their illness, may present with behaviours that challenge. The accommodation is split into two units, named Mason and Sheldon, situated over 2 floors and provides 45 bedrooms and a range of communal and activity areas. The home has a large outdoor garden area at the rear for leisure and activities. The service is located in the Ashton-under-Lyne area of Tameside. Downshaw Lodge is part of a large organisation; Qualia Care Limited. This inspection was the first inspection since the change in ownership of the home.
At the time of our inspection there were 45 people living at Downshaw Lodge.
This inspection was carried out over two days between 12 and 13 November 2018. Our initial visit on 12 November was unannounced.
The service had a registered manager in place. 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 identified breaches of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were around medication errors, infection control and management oversight. You can see what action we told the provider to take at the back of the full version of the report. We also made recommendations around making the home environment more dementia friendly.
We looked at the safe management and administration of medicines and found medication was not always managed safely. We found regular checks and balances were carried out by senior staff; however, we found medication errors during our audit of safe medication management. We were unable to ascertain if people had received the right medicines in the right amounts at the right time. As a result, we requested immediate action be taken to ensure the safety of the people involved. We checked with the registered manager, who had taken appropriate action, and found no-one had come to harm as a result of the errors.
We identified concerns regarding infection control practice within the home. A recent infection control audit carried out in July 2018 had identified the same concerns we found during the inspection. We found some areas of the home were not always clean.
There were systems and checks in place to monitor the quality of the service to ensure people received safe and effective care. However, these checks had not always addressed the concerns we found during our inspection.
Systems were in place to safeguard people from abuse. Staff were aware of their responsibilities in reporting any issues or concerns so that people were protected.
People were supported by sufficient numbers of staff. Relevant recruitment checks were carried out to make sure people applying to work at the service were suitable.
Care files we looked at showed plans and risk assessments documenting people’s specific care and support needs. These plans outlined how people needed to be cared for in an effective and safe way
Care records at the home showed us that people received input from health care professionals, such as psychiatry and social care workers. People were supported to visit the dentist and general practitioner.
The home has good links with partnership agencies and the community. Several people accessed the community on a daily basis and people were offered a range of activities and events to take part in.
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.
There was a complaints policy in place and we saw that complaints were acted upon. The registered manager also regularly sought the views of people living at the home and their relatives. They were able to demonstrate action taken at the home as a result of this feedback.
The required safety checks and maintenance for the building and equipment were in place and were regularly monitored.
Mealtimes were sociable and food was of high quality. People and their relatives told us they were happy with the menu and food choices provided at the home. Kitchen and care staff were aware of people’s specific dietary needs.