Downsvale Nursing Home

Updated 2 July 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

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

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and other professionals. We used all of this information to plan our inspection.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with four people who used the service and one relative about their experience of the care provided. We spoke with nine members of staff including the nominated individual, registered manager, the registered nurse on duty, senior care workers, care workers and the maintenance person. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We observed interactions between staff and people using the service.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at five staff files in relation to recruitment, staff supervision and training. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We spoke with three relatives. We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visit the service.

Updated 2 July 2021

About the service

Downsvale Nursing Home is a residential care home providing personal and nursing care for up to 35 older people and people living with dementia. The service was supporting 30 people on the day of the inspection, some of whom were living with dementia. The service accommodates people across two connected buildings.

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

Staff did not always follow national infection and prevention control guidelines in the use of face masks whilst in close proximity to people using the service.

There were systems in place to monitor the quality of care provided, however audits were not always robust enough to ensure compliance of staff wearing masks in accordance with government guidance. Following the inspection, the provider sent us an action plan outlining the steps they have taken so far and are planning to take in response to our findings.

People told us they felt safe and staff were kind and caring towards them. People using the service and relatives told us they were supported with their care needs. People received their medicines on time and were supported to administer medication independently if they wished to do so.

There were sufficient staff to support people with their care needs. Staff were aware of the risks associated with people’s care and ensured people were supported appropriately. Care records including those relating to identified risks were in place. Safety checks of the premises and equipment were undertaken in line with requirements.

Staff had regular supervisions and told us they felt supported in their role. Staff were clear on the governance structure within the service and knew their roles and responsibilities.

People using the service and relatives told us they knew how to complain and felt confident that complaints would be addressed. Staff told us they could approach the provider with any suggestions on improving the care provided.

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 this service was good (published 31 May 2018).

Why we inspected

We received concerns in relation to staffing, the culture at the service, training, the management of medicines and recruitment practices. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has not changed and remains Good. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Well-led section of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downsvale Nursing Home on our website at www.cqc.org.uk.

Follow up

We have received an action plan from the provider detailing the actions they have taken and are planning to take and we will review this at the next inspection. We will share our findings with the local authority. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.