Downsvale Nursing Home

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.

Downsvale is a care home which provides nursing care and accommodation to people. The service is divided into two separate houses, each with its own dining and communal space. Most people living at Downsvale are living with dementia or have a nursing need. At the time of our inspection 29 people were living at the service.

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

People said they felt safe living at Downsvale and they told us they did not have to wait for attention from staff. Staff were knowledgeable about the risks to people and knew how to help keep them safe and free from harm.

Where people had an incident or accident these were responded to, lessons learnt and action taken to prevent further accidents. Staff knew how to recognise and report any safeguarding concerns.

Changes had been made to the service during the pandemic to help reduce any risk of infection. We had no concerns about the infection prevention and control practices of staff.

The registered manager had an open-door policy and staff told us they felt supported and valued by them. They said they could approach the registered manager to raise concerns and they felt listened to. Robust recruitment processes were in place.

Relatives told us they were very happy with the care their family members received. They told us the registered manager was very supportive and put people first.

A range of audits was completed to ensure people received a good level 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

The last rating for this service was Good (report published 31 May 2018).

Why we inspected

This targeted inspection was prompted due to concerns we received about various aspects of the service. This included infection control, staffing and unsafe care for people. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from these concerns. The overall rating for the service has not changed following this targeted inspection and remains Good.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

At this inspection we reviewed selected Key Lines of Enquiry in the key questions of Safe and Well-Led only and this report covers our findings in relation to those.

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 will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme when we will carry out a fully comprehensive inspection looking at all key questions. If we receive any concerning information we may inspect sooner.

There was 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. The registered manager was at the home during the time of our inspection.

We last carried out a comprehensive inspection of Downsvale Nursing Home in December 2016 where we found the registered provider was in breach of 3 regulations. These related to activities, mental capacity assessments and quality assurance. Following this inspection the registered provider sent us an action plan of how they would address these issues.

The inspection took place on 26 April 2018 and was unannounced. During this inspection we found that the concerns raised at our previous inspection had been addressed.

Accidents and incidents were recorded and an analysis of why accidents or incidents had occurred or what action could be taken to prevent further accidents had been developed. There were enough staff to meet the needs of the people and for people to take part in meaningful activities. Robust recruitment procedures were completed to ensure staff were safe to work at the service. People felt safe living at the home. Staff understood their responsibilities around protecting people from harm. The provider had identified risks to people’s health and safety with them, and put guidelines in place for staff to minimise the risk. Infection control processes were in place that helped to reduce the risk of infection. People received their medicines as prescribed by their GP.

Staff understood the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that decisions were made in the least restrictive way. Where there were restrictions in place, staff had followed the legal requirements to make sure that this was done in the person’s best interest. People’s nutritional needs were assessed and individual dietary needs were met. People had involvement from external healthcare professionals and staff supported them to remain healthy. Staff received appropriate training and had opportunities to meet with their line manager regularly that helped them to provide effective care to people. The environment was suitable for people living with dementia.

People’s care and support was delivered in line with their care plans. People’s privacy and dignity was respected. Staff were knowledgeable about the people they cared for and were aware of people’s individual needs and how to meet them. People were supported with their religious beliefs and were able to practice their faith.

Documentation that enabled staff to support people and to record the care they had received was up to date and reviewed on a regular basis. People would receive end of life care that was in line with their needs and preferences and staff had received training in regard to this. Care plans included people’s requests about their end of life wishes that included if they wanted to remain at the home or be admitted to hospital.

Complaints were addressed within the stated timescales to the satisfaction of complainants. A complaints procedure was available to people, relatives and visitors.

The provider and staff undertook quality assurance audits to monitor the standard of service provided to people. An action plan had been produced and followed for any issues identified. People, their relatives and other associated professionals had been asked for their views about the home through surveys and resident and relatives meetings.

The interruption to people’s care in the case of an emergency would be minimised. The provider had a Business Continuity Plan that provided details of how staff would manage the home in the event of adverse incidents such as fire, flood or loss of gas or electricity.

There was a new manager in post. The new manager started in post in October 2016. They were not yet registered with CQC, however they had submitted the relevant paperwork and an interview with CQC was pending. 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

At the last inspection on 27 and 29 April 2016 we told the provider to take action to make improvements in the management of medicines, and reducing the risks of harm to people and staffing deployment. Whilst some improvements had been made, there was still some work to be done. We told the provider to put systems in place to monitor, review and improve the quality of care, to ensure that it was personalised and responsive. We also told the provider to ensure that processes were in place to ensure that people’s rights were protected if they lacked mental capacity. Whilst some improvements had been made, there was still some work to be done. We told the provider that they needed to make improvements in promoting people’s dignity and respect, safe recruitment of staff, equipment to be safe and safeguarding to be reported to the appropriate authorities. These actions have been completed.

Some people’s rights were not always protected because the manager did not always act in accordance with the Mental Capacity Act 2005 (MCA). Where people were assessed to lack capacity to make some decisions, mental capacity assessment and best interest meetings had not always been undertaken. Relatives had made decisions regarding people’s care and the manager had not always ensured that they had the legal right to do so. This is a continued breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what we told the provider to do at the back of the report. Staff were heard to ask peoples consent before they provided care.

Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People told us that they wanted to do more activities. There were some activities on offer, improvements could be made.

There were some systems in place to monitor, evaluate and improve the quality of care provided. However, improvements could be made as they had not always identified areas of improvement.

People told us that they had enjoyed the food. People had sufficient to eat, but improvements could be made regarding the fluid intake of people. We have made a recommendation. People were seen to be offered choice of what they would like to eat and drink.

People’s medicines were now administered, stored and disposed of safely. Staff were trained in the safe administration of medicines and kept relevant records that were accurate. For people who needed PRN (as required medicine) medicine, there were some guidelines in place.

The manager had oversight of incidents and accidents and ensured that actions had been taken to reduce the risks of them occurring again.

There were inconsistencies to how risks to people were managed. There were risk assessments in place to maintain people’s skin integrity, to reduce the risk of falls and to ensure people’s weights were maintained. However, some risk assessments lacked detail to tell staff how to keep people safe. We have made a recommendation in relation to this.

People had personal emergency evacuation plans (PEEP) in place to tell staff how to keep people safe in the event of an emergency.

People were protected from avoidable harm. Staff received training in safeguarding adults and were able to demonstrate that they knew the procedures to follow should they have any concerns. The manager ensured that they notified us and the appropriate authorities when there was a concern.

There were now sufficient staff to keep people safe. However at lunch times this was not always the case. We have made a recommendation for the manager to review the staff deployment at lunch times. There were now robust recruitment practises in place to ensure that staff were safe to work with people.

People were supported to maintain their health and well-being. People had regular access to health and social care professionals.

Staff were trained and had sufficient skills and knowledge to support people effectively. There was a training programme in place and training to meet people’s needs. Staff received supervision. Some people told us that they could not always make their needs known as some staff English was not their first language. We have made a recommendation about the provider reviewing their training to include communication training.

Positive and caring relationships had been established. Staff interacted with people in a kind and caring manner. Relatives and other professionals were involved in planning peoples care.

People were offered choices throughout the day and they were respected by staff. People’s privacy and dignity was respected. People could be more involved in planning their own care.

Care plans were in place; however improvements were needed to make care plans more detailed and personalised. We have made a recommendation. This was identified by the management of the home as an area that required improvement. A new electronic care planning system was in place. Staff told us that this gave them up to date information on people’s needs. Staff knew people’s preferences.

The service listened to people, staff and relative’s views. There were systems in place to obtain feedback from staff, people and relatives.

The management promoted an open and positive culture. The staff were motivated. The manager and provider understood the requirements of CQC and sent appropriate notifications.

Staff told us they felt supported by the manager and the provider. Staff told us that they had seen improvements in the home. Staff, people and their relatives told us they felt that the management was approachable and responsive.

We found three continued breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found continued breaches in 9, 11 and 17. You can see what we told the provider to do at the back of the report.

We last inspected the service on 27 and 29 April 2016, where concerns were identified and breaches to the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014). We took enforcement action against breaches of Regulation 12 and 17 and issued warning notices. We also found breaches in Regulation 9, 10, 11, 13, 15, 18 and 19 and requirement actions were set.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service is registered for 35 people. At the time of the inspection there were 31 people living in the service. People had a range of needs. Some were living with dementia; others required nursing care to manage pressure areas and end of life care whilst other people required minimal assistance.

The service had a registered manager. 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 were not always protected from harm. Risks to people had not always been assessed and therefore put them at risk of harm. For example, one person had a pressure sore and there was no risk management plans in place.

Care equipment that was provided was not always safe for use. One person had a bed rail, yet they managed to sustain an injury to their head as a result of poorly fitting bed rails. Hoists, commodes and wheelchairs were not always cleaned.

The registered manager and provider had not always identified when there was a safe guarding concern. One staff member had been “quite rough” with a person and this was not reported as a safe guarding concern.

There was not always enough staff on duty to meet people’s needs. People told us that they had to wait for staff when they needed something. Half of the staff we spoke to said they felt rushed and they would like to spend more time with people.

People did not always have their medicines administered safely. One person had not received a medicine for six days. Medicines were not always stored and disposed of safely.

Robust recruitment practises were not in place to ensure that staff were safe to work with people. References and applications were not always in place for staff, the registered manager had not ensured staff were of good character.

People’s human rights could have been affected because the requirements of the Mental Capacity Act were not always followed. For people who lacked capacity to make decisions about their care, mental capacity assessments and best interests decisions had not occurred.

People did not always receive effective care. The registered manager had not always ensured that staff had the knowledge; skills and regular supervision to enable to them care for people safely and effectively.

People had sufficient food and fluids. Some people told us that they could not always reach their drinks when they were in their beds. People said they liked the food.

People were not always involved in the care. Some relatives were involved, but others had not been. People and relatives said that the staff were kind and caring. People’s privacy and dignity was not always respected. Staff did not knock on people’s doors and waited until they were told to enter.

People did not always receive personalised care. Three people, who were newly admitted, did not have their needs assessed, this meant that staff would not know how to support people. People’s preferences and wishes were not always recorded in their care plans.

There was an activities programme in place; people said they enjoyed the activities.

People and their relatives knew how to make a complaint. Complaints had been responded to in line with the service’s policy.

The service was not well led. There was not a robust system in place to monitor and review the incident and accidents.

There was not a robust process in place to monitor and evaluate the care provided to drive improvements. Record keeping was inconsistent and records were not stored securely.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For breaches 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 we took enforcement action and issued Warning Notices. You can see what action we told the provider to take at the back of the full version of the report.

We therefore found that People who used the service, staff and visitors protected against the risks of unsafe or unsuitable premises.

People also told us they liked their rooms, and they were warm enough. They said that they had no complaints but knew how to make one if they did.

One person told us the home was like a home from home, and if they had any concerns they would tell the manager, as they intended to do that day about a minor issue. They also told us that if they had a problem they would not have stayed at Downsvale for so many years.

Another person told us one of their windows did not open and the other one was wonky.

We saw that people were supported to eat and drink sufficient amounts to meet their needs.

We found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

We saw that people were given support to make a comment or complaint where they needed assistance and had their comments or complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint.