• Care Home
  • Care home

Downhurst Residential Home Limited

Overall: Requires improvement read more about inspection ratings

76 Castlebar Road, London, W5 2DD (020) 8997 8421

Provided and run by:
Downhurst Residential Home Limited

Important: We are carrying out a review of quality at Downhurst Residential Home Limited. We will publish a report when our review is complete. Find out more about our inspection reports.

Latest inspection summary

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Background to this inspection

Updated 7 October 2023

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 Health and Social Care Act 2008.

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 conducted by two inspectors, and a medicines specialist advisor. An Expert by Experience supported the inspection by contacting the relatives (and friends) of people who used the service after our visit. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Ealing Eventide Homes Limited – Downhurst is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ealing Eventide Homes Limited – Downhurst is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

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 used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 7 relatives. We also spoke with 7 staff members which included the registered manager (who is also the nominated individual), 5 care workers and the activities coordinator. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records which included 6 people’s care plans, various medicines records and the recruitment records for 4 new care workers and supervision records for 7 staff members.

Overall inspection

Requires improvement

Updated 7 October 2023

About the service

Ealing Eventide Homes Limited – Downhurst is a care home for up to 26 older people. At the time of our inspection, 21 people were living at the service. Some people were living with the experience of dementia. The service is managed by Ealing Eventide Homes Limited, a charitable organisation. This is their only registered care home.

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

Medicines were not always administered as prescribed and records did not always reflect the medicines received by people. Incidents and accidents were recorded but lessons learned were not always recorded to reduce future risks. The provider did not ensure their safeguarding procedure was always followed. Quality assurance procedures were not robust enough to enable the provider to identify where action may be required to make improvements.

The provider had made improvements in relation to the management of risk and information was now provided for staff on how they could reduce the possible risks to the person’s health and wellbeing. The provider had also made improvements to the care plans to ensure they were person centred and identified people’s current support needs. Improvements had been made to the range of activities provided for people living at the home.

Relatives felt their family members received care in a safe and appropriate manner. There was a robust recruitment process in place. The provider followed an infection prevention and control procedure and staff had access to personal protective equipment (PPE).

People were supported to have maximum choice and control of their lives and staff supported support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Relatives were aware of how they could raise any concerns about the care provided. The provider had a process for responding to complaints. The provider worked in partnership with a number of organisations. Relatives were happy with the care provided to their family member. Relatives felt the registered manager was accessible, listened and responded to any questions they might have.

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 16 December 2022). 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 the provider remained in breach of regulations.

At our last inspection we recommended that the provider seek and implement national guidance on the provision of social and recreational activities for older people in care settings. At this inspection we found the provider had made improvements to the activities provided.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 17 and 18 October 2022. 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 safe care and treatment, person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm if they now met legal requirements. We have found evidence that the provider still needs to make improvements. This report only covers our findings in relation to the Key Questions Safe, Responsive 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 remained requires improvement. 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 Ealing Eventide Homes Limited - Downhurst on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and good governance at this inspection.

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 request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.