6 June 2023
During an inspection looking at part of 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.