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Archived: Downs Cottage Care Home (with Nursing) Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 September 2016

Downs Cottage Care Home provides nursing care for up to 23 older people including people who live with the experience of dementia and other mental health conditions. At the time of our inspection 13 people were living at the home. All required support with personal care and mobility.

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 inspection took place on 8 August 2016, in response to concerns we had received, and was unannounced. The inspection was planned to be a ‘Comprehensive’ inspection to cover all five key questions about is the service Safe, Effective, Caring, Responsive and Well Led.

At the beginning of our inspection the provider announced that the home would close in four weeks. Due to this we changed to a ‘Focussed’ inspection to check that people would be kept Safe during the home closure. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Downs Cottage Care Home on our website at

People were not protected from the potential risk of harm.

People at risk of choking had been given inappropriate food that increased the likelihood of a choking incident. People who should have been on a pureed diet to aid swallowing had been given chopped up burgers, sausages, pasta back, and sandwiches. The registered manager took immediate action to ensure this did not happen again.

There were not enough staff to meet the individual needs of people. The numbers of staff deployed left people at risk of falls unsupported. Arrangements for staff to call on other staff for help in an emergency, such as if someone fell, were inadequate. Staff made reference to sounding the alarm bell to call for aid, but this could not be found on the day of our inspection.

The home had not been maintained to assure peoples safety. The landlords gas safety certificate expired in April 2016, so they could not be certain the gas appliances were safe at the home. Risks to people from the spread of infection had also not been managed in a timely way. A risk identified during a night shift was not dealt with by staff the next day, until we brought it to the provider’s attention. This increased the chance that the infection would spread around the home. The provider took action to alert the appropriate authorities, and have the situation dealt with the day after our inspection.

We identified one breach in the regulations. We met with the provider, and wrote them a formal letter to outline the actions we required them to take to ensure people where kept safe during the closure of the home.

Inspection areas



Updated 8 September 2016

The service was not safe.

Identified hazards to people�s health and safety had not been managed in a safe way, for example the management of choking risk.

There were not enough staff deployed to meet the individual needs of people.

The environment was not suitably maintained. People were at risk of infection because infection control was not managed well.

People were at risk because accidents and incidents were not always reviewed, or reported to the appropriate authorities.


Requires improvement

Updated 21 June 2016

The service was not always effective.

Staff had access to training to enable them to support the people that lived there. However the absence of the registered manager meant that staff had not had supervisions or appraisals in line with the provider�s policies.

People�s rights under the Mental Capacity Act were met. Assessments of people�s capacity to understand important decisions had been recorded in line with the Act. Where people�s freedom was restricted to keep them safe the requirements of the Deprivation of Liberty Safeguards were met.

People had enough to eat and drink and had specialist diets where a need had been identified.

People had good access to health care professionals for routine check-ups, or if they felt unwell. People�s health improved as a result of the care and support they received.



Updated 21 June 2016

The service was caring.

Staff were caring and friendly. We saw good interactions by staff that showed respect and care.

Staff knew the people they cared for as individuals. Communication was good as staff were able to understand the people they supported.

People could have visits from friends and family whenever they wanted.



Updated 21 June 2016

The service was responsive.

Care plans were person centred and gave detail about the support needs of people. People were involved in their care plans, and their reviews.

People had access to a range of activities that matched their interests. People�s access to the local community could be improved.

There was a clear complaints procedure in place. Staff understood their responsibilities should a complaint be received.


Requires improvement

Updated 21 June 2016

The service was not always well- led.

The registered manager had been absent from the home, and the management cover had not been completely successful in supporting staff, and ensuring actions identified to improve the home were completed in good time.

Quality assurance records were up to date and used to improve the service, however these were not always available when requested.

People and staff were involved in improving the service. Feedback was sought from people via an annual survey.

The registered manager understood their responsibilities with regards to the regulations, such as when to send in notifications.