Downham Grange

Downham Grange is a nursing home providing accommodation and personal care to up to 62 people. At the time of our inspection there were 56 people using the service. The service is purpose built and set over two floors with lift access. There are several communal areas, including gardens. The service accommodates people who require nursing or residential care and for people living with dementia.

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

People were not receiving good quality standards of safe care. Areas of the care environment were visibly unclean and increased the risk of the spread of infection. People, including those living with dementia were at risk of consuming items such as denture cleaning tablets, personal care products and prescribed creams as these were not being stored securely.

People with risks of developing pressure sores, the management of choking risks, as well as ensuring their fluid and nutritional intake was well monitored were poorly managed. This did not protect people from the risk of harm. Diabetes care needed improvements to ensure people’s long-term healthcare needs were well managed.

People were not receiving their medicines safely, with medicines running out, and not being re-ordered to ensure they were available to people. Unsecured creams increased the risk of people accessing items that could cause them harm. We found issues with record keeping in relation to the application of creams, and rotation of medicines given in a patch form.

Changes to levels of staffing, particularly at night time were needed to ensure people’s needs were met safely and in a timely way. Increased levels of governance and oversight of the service were required to ensure people’s basic standards of care were being met, such as personal cleanliness and appearance, as quality checks and audits of care records were not identifying gaps in the completion of care tasks.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 requires improvement (published 26 September 2022). The service has been rated requires improvement for the last 2 consecutive inspections and has not held a compliant rating since 2019.

Why we inspected

This focussed inspection was prompted by a review of the information we held about this service. 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 changed from requires improvement to inadequate based on the findings of this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downham Grange on our website at www.cqc.org.uk.

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.

Enforcement and Recommendations

We have identified breaches of the regulations in relation to safe care and treatment, staffing 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 rating, 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.

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

Concerns over the quality and safety of the care provided at Downham Grange led to this inspection. Poor governance and a lack of consistent management over time had resulted in the service being rated requires improvement at the last rated CQC inspection and the service had been unable to retain a good rating over a longer period of time.

At this inspection we found improvements had been made but not firmly embedded. The action plan following the local authority visit in January 2022 had been implemented and most actions had been achieved. Some of the issues raised by the local authority were the same concerns raised by the CQC during their inspection on 18 February 2021. A coroner’s court also raised concerns in April 2022 about record keeping, communication and accountability.

The oversight and monitoring of risk had not always been effective resulting in a poor experience for some.

At our recent inspection we found some daily notes did not clearly show how people’s needs were being met in line with their needs. Some staff chose to use standard text rather than free text. The provider had contacted the manufacturer of the software to try and improve its use and remove some of the generic, non-descriptive words and icons.

A software champion had been put in place to provide support and enhanced training for staff. These measures had only recently been implemented despite concerns about records being raised consistently across different inspections.

We noted the risks associated with topical creams had not been eliminated as creams were left out in people’s rooms and not secure which could cause harm if ingested.

Pressure ulcers acquired at the service had been responded to appropriately and lessons learnt.

Infection control measures were in line with current government guidance, but no checks were in place prior to inspectors or visitors entering the building. This would have helped ensure they were not displaying any symptoms of COVID 19 or if they had completed a recent lateral flow test. The standards of cleanliness throughout the home were high and daily records evidenced regular cleaning.

The registered manager had a good ethos and was supporting staff to make positive changes within the workplace to help change the culture of the service. They explained that the first hurdle had been to reduce their dependency on agency staff and were now supporting staff to work well together and to develop the team.

Daily management walkarounds were not recorded although there was a tool for managers to use which would help evidence how people’s needs were being met.

Staff were being supported to develop their skills and competencies. A number of staff had lead roles and the provider had recently employed food and fluid champions who had an important role in keeping people hydrated. An activity team had been put in place and they worked hard to support care staff, but we noted teamwork across the service was not yet fully embedded.

Staffing levels were appropriate on the day of inspection to the needs of the people using the service. There were core staff teams on each unit which helped to ensure consistency of care for people, whilst rotation of staff and reduction in agency meant staff were familiar with people’s needs and this was working well but again had only recently been implemented. Safe recruitment practices ensured suitable staff were recruited.

Medicines were comprehensively managed.

We spoke with fourteen relatives and they were largely positive about their family members experiences. Staffing was a concern for some, and relatives said access to and from the building could be delayed whilst waiting for staff to become available.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Rating at last inspection and update

The last rating for this service was requires improvement (09 April 2021.)

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident was subject to an investigation. We wanted to follow up to see if recommendations had been implemented and improvements made.

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.

You can see what action we have asked the provider to take at the end of this full report. 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 not changed and is still requires improvement based on the findings of this inspection.

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

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Downham Grange is a nursing home which is registered to provide personal and nursing care to up to 62 people. At the commencement of the inspection, there were 57 people living in Downham Grange. Care is

provided to people in three separate wings, each with separate adapted facilities.

We found the following examples of good practice.

People were being supported to receive visits from their family and loved ones. Visits were being completed in line with current government guidance.

The service appeared clean and equipment had been maintained. Windows were observed to be open to support with ventilation in the service.

Staff and people supported received regular COVID-19 testing in line with current government guidelines to keep themselves safe.

Vaccination records were monitored and stored by the management team for people, staff and regular visitors. Where visiting professionals attend the service their vaccination status is checked at this time.

Downham Grange is a nursing home which is registered to provide personal and nursing care to up to 62 people. At the commencement of the inspection, there were 45 people living in Downham Grange. Care is provided to people in three separate wings, each with separate adapted facilities.

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

The oversight and monitoring of risks to people’s safety required improvement. Risks had not always been assessed or managed appropriately. Some people’s care records contained inaccurate or conflicting information. This increased the risk of people receiving care that was unsafe and that could result in harm.

The registered manager had already identified some of these issues and was working to make the necessary improvements, but these had not yet been fully embedded. Following our inspection, the provider told us they had reviewed their monitoring systems and enhanced them to ensure risks to people’s safety were identified and managed effectively. We will check these are effective when we next inspect the service.

People and relatives were happy with the quality of care provided at Downham Grange. All felt they or their family member was safe and that the home was managed well. They felt listened to and that the management and staff were approachable, friendly and kind. Good communication had been in place which had been particularly important during the pandemic.

There were effective systems in place to protect people from the risk of abuse. People received their medicines when they needed them, and good infection control procedures were in place to reduce the risk of the spread of infection as much as reasonably possible.

There were enough staff to keep people safe, but staff told us they could not always spend as much time with people as they wished. The registered manager agreed to keep staffing levels under regular review.

Incidents and accidents were recorded and investigated so lessons could be learnt to try to reduce them from happening again.

Staff told us they enjoyed working at Downham Grange and felt the leadership of the home was good. The majority felt supported and listened to.

Rating at last inspection

The last rating for this service was Good (published 26 July 2019).

Why we inspected

We received concerns in relation to staffing and the management of risks to people’s safety. As a result, we undertook a focused inspection to review the key questions of Safe and Well-Led only.

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 coronavirus and other infection outbreaks effectively.

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.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence the provider needs to make improvement. Please see the Safe and Well-Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downham Grange 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. If we receive any concerning information we may inspect sooner.

Downham Grange is a residential care home providing personal and nursing care to 44 older people at the time of the inspection. The service can support up to 62 people in one adapted building.

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

People were happy with the care home and the staff that provided their care.

People felt safe living at the home because staff knew what they were doing, they had been trained, and cared for people in the way people wanted. Staff assessed and reduced risks as much as possible, and there was equipment in place to help people remain as independent as possible. There were enough staff, and the senior staff also spoke with people regularly. The provider obtained key recruitment checks before new staff started work.

People received their medicines and staff knew how these should be given. Medicine records were completed accurately and with enough detail. Staff supported people with meals and drinks. They used protective equipment, such as gloves and aprons. Staff followed advice from health care professionals and made sure they asked people’s consent before caring for them.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People liked the staff that cared for them. Staff were kind and caring, they involved people in their care and made sure people’s privacy was respected. Staff worked well together, they understood the home’s aim to deliver high quality care, which helped people to continue to live as independently as possible.

Staff kept care records up to date and included national guidance if relevant. Complaints and concerns were dealt with and resolved.

Systems to monitor how well the home was running were carried out. Concerns were followed up to make sure action was taken to rectify any issues. Changes were made where issues had occurred elsewhere, so the risk of a similar incident occurring again was reduced. People were asked their view of the home and action was taken to change any areas they were not happy with.

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 4 January 2019) and there were multiple breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We last carried out a focused inspection to this service on 12 July 2018 because we had concerns about the service. These included the departure of the registered manager, the clinical lead and one of the operational managers. We felt this would have a significant impact on the stability and safety of the service. There had been a sharp rise in medication errors. Our concerns were shared with the Local Authority and other health care professionals. We also received a number of whistle-blowers who raised concern about the safety of the service. Before the focussed inspection we met with the providers to seek assurances. We also requested a written action plan from the service stating how they would address the concerns and improve the service for people living there.

At our focussed inspection on 12 July 2018 some improvements had been made and a new manager appointed. We received positive feedback about their impact. There was a new clinical lead in post and a reduction in the use of agency staff. There had been no recent medication errors. Despite these improvements we found some shortfalls and three breaches of regulation. We had concerns about insufficient staffing, poor risk management and poor governance and oversight. We rated both key questions, safe and well -led as requires improvement.

Soon after our focussed inspection the registered manager left. The service recruited another manager but they failed to start. The service did not have a registered manager at the time of our most recent inspection. It is a condition on the homes registration to have 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.

Downham Grange 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 home can accommodate people with a nursing or residential care need including those people living with dementia. It is registered for 62 people. On the day of inspection there were 56 people living in the service. The service is divided up into three separate units, on the ground and first floor. The building is modern and lends itself to the needs of the people using the service.

At our inspection on 27 November, 3, 5 and 19 December 2018. We found three repeated breaches of regulation including insufficient deployment and skill mix of staff, poor oversight and governance and poor risk management. We identified three further breaches in relation to the care people received which was not person-centred care and found there was poor oversight of complaints and poor oversight of people dietary and hydration needs.

Management oversight of the service was shared between the service manager, interim manager and regional manager. The clinical lead was in post Monday to Friday and had oversight of the clinical care. Registered nurses led the nursing dementia floor and the nursing unit. The service was almost fully recruited to all staffing positions. Despite this we found there was poor oversight on shift with insufficient deployment of staff at busier times of the day and care being compromised at these times. Not all staff had the necessary skills or training for the job they were expected to do. Staff supervision and personal development was improving but not yet firmly established. On the 5 December 2018 the service manager became the acting manager for the service until a permanent manager could be appointed. They told us they would apply to CQC for registration and being in this post would provide the service with some stability, oversight and continuity. We visited the service again on the 19 December 2018 and were assured that some improvements had been made and a permanent manager had been appointed.

We found the care provided to people focussed mainly on their physical care needs and holistic assessments were not carried out to consider people’s preferences and well -being. Care plans and the observed care did not match people’s preferences and preferred routines. Activities were provided but peoples experiences of these were varied. Risks associated with people’s care were poorly planned for.

Complaints and feedback about the service provided were not routinely collated or used to show how the service acted on people’s feedback to improve the service. There was little evidence of audits which took into account observation as a way of judging the care being provided which is important when people might not be able to give verbal feedback. There was an over emphasis of using electronic monitoring as a way of assessing the impact of care.

The service had not had consistent management and this had resulted in a fragmented service without a clear vision or overview. Audits had not identified concerns that we had and were not consistent with CQC standard and regulation.

We found because of staff deployment people were not always adequately supported to eat and drink enough for their needs and people were at risk of not having their health care needs met.

Staff knew how to safeguard people and were not afraid to report concerns. Staffing continuity had improved which meant staff were mostly familiar with people’s needs. We did find some information in care records which was out of date and not sufficiently informative.

Staff had enough knowledge of the Mental Capacity Act and were able to support people lawfully and gained consent before carrying out care tasks. Best interest decisions were not always recorded.

Staff recruitment practices were sufficient but we have made a recommendation.

Staff were sufficiently trained in administering medicines and we were assured people received this safely.

The environment was purpose built and suitable for its intended purpose. It was well maintained and clean and risks were reduced because of it.

Downham Grange is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate people without a nursing need or people living with dementia. It is registered for 62 people. On the day of inspection there were 53 people using the service.

A condition of the home’s registration is there should be a registered manager in post. A manager was in post but not yet registered with CQC. 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.

In summary we found concerns about the service but recognized the service was on an upward trend having already made some improvements to the service. There was confidence about the manager and their ability to bring about positive change and there was a full complement of nursing staff but some vacant hours for care staff. However there had been a significant reduction in agency usage which helped reduce cost and improved continuity for people using the service. There was also a new clinical lead who had been in post three weeks. This helped strengthen the management team. The level of skill and experience of the staff team was a concern given that not all staff had a good knowledge of people’s needs.

We had concerns about staffing. We were not assured there was an adequate skill mix across the three separate units, the dementia unit, residential unit and nursing unit. The shifts were poorly organized without effective leadership and staff were not deployed sufficiently across the day. This meant people were not provided with the necessary support taking into account their wishes and preferences. We found lunch time on two of three units were poorly organised and did not help ensure people had enough to eat and drink. We also found the provision of activities did not effectively demonstrate how they met individual’s needs. We had concerns that people were not adequately monitored for their safety in communal areas and the risks of this had not considered.

The management of individual risks were adequately documented in people’s care plans and known by staff. However, information was hard to track through and we could not always see what actions had been taken. We found some concerns regarding risks posed by the immediate environment which is discussed in the main body of the report.

We had received concerns about the electronic medicines system introduced to the service about a year ago. Medicines errors had meant people did not always get their medicines as intended. We carried out some observations and looked at the system in place and found this to be well managed with minimal errors. We saw that staff received sufficient training to help ensure they were sufficiently skilled and competent to administer medicines as intended.

Staff recruitment processes were not adequate and helped ensure only staff suitable for employment were appointed. Some gaps in records were identified which meant the processes were not always robustly recorded.

Staff had a reasonable understanding of safeguarding people in their care and what actions to take if they though a person was at risk of harm or actual abuse. They were able to recognize what constituted a safeguarding and who to report it to both internally and externally.

The service was adequately cleaned and there were sufficient measures to promote the control and spread of infection. However shared manual handling slings posed a significant risk.

The service was not yet well-led. Not all staff had received recent supervision or support around their working practices. Communication across shifts were not always effectively disseminated and the whole service did not work as a team to ensure people’s needs were met.

The service was slowly introducing positive changes but these were not yet fully embedded. The culture of the service did not reflect the needs of individuals or adequately show how people’s environment was respected and care was planned around their individual needs.

We undertook an unannounced focused inspection on 7 November 2016 to check that our warning notices had been complied with. At that inspection, we found that the provider had taken sufficient action to achieve compliance with the warning notices.

We undertook this unannounced comprehensive inspection 23 and 30 January 2017 to look at all aspects of the service, and confirm that the service now met legal requirements. At this inspection, we found improvements had been made in the required areas and the provider was no longer in breach of the regulations.

You can read the report for previous inspections, by selecting the 'All reports' link for 'Downham Grange’ on our website at www.cqc.org.uk

Downham Grange is registered to provide accommodation for up to 62 older people who require nursing and personal care, some of whom may be living with dementia. On the days of our inspection, 51 people were living at the home.

There was a newly registered manager in post who had commenced employment at the home in October 2016. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

During this inspection people said they felt safe and that staff treated them well. Safeguarding adults' procedures were in place and staff understood how to protect people from the risk of abuse. Risks associated with people's care were identified, assessed and recorded. There was a whistle-blowing procedure available and staff said they would use it if they needed to.

Policies and procedures were in place to guide staff with the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely by trained staff.

There were sufficient numbers of suitably qualified staff employed at the service. The provider’s recruitment process ensured they only employed staff deemed suitable to work with people in a care setting. Staff had completed an induction programme when they started work and they were up to date with the provider's mandatory training.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the registered manager was knowledgeable about when a request for a DoLS application would be required. Applications had been submitted appropriately to the relevant local authority.

Staff respected and maintained people’s privacy. People received care and support as required and people did not have to wait for long periods before having their care needs met. This meant that people’s dignity was respected and that their care needs delivered in a timely manner.

People’s assessed care and support needs were planned and met by staff who had a good understanding of how and when to provide people’s care whilst respecting their independence. Care records were detailed and up to date so that staff were provided with guidelines to care for people in the right way.

People were supported to access a range of health care professionals. Risk assessments were in place to ensure that people could be safely supported at all times.

People enjoyed a varied menu and had a range of meals and healthy options to choose from. There was a sufficient quantity of food and drinks and snacks made available to people.

Staff provided people with care in a respectful, caring, kind and compassionate way.

People were not always provided with enough activity and stimulation on a daily basis. The home had recently recruited an activities co-ordinator, but it was too early for this to have had an impact. Some staff engaged in meaningful conversations with people, but this was not consistent across all of the units in the home.

People’s expressed preferences were not always met. Although staff knew what people liked, there were occasions when this was overlooked or assumptions wrongly made by staff, which frustrated people. Staff at times were task orientated and did not always confirm people’s choices with them.

The service had a complaints procedure available for people and their relatives to use and staff were aware of the procedure. The registered manager took action to address people’s concerns and prevent any potential for recurrence.

There was an open culture within the service and people were freely able to talk and raise any issues with the registered manager and staff team. Staff morale had greatly improved, they were motivated and felt proud to work at the home. The registered provider had ensured that the registered manager had been provided with the support and resources required in order to drive up quality at the home. The impact of this was that the home was now meeting its legal obligations.

People, staff and relatives were provided with several ways that they could comment on the quality of their care.

We have not changed the overall rating for this service as a result of this inspection, which was only to follow up our enforcement action. The service remains rated as requires improvement. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downham Grange on our website at www.cqc.org.uk

Downham Grange provides accommodation and support to a maximum of 62 older people, some of whom are living with dementia. The home provides a mixture of nursing and residential care.

At the time of this inspection, the homes registered manager had recently resigned and was no longer working at the home. The provider had recently recruited a new manager for the home, who had been employed for three weeks. They told us that they were applying to become the registered manager for the home. 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 and associated Regulations about how the service is run.

At the previous comprehensive inspection, effective monitoring systems were not in place to ensure quality and safe care. This had resulted in people receiving poor care and being at risk of harm. We found that medicines had not been managed safely and people did not receive them as the prescriber intended.

Since our last inspection, the provider had deployed a number of staff to focus on improving the quality and safety of care provided to people. This included a regional operations manager to oversee the improvements required and take responsibility for the implementation of these. At this inspection we saw that there were effective systems in place that had been developed since our last visit. These were to monitor the quality and safety of people living at the home, and to reduce the risk of harm and poor care. The regional operations manager had identified where improvements had been needed and actions had been undertaken to achieve this. The regional operations manager had, as a result of this also identified where they would like to make future improvements and a plan was in place for this.

The Warning Notices we issued were complied with.

During our inspection of the home in January 2016, we found that the provider was in breach of seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. These were in respect of sufficient staffing, safe care and treatment, treating people with dignity and respect, the need for consent, providing person centred care, statutory notifications and good governance.

At this inspection, although we found that some improvements had been made we found further and continued concerns. The provider is in breach of Regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we told the provider to take at the back of the full version of this report.

Following the inspection in January 2016, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

Downham Grange is a service that provides accommodation and care to a maximum of 62 older people, some of whom may be living with dementia. On the day of our inspection, there were 46 people living at the home.

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.

We found that there were continuing issues regarding the governance and quality monitoring of the service. The provider's quality monitoring did not always identify shortfalls in the provision of care to people, and when it did, did not identify actions that needed to be taken. The registered manager did not have a full understanding of their responsibilities and had not always taken the required actions. We have told the provider that they need to make improvements in the way the service is led and monitored.

Medicines were not always managed safely. On the day of our inspection, there was an avoidable delay in people receiving their medicines on time. There was a lack of guidance about how medicines for occasional use, to assist people who were distressed or anxious were used.

Records of when people received their medicines were incomplete and the registered managers systems to check this was not effective. Peoples preferences about how they liked to take their medicines were not documented, and any allergies and sensitivity’s to medicines were wrongly documented. There were numerical discrepancies of medicines and systems to account for them were not being used accurately.

Not all staff had completed training to support them in recognising and responding to suspicions that people might be at risk of harm. However, most knew what was expected of them and how they should report any concerns. The registered manager did not always identify and take action to manage situations that placed people at risk.

Not all staff had received the training they needed in order to meet people's needs. Training that the provider had identified as mandatory had not been completed by all staff.

People did not always receive the care and support they needed to eat their meals in a pleasant and timely way. Staff did not always know what assistance people needed, or support people in an appropriate way.

People received support from staff who were mainly kind and caring. However, people were not always treated with dignity and respect because staff were task focussed and care took place in a manner that was hurried with little or no interaction.

Improvements had been made to identify peoples preferences about the way they wanted their care delivered. The way in which these were recorded and presented had also improved which meant staff found them easier to use. Interests, hobbies and backgrounds were not always taken into account. There was a lack of activities to meet people’s preferences. People were bored, isolated and unstimulated.

People and their visitors knew who they needed to go to if they needed to make a complaint. However, most found approaching the manager to be difficult.

Downham Grange provides accommodation and care to a maximum of 62 older people, some of whom may be living with dementia. It is able to deliver nursing care to people using the service. When our inspection started, there were 58 people using the service.

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.

There were shortfalls in the safety of the service because not enough suitable and competent staff were always properly deployed. People sometimes experienced significant delays before staff were available to assist them with the care they required. Risks to individuals were assessed but staff were not always available to address these. We have told the provider that they need to make improvements to ensure people's safety.

Medicines were not always managed safely. Whilst the majority of people received their medicines at the appropriate time, there was a lack of guidance about how medicines for occasional use, to assist people who were distressed or anxious, were to be used. Insulin administration was not always consistent and there was a lack of guidance for nursing staff to support them with this. There was an audit process in place. However, this was partially compromised as balances in stock at the beginning of each month were not always clearly recorded. We have told the provider they need to make improvements in this area to ensure that people receive safe care and treatment.

Not all staff had completed training to support them in recognising and responding to suspicions that people might be being abused. However, most knew what was expected of them and how they should report any concerns to contribute to people's safety.

The service people received was not always effective. Significant numbers of staff had not been properly trained to understand how they should support people who could not make decisions for themselves. There were inconsistencies in the way people's capacity to make decisions was assessed to demonstrate that their rights were protected. Staff were unclear who was subject to any authorised restrictions on their freedom and the manager was unable to clarify this at inspection. We have told the provider that they need to make improvements to ensure consent to care and treatment is properly and lawfully obtained.

Mandatory staff training and induction was not always completed promptly so that staff had consistent underpinning knowledge about their roles and how to support people well. The provider had identified this as an area needing to improve and had a plan to address shortfalls.

People did not always receive prompt and appropriate assistance to eat their meals and drink enough. The mealtime experience was not always as pleasant as it could be in encouraging people to eat. Staff took action to ensure people's health needs were referred for professional advice where necessary.

People received support from staff who were largely kind and compassionate. However, they were not always available to intervene promptly when people needed support and sometimes people's dignity and privacy was compromised. We have told the provider they need to make improvements in this area.

People's needs and preferences about the way they wanted their care delivered were not always acted upon. Their interests, hobbies and backgrounds were not always taken into account. There was a lack of activities to meet people's preferences. We have told the provider that they need to make improvements in the way the service responds to people’s needs and wishes. The manager was recruiting staff specifically to assist with activities.

People and their visitors were not always confident they knew who to go to if they had complaints about their care, or that these would be resolved promptly where practicable.

The service people received was not well organised. Duty rosters were poorly structured and information was conflicting about the numbers of staff on duty. Staff morale was affected and team spirit and cooperation varied. Although there were systems for checking the quality of the service, these were not always effectively applied and improvements that had been identified as needed were not always made and sustained. We have told the provider that they need to make improvements in the way the service is led and monitored.

You can see the action we have asked the provider to take at the back of the full version of this report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. It is based on our observations during the inspection, speaking with people who used the service; the staff supporting them and from looking at a range of records.

SAFE

We found that medicines were managed well and that people received their medication safely, and as prescribed by their GP. Equipment at the home was regularly maintained and serviced to ensure its safety for people. Each person had a personal evacuation plan in place to that they could be moved effectively in the event of an emergency.

However we found that the home's recruitment practices were not robust and some staff had been employed with unsuitable references. Although staff had received recent training in the Mental Capacity Act, we found their knowledge of its practical application was limited and they were unable to identify when a person might need safeguards in place to protect their liberty.

We saw that a number of staff had long, and sometimes painted, nails. This not only compromised good hand hygiene, but also posed a risk of injury to people. We saw staff carrying soiled laundry in their arms, rather than putting it in laundry bins to reduce the spread of infection. Not all night staff had received relevant training in first aid to ensure they could deal with a medical emergency if required.

EFFECTIVE

We found that people's health was regularly monitored to identify changes to their needs and that they were supported to see a range of health care professionals to maintain their well-being. People's needs had been regularly reviewed by staff. However, health care professionals we spoke felt that staff did not always have the relevant skills to look after nursing patients appropriately. The monitoring of people's fluid intake was poor, as were observation checks of their well-being at night.

Activities at the home for people to enjoy were limited and were not provided on a daily basis to ensure people were stimulated and entertained.

CARING

We observed positive interaction between staff and people using the service on the day of our inspection. Most people told us that staff treated them in a way that they liked, and that their decisions were respected by them. Relatives we spoke with reported the staff were caring and respectful toward their family member and spoke to them appropriately. The also told us that staff were good at keeping them up to date about what was happening with their family member. One relative stated, 'They always ring if mum has a funny turn, they're very caring that way'. Another stated, 'The staff seem to genuinely love my mother, she can be awkward at times but they take it in their stride'

However we witnessed several instances where staff just walked into people's bedroom without knocking, or asking if it was alright for them to enter. On one occasion this was when we were having a confidential conversation with someone about staff's behaviour towards them. During our inspection one relative told us that her husband had overheard two members of staff arguing outside his door, which he had found inappropriate and inconsiderate.

RESPONSIVE

We noted many aspects of the home's environment that were responsive to the needs of people with dementia. There was dementia friendly signage throughout the home to help people identify their bedroom and key locations such as toilets and bathrooms. Corridor walls were decorated with reminiscence objects to create an interesting and stimulating environment for people We received particularly positive comments about the home's administrator who was described as efficient, helpful and who responded to people's requests quickly and efficiently.

People were involved in the assessment and planning for their end of life care, and were able to make choices and decisions about their preferred options. However they were not actively involved in reviewing their care plans so that they could contribute to decisions about their care and welfare.

Staffing levels at the home were not enough to ensure that people's needs were met in a timely way. It was not clear how staffing levels were assessed and monitored to ensure they were sufficient to meet people's needs.

WELL-LED

Prior to our inspection we had received a number of concerns from visiting health care professionals about the leadership in the home and its lack of responsiveness when they had raised their concerns. We received mixed views from staff about the leadership of the home, some felt well supported by the management team but others felt that their concerns, especially around staffing levels, had not been listened to. Poor morale had been raised as an issue in the latest staff survey and also during our inspection.

Many of the themes such as poor staffing levels, a lack of activities and relatives not being involved in care planning that people who lived at the home and their relatives had raised in July 2013 still remained an area of concern during our visit. The manager had not been effective in addressing these issues or in bringing in the improvements needed.

The manager conducted a number of monthly audits to assess the service, but these had not identified many of the shortfalls we found during our inspection. The stability of the home's staffing was a concern. At the time of our inspection the home was without a clinical lead nurse and a number of staff had left or had been dismissed.

We found that the needs and welfare of people living in the home were being met. Members of staff, people living in the home and a visitor told us that at times there was a need for more staff to be on duty. One regular visitor to the home said that this was often the case at meal times when people may need some assistance.

People living in the home told us they felt cared for and that staff were available when they needed any assistance or care. During this inspection we found a calm environment with a staff team on duty that knew and understood the individual needs of people living in the home.

People's health and welfare was maintained with appointments being made with healthcare professionals, as was necessary. We saw that care plans were current and had been updated regularly. This meant that people could be assured that staff would provide the appropriate assistance.

We saw there were menu options for people at each meal time and that the dining experience was a calm and social event. Records showed us that staff monitored the nutrition of people and ensured their continued health was maintained.

The building at Downham Grange had been purpose built and we saw that the last stages of the build were currently in progress. The building had been fully risk assessed and the plans ensured the continued safety of people living in the home while the building work was being undertaken. All bed rooms now have an en-suite bathroom and people have a choice of which type of bathroom they use.

We spoke with three members of staff and reviewed four staff files. We found there were appropriate checks completed before any new members of staff started working in the home.

People told us they felt safe and no-one we spoke with had any concerns about the way they were treated. One person commented, 'The staff are all nice; I don't feel uncomfortable with anyone.' Staff received training to help them to recognise and respond to any suspected abuse.

Staff received regular training in a range of topics relating to the health, safety and welfare of the people using the service. One person told us, 'I don't know what training the staff have to do but the end result is good.' Staff told us that senior staff supported them to carry out their role.

People were consulted about things that were happening in the home. They, their family and friends had opportunities to comment about the service they received and make suggestions for improvements. Staff and visiting professionals were also asked for their views about how the home was run.