Downham Grange

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. Although there had been some improvement, some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of the legal regulations in relation to people’s safe care and treatment and safe and effective staffing.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff we spoke with informed us how incidents within the service were investigated and any lessons learnt were shared between the teams and discussed in daily meetings.

People we spoke with knew who to raise safety concerns with, one relative we spoke with said “All my previous concerns have been dealt with adequately.” We reviewed the services processes for managing safety concerns and their complaints file. Partners who work alongside the service said “the service make timely and appropriate referrals to external partners”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff informed us of the admission process when people moved into Downham Grange, this was across all departments to evidence a collaboration between the different teams within the service.

We reviewed pre-admissions assessments and could see they were completed in full prior to a person being admitted. People we spoke with confirmed the admissions process was robust and people were at the centre of their care and support needs. They were given all relevant information and time to make their decisions. One person we spoke with said “On the second visit I saw the manager and she explained the cost and things I could be doing daily. As I made my decision, they did my pre-admission the same day”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We found systems and practices were not always effective and did not always protect people from avoidable harm and neglect.

The provider did not always share concerns quickly and appropriately. We reviewed the services processes on site, and we identified a safeguarding concern that the service was not aware of and had not been reported to the local authority or the care quality commission. The registered manager reported this retrospectively and checked their processes to be assured it was an isolated incident.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were not assured that all risk assessments were consistently robust or clear for staff to follow. Where people had made decisions about having bed rails on their beds, this was not always risk assessed appropriately, this could have put people at risk of harm by not assessing the risk of falls, entrapment or injury. People were risk assessed for having access to emollients within their room, however this was a generic risk assessment for a unit and not assessed on the risk to people’s individual needs.

Following our assessment, the manager addressed these shortfalls and reviewed other people’s care plans and created individual risk assessments. We spoke to staff, and they could inform us of people’s individual risks within the service and how they were supported to maintain their independence and be empowered

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment had recently been decorated and was bright and spacious and adaptions were installed to meet the needs of the people in the service. We reviewed the services processes and all environmental and building risk assessments and checks were carried out appropriately to ensure equipment was well maintained. This was echoed by speaking people in the service, 1 relative said “They never have anything in their way; they do not always want to use the walking frame but they hold on to the railing in the hallway”

The provider did not work together well to provide safe care that met people’s individual needs. We reviewed the services training records and we identified that staff were not always trained appropriately to meet the needs of people in the service in some areas. We reviewed the

services Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training, and it was not completed by all staff. 10 staff had either not completed the training or it was recorded no longer needed. Some people living in the service lacked mental capacity to make specific decisions and some people were able to make their own decisions. Staff were not trained to identify restrictive practice within the service to ensure people were supported in the least restrictive way. We identified falls prevention training was not completed by staff when it was appropriate to their job role, for example, support workers, senior support workers, registered nurses and unit managers had not completed this training; this increased people’s risk of harm.

We reviewed staff recruitment records and found recruitment records where staff were interviewed and scored poorly or it was identified that they may meet the job requirements with additional training and support, they were given the position, but no additional training or support was given. Instead, they completed the normal induction that all staff received. 1 staff member did not have adequate references on their file and the services internal audits failed to identify and risk assess this. We received a mixed response from people about the staffing levels.

However, we observed that there appeared to be a sufficient number of staff on shift and that

people did not wait long when they required assistance. Staff we spoke with felt they had



sufficient staff on to maintain a safe environment. All staff had regular supervisions and an annual appraisal.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was visibly clean and recently decorated. Equipment was in clean working order. Staff had access to appropriate protective personal equipment (PPE) and were using it when suitably when required.

People were happy with the infection control measures in the service, 1 person we spoke with said “They also clean my room very well. They do it how I like it to be cleaned, they pull out the bed and clean behind it. My laundry comes back every day.”

The provider did not always make sure that medicines and treatments were safe and met

people’s needs, capacities and preferences. Staff did not always involve people in planning.

There were some gaps in the information available to staff to be able to give people their medicines prescribed for occasional use at the discretion of staff (PRN medicines). Records did not always confirm that medicines such as insulin and medicated skin patches were administered to varying sites as appropriate on people’s bodies to avoid localised adverse effects. The provider said this was due to people in the service refusing the sites to being rotated, however failed to share this information with the relevant healthcare professionals and implement an appropriate risk assessment. Staff were regularly assessed as competent to manage and administer people’s medicines. People received regular reviews of their medicines by prescribers