Downside House

Downside House provides accommodation and personal care for up to 21 people, including people living with dementia care needs. At the time of our inspection there were 21 people living in the home.

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

People were happy living at Downside House and told us they felt safe.

Recruitment practices were safe and there were sufficient numbers of staff available to meet people’s needs. People were protected from avoidable harm, and infection control risks were managed appropriately.

Systems were in place to monitor incidents, accidents and near misses. There were clear processes in place to monitor risks to people which helped to ensure they received effective care to maintain their safety and wellbeing.

There were suitable systems in place to ensure that medicines were securely stored, ordered and disposed of safely and people received their medicines as prescribed.

Staff training had not always been updated in a timely way, however plans were in place to address this. Staff received regular supervision to help develop their skills and support them in their role.

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 were supported to access health and social care professionals if needed, received enough to eat and drink and were happy with the food provided.

People were supported by staff who were kind, compassionate and caring and who understood their likes, dislikes and preferences. People had detailed and accurate care plans in place which were person centred. People told us that they were provided with person centred care and fully involved in planning their care and the support they received.

People, relatives and staff were positive about the running of the service and the support they received from the management team and providers. People and staff felt there had been improvements in all aspects of the service since the last inspection.

The management team were open and transparent. They understood their regulatory responsibilities. People and their relatives said the management team were open, approachable and supportive. There were effective governance systems in place to identify concerns in the service and drive improvement.

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 21 December 2018) and there were three 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

There is no required follow up to this inspection. We will continue to monitor all information received about the service to understand any risks that may arise and to ensure the next inspection is scheduled accordingly.

This inspection took place on 9 and 11 October 2018 and was unannounced.

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. At the time of the inspection there was not a registered manager in place. The previous registered manager had left the service in June 2018. At this inspection there was a manager in place who had taken over the overall running of the service, with support from the directors of the provider's company. The manager had commenced the registration process with the Care Quality Commission (CQC).

Risks posed by equipment which could result in significant injury or harm to people had not been assessed or considered. Personal evacuation and escape plans which aimed to keep people safe in the event of a fire were not up to date.

People felt safe living at Downside House and staff knew how to identify, prevent and report abuse and had received training in this area. However, some staff had failed to ensure people were protected from receiving improper treatment.

Oral medicines were managed safely and administered in line with the prescribing instructions. However, systems in place to ensure topical creams were used safety were not effective and clear guidance in relation to when ‘as required’ medicines should be provided was not in place.

The principles of the Mental Capacity Act 2005 were not being followed to ensure people were only cared for with consent; capacity assessments had not always been completed and best interest decisions were not in place for all people that required them.

The systems and processes in place to monitor the quality and safety of the service, were not always robust. There were a number of audits in place to check the quality and safety of the service, however, some of these were not always effective in identifying concerns. People, their families and staff had the opportunity to become involved in developing the service. However, actions were not always taken in a timely way when themes for improvements had been identified.

Staff supported people to be independent; however, changes to the environment had not been implemented to help people further increase their abilities to complete tasks without full support.

There were enough staff to meet people's needs in a timely way and staff were able to support people in a relaxed and unhurried way. People received care from staff who had received an induction into their role, who were competent and suitably trained. However, staff were not consistently supported in their roles as per the provider’s policy.

There was not always a person-centred approach to care and for some people their views and wishes had not always been considered. People’s care files contained individual information about their physical and psychological needs and provided staff with guidance on how people should be supported and what they could do for themselves. However, we found that information for some people about their preferences, likes and dislikes and life history was insufficient.

People were supported to have enough to eat and drink and had access to health professionals and other specialists if they needed them. Procedures were in place to help ensure that people received consistent support when they moved between services.

Staff worked in partnership with health and social care professionals to provide them with the opportunity to share knowledge and ideas with others to aid the delivery of effective care.

People and their families were positive about the care received. Staff had developed caring and positive relationships with people. Staff protected people's privacy and responded promptly when people's needs changed.

People received mental and physical stimulation and had access to a range of activities. Staff supported people to meet their cultural and religious needs.

The directors of the provider’s company were fully engaged in running the service and their vision and values were clear and understood by staff. There were processes in place to deal with any complaints or concerns.

The home was clean and there were systems in place to protect people from the risk of infection.

At this inspection we found the service to be in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

There was a registered manager in place. 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.

Most risks to people’s safety had been assessed and were being managed appropriately. However, we found risk assessment had not been conducted for people at risk of pressure injuries and there was no process in place to make sure that special pressure-reducing mattresses were kept at the correct setting.

People and their relatives praised the quality of care delivered with end of life care, in particular, being highlighted. Feedback from a family member described this as “tender, tactile, sensitive and sincere”. They said their relative had received a “calm, dignified and comfortable” death. One doctor told us “Downside has the best end-of-life care that anyone could wish for.” Another doctor described it as “exemplary”. Staff also supported relatives of the person dying with empathy and understanding.

Staff showed commitment to people’s well-being by going ‘the extra mile’, for example by taking them to events in their off-duty time. These included shopping, visits to coffee shops and trips to local attractions. Without exception, all the interactions we observed between people and staff were positive. Staff knew people very well and built positive relationships with them.

People felt safe living at Downside House. Staff knew how to identify, prevent and report incidents of abuse. An innovative solution, using a bead curtain, had been found to prevent a person from entering another’s room and putting themselves at risk.

Medicines were managed safely by staff who were suitably trained. The home was clean and there were appropriate arrangements in place for preventing and managing the risk and spread of infection. Plans were in place to deal with foreseeable emergencies.

Recruitment practices were safe. There were enough staff deployed to meet people’s needs. Staff had received relevant training and were supported in their work through one-to-one sessions of supervision and appraisal.

Staff sought consent from people before providing care and support. The ability of people to make decisions was assessed in line with legal requirements to ensure their rights were protected and their liberty was not restricted unlawfully. Decisions were taken in the best interests of people.

People enjoyed the meals and were supported appropriately to eat and drink enough. The home was taking part in a pilot project to prevent unnecessary admissions to hospital. This had help ensure people received prompt medical attention when needed.

Care and support were delivered in a personalised and flexible way. People were supported to make choices. Their privacy and dignity were respected at all times. The provider sought and acted on feedback from people and there was an appropriate complaints policy in place.

People and their relatives told us the home was run well. There was an open and transparent culture. Visitors were welcomed, staff enjoyed good working relationships with external professionals and there were strong links with the local community.

There was a clear management structure in place. Staff understood their roles and worked well as a team. Staff described managers was “approachable” and “supportive”. This had contributed to a low level of staff turnover which meant people were cared for by a consistent team of staff who knew them well.

During this inspection we found the necessary improvements had been made. We considered all the evidence we had gathered under the outcomes we inspected. We spoke with two people who use the service, the manager and five members of staff. We looked at medication administration records and records relating to the management of the service.

We looked at the areas of infection control, management of medicines and quality assurance. We used the information to answer the questions we always ask;

' Is the service safe?

' Is the service well-led?

This is a summary of what we found:

Is the service safe?

We found the service was safe.

Appropriate arrangements had been put in place to manage infection control risks. Staff had received training, used protective equipment when necessary and followed best practice guidance when handling soiled linen. The provider had a suitable infection control policy in place and a recent audit showed procedures were working effectively.

Medicines were managed safely. All prescribed medicines were in stock, were stored securely and records showed they had been administered as prescribed. Weekly audits were conducted by a senior member of staff and were effective in identifying any discrepancies.

Is the service well-led?

We found the service was well-led.

The provider obtained people's views by completing an annual survey. This showed people were satisfied with the level of care provided and people's comments had been used to improve the service. Staff were also encouraged to make suggestions for improvement.

The provider had an effective system in place to regularly assess and monitor the quality of service people received. A range of audits was conducted and these were used to maintain standards. Risks to the health, safety and welfare of people were managed effectively.

During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We spoke with four people who use the service, three family members of people who were unable to communicate with us due to their mental frailty and six members of staff. We looked at three care plans and records relating to the management of the service. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We looked at the areas of respecting and involving people who used the service, care and welfare, infection control, management of medicines, staffing and quality assurance. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found:

Is the service safe?

We found not all aspects of the service were safe.

Infection control guidance was not always followed. The sluice room and some bedding were not clean. Not all staff were aware of how to process dirty linen safely and one of the cleaners had not received training in infection control.

Medicines were not always managed safely. The provider was unable to account for the use of some medication. The use of creams and ointments was not always recorded and there was no system in place to ensure they were not used beyond their shelf life.

The provider ensured there were sufficient staff with the right skills to meet people's needs. Risks were managed effectively and equipment required to manage risks, such as walking aids and pressure relieving cushions, was readily available.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service had policies and procedures in place in relation to Deprivation of Liberty Safeguards (DoLS). The registered manager was in the process of seeking a DoLS authorisation in respect of one person. This would ensure their human rights were protected.

Is the service effective?

The service was effective because people were cared for by staff who were knowledgeable about their needs and had the skills to provide appropriate care and support. People told us their needs were met consistently. One person said, 'I'm very happy with the care, they'll do anything for you.' A family member told us 'The care is very personalised; [the person] gets all the help they need.' Care records showed people had access to appropriate medical care, including GPs and chiropodists. People's needs were clearly known and met.

People had access to a choice of suitably nutritious meals. We spoke with the chef, who was aware of people's dietary needs and those who required their meals preparing in a specific way. For people at risk of malnutrition, we saw food and fluid charts were maintained and their weights were monitored appropriately.

A range of activities was provided by an activities coordinator and we saw people enjoying a ball game and a quiz. The home's garden had been made accessible to people with limited mobility. We saw this being used during our inspection.

Is the service caring?

We found the atmosphere at the home felt friendly and people were supported in a kind and caring way. One person said of the staff, 'They're very kind and they've helped build up my confidence.' Another person told us how staff prepared them for bed in a particular way that gave them 'great comfort'. They said, 'The staff are wonderful, they're more like friends.'

We observed care and support being provided in communal areas. Staff interacted positively with people, using people's preferred names and speaking with them in a calm and respectful way. They took time to sit and engage with people and understand their needs.

Is the service responsive?

The service was responsive to people's changing needs. We saw assessments were carried out before people moved to the home and their care plans were updated monthly. We spoke with a community health care professional who said of the staff, 'They're very good; they provide good, reliable information and follow through on recommendations we make.'

However, we found that decisions made in respect of people's ability to manage their own medication were made by staff based on information provided when the person was admitted to the home. No person living in the home at the time of our inspection was managing their own medication. Records did not show whether people had consented to these arrangements or that decisions had been taken in accordance with the Mental Capacity Act, 2005.

Is the service well-led?

We found not all aspects of the service were well-led.

There was a clear management structure in place, including a registered manager; the home benefited from an experienced management team and a low level of staff turnover.

We saw the provider obtained people's views by completing an annual survey. We looked at the questionnaires used for the latest survey, conducted in April 2013. Family members had also provided feedback. We saw people's comments had been used to make changes to the environment. The registered manager told us this survey was due to be completed again soon.

The provider took account of complaints and comments to improve the service. Records showed complaints were recorded, investigated and resolved in a timely way. Systems were in place to ensure lessons were learned from incidents.

The registered manager told us they monitored the service informally by working with staff and reviewing care plans. However, the provider was unable to demonstrate the effective operation of systems designed to monitor the quality of services provided. Audits of infection control and medication had not identified the concerns we found during our inspection. This meant people were not protected against the risks of inappropriate or unsafe care.

We found before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Records of care provided on a daily basis showed times when people had declined care and their wishes had been respected.

We looked at five care plans and related records of care. We saw these were comprehensive and person centred; they provided very clear, detailed information about how care and support should be delivered. People told us their needs were met consistently. One person said, 'The staff are wonderful, they are all so kind'. A family member told us 'The care is very good; they look after [my relative] well'.

People were cared for in a clean environment and personal protective equipment was used appropriately. However, infection control risk assessments and audits had not been completed. There were no hand decontamination facilities in the laundry room. Staff had not received infection control refresher training in accordance with the provider's policy.

The management of 'as required' medicines was not appropriate. There was no guidance about the use of sedatives and variable doses were not recorded. We found paracetamol and laxatives were not dispensed from each person's supply, as stock was shared communally. Guidance issued by the Royal Pharmaceutical Society was not being followed.

Appropriate checks were undertaken before staff began work and there were effective recruitment and selection processes in place. People's personal records including medical records were accurate and fit for purpose. They were kept securely and could be located promptly when needed.

We also spoke with a relative. They were very happy with the care that was provided at Downside House. They told us that they were fully involved in, and informed about, the care their relative was receiving and felt confident in the staff. We spoke with two health professional involved in the care of people. They were complimentary about the way the service met people's needs. We were told that the home contacted them appropriately and followed guidance and suggestions.

Everyone, people, relatives and other professionals, we spoke with confirmed that people's privacy and dignity was maintained at all times. We observed that staff were courteous and respectful of people's views and opinions and that dignity was respected. We saw that people were offered choices about meals, where they sat and activities.