Downs House

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 requires improvement. At this assessment the rating has changed to good.This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulations in relation to safe care and treatment and staffing. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

This service scored 75 (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.

During our previous inspection, we identified concerns relating to the management of falls, unsafe storage of thickeners, and fire risk when using emollients. In response, the provider had implemented robust systems for identifying, recording, and reporting safety incidents, including accidents and near misses. Staff were trained to recognise risks such as falls, and incidents were logged promptly and reported to the Care Quality Commission (CQC) when required. Management reviewed incidents regularly to identify trends and implement corrective actions, fostering a learning culture where staff felt confident to report issues.

The provider acted on national safety alerts, maintaining evidence of compliance through documented action plans and updated policies. Alerts on safe storage of thickeners led to secure storage and staff training, while guidance on fire risks from paraffin-based emollients resulted in revised fire safety procedures and resident clothing checks. These measures demonstrated best practice by ensuring timely reporting, proactive risk management, and continuous improvement to protect people’s health and safety.

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 regularly monitored people’s health and wellbeing, ensuring any changes in their condition were promptly identified and addressed. Records demonstrated staff worked well with the care team, GPs, community nurses, and physiotherapists to develop individualised care plans, including risk assessments for falls, mobility, and nutrition.

Continuity of care was maintained when people moved between services, such as when someone was admitted from hospital, staff ensured all relevant information, including care needs, and risk assessments, was received and reviewed. Staff supported people during hospital appointments and communicated any changes in health to the wider team to update care plans accordingly.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff demonstrated a strong understanding of safeguarding, including how to recognise and report abuse, neglect, or harm. They were confident in following correct procedures and knew how to escalate concerns to the manager, local authority, police, or CQC. An external professional commented positively, stating: ‘We come here very regularly, and I feel people are safe, the management team are getting better and more organised”.

The provider had safeguarding policies aligned with relevant legislation. Records confirmed any concerns were addressed promptly, with investigations carried out and notifications made to the police, local authority, and CQC when required.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to understand and manage risks in partnership with staff. Individualised risk assessments addressed areas such as mobility, falls, skin integrity, and other personal risks. We consistently observed staff involving people in discussions about risks related to their mobility, meals, activities and when going into the wider community.

Interventions were carefully balanced to promote independence while ensuring safety. Staff regularly reviewed risk management plans with people and, where appropriate, their relatives, to ensure these plans reflected what mattered most to each person.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During our previous inspection, concerns were noted regarding the management of environmental risks. At this inspection improvements had been made.

The unsecured window was made safe by locking the door and displaying clear signage to ensure it remained locked. Fire doors were fitted with alarms, and evacuation routes were cleared of any obstructions to maintain safe egress. Hazardous substances and storage areas were secured to prevent unauthorized access. These measures demonstrate the provider’s compliance with health and safety standards and their commitment to implementing immediate corrective actions.

At the time of this review, the provider was actively working on two outstanding requirements identified in the fire risk assessment, ensuring that these actions were incorporated into their ongoing safety improvement plan.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

During our previous inspection, we identified gaps in staff training, including safe medicines administration, dementia care, managing behaviours that may challenge, and core areas such as MCA, fire safety, infection control and health and safety. This meant people could have been cared for by staff without the necessary knowledge and skills to fulfill their roles.

At this inspection, we found that improvements had been made. Staff had received appropriate training through a combination of face-to-face sessions and e-learning, and records showed a marked reduction in gaps. Training in dementia care and non-medical interventions for agitation had been prioritised, reducing reliance on PRN medicines. The provider had an ongoing training plan in place, which was reviewed regularly to ensure staff maintained the required competencies. In addition, staff were subject to competency assessments relating to moving and handling and medication administration to confirm their practical skills aligned with training

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.

During the inspection, we observed good infection control practice by staff. Staff consistently wore the personal protective equipment (PPE) provided and used it appropriately. Clear guidance was displayed throughout the home to prompt good hygiene practices, including signage on the importance of handwashing. The environment was clean and well-maintained, and people and their relatives told us they were satisfied with the cleanliness of the home.

We identified several minor concerns during the inspection and discussed these with the provider and manager. The provider took immediate action to rectify these issues while we were on site.

Staff received appropriate training on hand hygiene and demonstrated a clear understanding of which cleaning products were safe to use. These actions provided additional assurance that infection prevention and control measures were being managed effectively and in line with best practice standards.

During our previous inspection, we identified concerns relating to the safe management of medicines and associated risks. These included issues with care planning, record-keeping, storage practices, and risk assessments, which could have placed people at risk of harm.

At this inspection, we found improvements had been made. Behavioural care plans were now in place to help support people using non-medical strategies before PRN medicines were considered. MAR charts were updated to include accurate and consistent instructions aligned with care plans, and prescription-specific directions were adhered to. Risk assessments for emollient use had been implemented, and medicines were stored within recommended temperature ranges. Allergy care plans were introduced for individuals at risk of anaphylaxis. Staff had received additional training on medicines management, and competency assessments were completed to ensure safe practice.

Allergy information was initially inconsistent across care and medication records; however, the manager acted immediately to correct this. A small number of missed doses and missing signatures were identified, and handwritten MAR entries were not always double-checked, which could increase the risk of error. Medication care plans remained generic and did not fully reflect individual preferences. Stock management processes required strengthening, as surplus medicines were noted. The manager arranged a GP and pharmacy review of ordering and disposal systems to address these issues.

Following our feedback, the provider took immediate action to address these concerns, scheduled additional medication training for staff, and implemented measures to improve governance and accuracy. We have since received evidence confirming these actions have been completed, with medication governance systems strengthened to ensure ongoing compliance and safety.