Downs View Care Centre

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 promoted an open and proactive safety culture. Staff raised concerns, reported incidents and used learning to improve practice. Following an incident where a person left the building unnoticed, learning was shared with the team, relatives were informed, and additional measures were put in place to reduce future risk. Staff told us learning was regularly shared through meetings and supervision.

The provider worked with people and healthcare partners to maintain safe systems of care and consistently monitor safety. Transitions between services were well managed. A relative told us their family member’s move from respite to a long‑term stay was “smooth,” and another said they were encouraged to share personal information to help staff understand the person’s needs. Staff told us assessments were completed before admission and used to help them get to know people on arrival.

The provider worked closely with people and healthcare partners to understand what safety meant to each individual and how it could best be achieved. Staff shared concerns promptly and monitored safeguarding issues effectively. Staff demonstrated a clear awareness of how to recognise changes in people’s emotional wellbeing, including distress reactions, as potential indicators of safeguarding concerns.

Staff had completed safeguarding training and understood their responsibilities. The provider worked collaboratively with social workers and other professionals to ensure safeguarding actions were appropriate, timely, and effective. The provider had safeguarding policies in place that were aligned with best practice guidance.

The provider worked with people to understand and manage risks in a holistic, person‑centred way. Staff delivered safe and supportive care while enabling people to continue with activities that were important to them. People were able to move freely around the home and garden areas. One person told us, “I go out in the garden for fresh air a lot; they have very nice gardens here.”

Care plans contained clear guidance to support staff in effectively managing identified risks. For example, people identified as being at risk of choking had their food and drink modified in line with the IDDSI (International Dysphagia Diet Standardisation Initiative) framework. This helped to reduce the risk of choking and supported safer eating and drinking.

The provider did not always identify or manage environmental risks effectively, and equipment and facilities did not consistently support safe care. For example, a hot food trolley containing hot water was stored in the communal dining area and was easily accessible, presenting a burns risk. This was highlighted on the day of inspection, and leaders took immediate action to put measures in place to reduce the risk of harm while longer‑term storage options were reviewed. As a result, systems to identify and address environmental risks were not always effective, increasing the potential for harm.

However, the provider had the required safety certificates in place, including fire safety systems, legionella testing, and other relevant building control certificates.

The provider ensured there were enough skilled and experienced staff, and staff worked together to deliver safe care. Relatives told us staffing levels were generally acceptable and that familiar staff supported continuity; however, some reported the home appeared short staffed at times, particularly during busy periods such as mealtimes or at weekends. On the day of the inspection, staffing levels appeared sufficient.

We identified gaps in training for care staff, including dementia awareness, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). The nominated individual acknowledged these gaps and told us actions were already underway to support the timely completion of outstanding training. These shortfalls increased the risk of staff not having the knowledge and skills to support people living with dementia effectively. However a new training programme was being implemented to better support senior staff in their roles and responsibilities, and a supervision schedule was in place for the year.

The provider assessed and managed the risk of infection effectively. They took steps to detect and control the spread of infection and shared any concerns promptly with the appropriate agencies. We observed domestic staff working throughout the home and maintaining a good standard of cleanliness.

We identified that 3 PPE (Personal Protective Equipment) stations did not have disposable aprons available; however, this was addressed immediately once raised, and stock was replenished. Staff were seen using PPE appropriately during mealtimes and prompted people to wash their hands after touching animals visiting the home. The kitchen had a ‘5’ food hygiene rating, and the home smelt clean and fresh throughout. One person told us, “Everything is beautifully clean.”

The provider did not always ensure medicines were managed safely or in line with people’s needs and preferences, and people were not always involved in planning their medicines support. Medicines were stored securely and administered as prescribed using an electronic medicines administration (eMAR) system. However, medicine fridge temperatures were not always maintained within the required temperature range, which may have affected the effectiveness of some medicines. This had not been identifiedand rectified prior to our inspection.

Medicine care plans and guidance for ‘when required’ medicines were in place, but these did not always clearly describe people’s individual preferences or the way they preferred or needed medicines to be administered. This meant that staff did not always have access to detailed information to support the safe management of medicines in line with people’s individual needs and preferences. A medicines policy was in place, alongside processes to report and investigate medicine‑related incidents. Staff also completed medicines management audits to identify gaps and support improvement.