Downing House

•The provider ensured that Covid-19 policies and procedures were frequently reviewed and updated in light of government changes.

•All staff received specialist training so that they understood how to prevent the spread of the Covid-19 virus and were supervised and monitored to ensure guidelines were followed.

•The cleaning schedule for the home was reviewed and domestic staff hours increased. Monitoring of cleaning was robust, and improvements made if required.

•Procedures for people entering the home, including new admissions or those returning from hospital, kept people safe. The procedures included completing a lateral flow Covid-19 test, having a temperature check, hand cleansing the donning of personal protective equipment (PPE) and a period of isolation. The isolation depended on the reason for entering the home, for example, until the test result was apparent for a visitor or 10 days for a new admission.

•Action was taken to keep friends and families in touch and regular video and phone calls were facilitated. The service demonstrated compassion and had risk assessed and enabled very limited visiting for a small number of people who had been particularly poorly.

•Staff and people were regularly tested in line with government current COVID-`19 testing program and people had received Covid-19 vaccinations in line with the Government mass-vaccination programme.

We found the following example of good practice.

The provider had developed, and employed at Downing House, a new post of Covid-19 Administrator, whose main responsibility was to take the lead in organising, completing and recording COVID-19 tests and test results. This was working effectively at Downing House.

Further information is in the detailed findings below.

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

People told us they felt safe and risks to people’s health and safety were managed well. People’s needs were met safely with appropriate staffing levels and well trained staff. People were supported by staff who understood how to identify and report potential abuse. Medicines were managed so people received their medicines as prescribed. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again. Checks were carried out on new staff to ensure they were suitable to work in the home. Infection control was well managed and the home was clean and free from hazards.

People were offered choices around their meals and maintained a well-balanced diet. People were fully involved in helping to shape menus. People received access to health care services when required. Various professionals were involved when necessary to meet people’s changing needs and to make sure people remained healthy. Improvements had been made to the environment with some new décor and brighter lighting. A room previously used as a bedroom had been turned into a quiet lounge.

Staff promoted positive, caring relationships with the people who lived at the service. The staff knew people well and were kind and caring. Staff planned and provided care to meet people's needs and to take account of their preferences. Staff respected people’s privacy and dignity and promoted independence, equality and diversity. There was no discrimination in the service. People and their relatives were involved in the planning and delivery of their care.

People's care plans were individualised and staff adopted a person-centred approach with the delivery of care. People had access to a range of activities and told us they enjoyed these. The registered manager was looking to appoint a new activities co-ordinator and to develop activities further. People and their relatives were confident to raise issues and concerns. Complaints procedures were effective. The service sought feedback to help maintain and improve standards of care. People's wishes regarding their end of life care were explored and documented, so these could be addressed at the appropriate time.

There was extremely positive leadership in the service. People, relatives and staff spoke highly of the registered manager. They described the registered manager as caring and approachable. Audits and monitoring procedures were used effectively to manage the service and to make improvements where needed. The registered manager made best use of networks and resources available to care homes, such as Skills for Care, and incorporated advice and guidance into staff practice.

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 24 December 2018).

Why we inspected

This was a planned inspection based on the previous rating.

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

Downing House is registered to provide accommodation and care for up to 25 older people, some of whom were living with dementia. The home is situated in a residential area of Withington, Manchester and is close to shops, public transport and the motorway network. At the time of this inspection, there were 21 people living at the service.

We last inspected Downing House in March 2018. At that inspection, we found multiple breaches of regulations. The service was rated inadequate in the safe, responsive and well-led key questions, rated requires improvement in the effective and caring key questions and therefore rated inadequate overall. We issued two warning notices with regards to the lack of evidence to demonstrate ‘Safe Care and Treatment’ and ‘Good Governance’. At this inspection we found no regulatory breaches and improvements had been made in each of the key questions previously rated inadequate, namely safe, responsive and well-led.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective and well led to at least good. The provider submitted an action plan and also produced an internal service improvement plan that was updated and shared with CQC at regular intervals.

At the time of this inspection a new manager was in place at Downing House. They had been appointed to the post in August 2018 and were in the process of applying for registration with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

There were effective and established systems in place to safeguard people from abuse and individual risk was now assessed and reviewed. Accidents and incidents were recorded and appropriate actions taken, although further analysis of these was required.

Medicines management and administration processes were reviewed during the inspection and found to be safe. A new medicines fridge was ordered during the inspection so that medicines were stored within the acceptable temperature range.

Improvements had been made which sought to ensure the service was working within the principles of the Mental Capacity Act (MCA) 2005. New care planning documentation had been introduced, including consent to treatment and personal care; there was evidence of the home raising and participating in best interest’s decisions and the wider staff group had completed specific MCA training.

Recruitment practices were safe and records confirmed this. Newly recruited care workers received an induction, although the delay in new starters accessing e-learning training on line was noted and discussed with the manager. Training was provided on a regular basis and updated when relevant.

We observed the mealtime experience and found this to be relaxed and well organised. People received any help, support and encouragement they required to eat and drink promptly.

Through our observations of staff interacting with people and from conversations with staff, it was clear that they knew the people they provided care for. They understood people's preferences, likes and dislikes.

People's needs were assessed before they moved to the home and care plans were in place to inform staff of their needs and how they should be met. Staff worked with other health care professionals to maintain people's health and wellbeing.

People’s care plans had improved and were person-centred and comprehensive and information was readily accessible to staff. There were plans to introduce a one-page profile that provided key information about the person. Reviews of care were in place but there was little evidence to support that people or their relatives had been involved in this.

Quality assurance practices were established. Information in relation to accident and incidents, complaints, training and recruitment were all reported centrally, however some processes needed to be more robust so that the local management team at the home were aware where improvements were required.

Following the last inspection, the service had designed a service improvement plan to address all the issues identified. Regular updates to this had been shared with CQC and the provider was transparent with the aspects of the service that had been addressed, completed and those which were ongoing.

The manager chose to leave the service shortly after this inspection and not to progress with their registration. The provider assured us that they were committed to improving the quality and safety of care provided at Downing House to Good and would look to recruit a manager as soon as possible, with continued oversight and support from area managers of the Abbeyfield Society group.

Downing House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

When we completed our previous inspection on 1 and 2 August 2017 we found the registered provider had not taken appropriate steps to ensure care provision was appropriate for people and care plans accurately reflected the current needs of people, equipment was not maintained, accidents and incidents were not analysed, regular checks of aspects of the home’s fire protection systems were not always taking place and systems to assess, monitor and improve the quality and safety of services provided to people at Downing House were not robust. We told the registered provider they needed to take action; we received an action plan. The purpose of this inspection was to see if improvements had been made and to review the quality of the service currently being provided for people. We also wanted to look to make sure people were safe following a recent incident.

At the inspection on 9 March 2018 we found some areas had improved, which included checks of the home’s fire system and the provision of care was appropriate. Although, we found people’s care plans had not been sufficiently updated, some areas of risk, medication management and infection control were not well managed. The programme to assess, monitor and improve the quality of the service was not robust or always effective.

At the time of our inspection the home had a registered manager in place who had been registered since 17 October 2017. Although we did note a further two people were still registered with CQC as manager. We spoke with the current registered manager who told the business manager was in the process of addressing this. 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.

Risks to people were not well managed and some areas of the premises did not comply with current Health and Safety guidance. We saw some bath and shower rooms were not clean and effective systems were not in place to reduce the risk and spread of infection.

People were not protected against the risks associated with medicines as appropriate arrangements were not in place to manage medicines safely. Staff had not had their competency assessed to administer medicines.

Quality assurance systems were not working well and were not effective to ensured people received safe quality care. People had the opportunity to comment on the quality of service through meetings.

There were sufficient staff on the day of our inspection, although, we noted the numbers of staff on some shifts were not at the levels stated by the registered manager. The registered provider had effective recruitment procedures in place. We received mixed views about feeling supported by the registered manager and staff did not always receive appropriate training and ongoing supervision.

Staff could describe signs that may indicate someone was at risk of abuse or harm, although, some staff had not received safeguarding training.

The principles of the Mental Capacity Act 2005 were applied. Although, some care plans did not contain a comprehensive set of mental capacity assessments. DoLS applications were not made timely following the completion of some of the mental capacity assessments.

People looked well care for and people and relatives we spoke with were happy with the care provided. The manager explained they provided a person-centred approach to end of life care.

Care plans we sampled did not always reflect the involvement of the person or their family members in their development. We observed people’s privacy and dignity was respected. People’s care plans did not always contain sufficient and relevant information to provide consistent, care and support.

People received good support which ensured their nutritional and health care needs were met. Activities and daily pastimes were available, although, limited when the activity co-ordinator was not at work.

Relatives and staff we spoke with were happy speaking with the registered manager if they needed to discuss any concerns. However, acknowledgements and detailed final outcomes had not been sent to the complainant and the service could not evidence complaint response timescales were being met.

Further work was required by the registered manager to be compliant with Accessible Information Standard.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. You can see the action we have told the provider to take at the end of this report.

This was an unannounced inspection carried out on the 1 and 2 August 2017 and at the time of inspection there were 22 people using the service, one of whom was on respite at the home. The service was last inspected in May 2016 and was found to require improvement.

At the last inspection the registered manager had not been in post long. We saw at this inspection that they had recently left the service and a new registered manager had been appointed in June 2017. The new registered manager was not available at the time of this inspection so we dealt with the deputy manager, a senior care worker and the business manager.

The service had been without a registered manager for approximately one month. Prior to this inspection we checked whether the new registered manager had submitted the necessary application to CQC to register as a manager. We saw that they had and this process was ongoing. 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.

People living at Downing House told us they felt safe however we found occasions when their safety was compromised. People’s safety was not protected. A poorly maintained piece of equipment was in use and regular checks to the home’s fire protection system had not been undertaken.

The correct protocols were in place with regards to the receipt, storage and disposal of medicines, including controlled drugs. There were protocols in place for people who were prescribed a time specific medicine however protocols were not in place for all PRN medicines

Recruitment of staff was safe and appropriate checks had been made. Staff understood what action they should take if they were concerned that someone was at risk from harm. Staff were supported to keep people safe through appropriate training in areas such as safeguarding and moving and handling training. There were robust processes and systems in place when dealing with residents’ finances and people were protected from possible financial abuse.

Applications had been made for DoLS as required and best interest decisions were documented. The service was acting in people’s best interests and adhering to the principles of the MCA.

The kitchen area was clean and tidy and we saw the service had been awarded five stars out of a possible five during their most recent food hygiene inspection.

The cook was knowledgeable about how to prepare foods for those with swallowing problems and how to fortify food and fluids for those individuals who needed to gain weight.

The communal areas of the home were quite small and the lounge got very busy during the day. People using the service had varying needs but staff told us these needs were increasing and people were less independent. We brought the lack of space to the business manager’s attention, particularly as the home was not full at the time of the inspection.

Feedback about the service and staff from other health professionals was complimentary. We saw that when necessary people had access to appropriate healthcare professionals however, we identified referrals to the falls clinic had not happened for two people who had experienced a number of falls.

A person’s dignity was potentially compromised as health professionals administered an injection whilst they were sat in the communal area. It was not clear from notes made if the person receiving the injection and other residents in the lounge had consented to this.Staff did not offer the privacy of the person’s bedroom or an alternative private space.

Staff recognised the importance of letting people be independent where possible and when safe for the individual.

An incident occurred in the dining room on the second day of our inspection. No harm was caused to the person who slipped from a wheelchair. Staff acted calmly and dealt with the incident professionally, treating the person with dignity and respect.

The service supported people with their end of life care and ensured their wishes were upheld whenever possible.

Care plans had not been reviewed in line with changes in need and not all care plans accurately reflected people’s support needs.

The home had not managed to recruit an activities co ordinator. Improvement was needed to ensure all people had an opportunity to pursue hobbies and interests which were important to them.

There was a formal complaints procedure in place and any complaints received were acted on appropriately. We saw examples of compliments in the form of thank you cards displayed on the noticeboard.

The registered manager was new in post, however we were not confident that they had received the right support to provide them with a good oversight of the quality of the service. Systems to assess, monitor and improve the quality and safety of services provided to people at Downing House were not robust enough.

The service did not have an effective way of monitoring and analysing accidents and incidents that occurred to help ensure people who had experienced a fall were protected from further harm.

Staff meetings occurred every three months. Staff felt comfortable in these meetings and were able to make suggestions of how to improve the service for the benefit of residents. Supervision of staff had slipped and was sporadic.

Notifications were submitted to CQC as required. The new registered manager understood their responsibilities with regards to this aspect.

We found three breaches in the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, person centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Downing House is located in Withington, Manchester. The home provides residential care and support for up to 23 people, some of whom are living with dementia. At the time of this inspection there were 22 people living at the home.

The service had a registered manager. 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.

The registered manager had been in post for approximately eight months but was already well respected by people using the service and staff. They were described as open and approachable and keen to listen to people's views. People said they could make suggestions and would be comfortable to make a complaint if they needed to.

There was a stable staff team who people told us were kind and caring. People felt safe at the home and with the staff who supported them. Staff showed patience and kindness when they assisted people.

There were sufficient numbers of staff to meet people's needs safely but staff said they would like more time to be able to ‘chat’ to people in a meaningful way. The home was suitably staffed to meet people's needs. Recruitment was done correctly and the service had a disciplinary procedure in place.

Staff told us and the registered manager confirmed more training was needed in relation to dementia care so that better support could be offered to people who were living with dementia.

Staff liaised with healthcare professions to make sure people received prompt care and treatment to meet their physical and mental health needs.

People had their nutritional needs assessed and were provided with a diet which met their preferences. There was mixed feedback about the food but people told us there was always a choice of meals and they had enough of it.

Care and support was personalised to each individual to enable people to maintain their own routines. Staff had a good knowledge of each person which enabled them to provide care in manner that respected their wishes and preferences. Staff sought people's consent before carrying out any care and knew what to do if people lacked the mental capacity to make a decision.

People's independence was promoted and risk assessments were carried out to enable people to take part in activities and receive their care safely. There was a variety of organised activities which people could join in with or they could choose to pursue their own interests and hobbies. More stimulation was needed for people who were living with dementia.

We found improvement was needed to ensure each person had an opportunity to engage in meaningful and stimulating conversations or activities. We recommended the home accessed best practice guidance to promote the health and wellbeing of people who were living with dementia.

People received their medicines safely from staff who had received specialist training in this area and were offered prescribed pain relief regularly to maintain their comfort.

One inspector carried out the inspection. We considered all the evidence we had gathered under the outcomes we inspected. 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 saw people were being cared for in an environment which was clean. Processes for the prevention and control of infection were in place. For health, safety and security reasons, visitors were asked to sign in and out. There were enough staff on duty to meet the needs of the people living at the home at the time of our visit.

The people we spoke with who used the service told us they felt safe. One person said 'I feel quite safe and I am looked after well.'

Discussion with staff and examination of records confirmed a programme of training was in place for all members of staff.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). The aim is to make sure people in care homes and hospitals are looked after in a way which does not restrict their freedom inappropriately. Staff had all received training about the Mental Capacity Act and Deprivation of Liberty Safeguards so they understood when an application should be made and how to submit one.

Is the service effective?

People's health, social and care needs were assessed with them and they were involved in writing and reviewing their care plans. Specialist needs had been identified in care plans, for example, mobility, sleep and nutrition. Care plans were reviewed every month and when people's needs changed.

The people we spoke with told us they were happy with the care they received and said their needs were met. They spoke positively about the staff who supported them. From what we saw and from speaking with staff it was clear they had a good understanding of the care and support needs of the people who used the service.

Is the service caring?

People we spoke with told us they liked living at the home. Comments included 'The staff are so caring' and 'Everyone is looked after here.'

We saw the staff showed patience and gave encouragement when they were supporting people so people were able to do things at their own pace and were not rushed.

In July 2014, the home had maintained its Gold rating from the local authority. The Bronze, Silver and Gold validation award is a rating given by the local authority based on meeting its quality criteria.

We saw evidence the home was working towards the Dignity in Care award from the local authority. Dignity in Care is a national initiative designed to put dignity and respect at the heart of care services to enable a positive experience of care.

Is the service responsive?

The records we saw confirmed people's preferences and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. People had access to activities which were important to them and had been supported to maintain relationships with their friends and relatives.

We saw evidence the home was working on the Six Steps programme. This is a care pathway designed to improve end of life care. It enables the supportive and palliative care needs of the patient and their family to be identified and met through the last phase of life and into bereavement.

Is the service well-led?

We saw documentary evidence which showed the service worked well with other agencies and services to make sure people received their care in a joined up way.

From speaking with staff we found they had a good understanding of the home's values. They told us about their roles and responsibilities and they were clear about these. We saw quality assurance processes were in place to make sure the provider monitored the care provided and made improvements where necessary. For example, people who used the service had the opportunity to express their opinions through meetings and questionnaires. One person told us 'We have meetings where they talk to us about what's going on.'

We observed the care provided and looked at supporting documentation. We spoke to six people who used the service, two members of staff, the registered manager and a relative.

Records showed that people's care needs had been assessed, planned, reviewed and delivered in line with their individual care plan. Each person had their own care plan and we found that people received care as detailed within their plan.

People we spoke with said their care needs had been met. Comments included, "I love this place," and "I'm very happy here".

There were systems in place to identify, assess and manage risks to people who used the

service. Risks to people's health and welfare were assessed and care was planned and delivered according to people's needs.

There was a robust policy and procedure in place to deal with any complaints.

The provider had effective record keeping systems which were fit for purpose.