Downshire House

Downshire House is a residential care home without nursing, providing accommodation and personal care for up to 8 older people and younger adults living with a learning disability, autistic people, people living with mental health needs, dementia, sensory impairments and physical disabilities. At the time of our inspection there were 7 people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Staff understood and effectively delivered care and support in accordance with the principles and values of Registering the Right Support and other best practice guidance. This ensured that people who used the service lived as full a life as possible and achieved successful outcomes.

Right Support

People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. Staff had completed additional training on how to recognise and report abuse and they knew how to apply it.

Staff were focused on people’s strengths and promoted what they could do, so people experienced a fulfilling everyday life. Staff had completed training in relation to reducing restrictive practice and positive behaviour support.

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.

Staff enabled people to make decisions following best practice decision-making and communicated with people in ways that met their needs.

Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcomes. Staff supported people to play an active role in maintaining their own health and wellbeing.

Right Care

People received kind and compassionate care from staff who protected and respected their privacy and dignity. Staff understood and responded to people’s individual needs.

People’s support plans reflected their range of needs and promoted their wellbeing and enjoyment of life. Staff provided care to meet people’s needs and aspirations, focused on their quality of life, and followed best practice.

Staff had the necessary skills to understand people who had individual ways of communicating, using body language, sounds, pictures and symbols. We observed people were happy and relaxed when interacting and communicating with staff.

Right Culture

The ethos, values, attitudes and behaviours of the manager and staff ensured people led confident, inclusive and empowered lives.

People were supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities of autistic people and people living with a learning disability.

We observed people receiving care that was tailored to their individual needs.

Since the last inspection, staff turnover was low, which supported people to receive consistent care from staff who knew them well and placed their wishes, needs and rights at the heart of everything they did.

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 inadequate (report published 8 December 2022).

This service has been in Special Measures since 8 December 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 13 September 2022. 7 breaches of legal requirements were found. The provider completed an action plan after the last comprehensive inspection to show what they would do and by when to improve good governance, safe care and treatment, safeguarding service users from abuse and improper treatment, need for consent, staffing, fit and proper persons employed, duty of candour and notification of other incidents. The provider was served with 3 warning notices for breaches of regulation in relation to good governance, safeguarding service users from abuse and improper treatment and the need for consent.

We carried out an announced targeted inspection of this service on 31 March 2023, to check whether the warning notices we previously served in relation to safeguarding service users from abuse and improper treatment and the need for consent had been met. At that inspection we found, although some improvements had been made, the provider had not met the warning notices in full and therefore remained in breach of regulations and remained in special measures.

We undertook this focused inspection on 14 June 2023, to check they had followed their action plan and to confirm they now met legal requirements, including those subject to the three warning notices. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link on our website at www.cqc.org.uk.This inspection was prompted by a review of the information we held about this service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Downshire House is a residential care home without nursing, providing accommodation and personal care for up to 8 older people and younger adults living with a learning disability, autistic people, people living with mental health needs, dementia, sensory impairments and physical disabilities. At the time of our inspection there were 7 people using the service.

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

This was a targeted inspection to follow up 2 warning notices served at the previous inspection about safeguarding people from abuse and proper treatment and the need for consent. We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Based on our inspection of safe and effective, we found aspects of the warning notices had not been met to ensure improvements were made in specific areas to evidence compliance with the regulations.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the last inspection the service was unable to demonstrate how they were meeting the underpinning principles of ‘Right support, right care, right culture’. This had improved since the last inspection. However, the provider was still not able to demonstrate how they were meeting some of the underpinning principles of ‘Right support, right care, right culture’.

Right Support:

The provider could not be assured that people were supported to have maximum choice and control of their lives and that staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. All staff had not been trained to support people in the least restrictive way possible and in their best interests.

Right Care:

People’s care did not always promote their human rights. The service was not consistently working within the principles of the Mental Capacity Act (MCA). The provider’s policies and systems in did not always support this practice.

Right Culture:

Staff told us people and their families were supported to express their views and be actively involved in making decisions about their care, support and treatment as far as possible. However, the two record systems used by the provider did not record people’s or their representative’s involvement in the decision making process.

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 inadequate (report published 8 December 2022).

At the last inspection we served warning notices in respect of safeguarding people from abuse and improper treatment and the need for consent. At this inspection we found, although some improvements had been made, the provider had not met the warning notices in full and therefore remained in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulation 13 and Regulation 11 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

Enforcement

The provider remains in breach of regulations found at the last inspection. These relate to keeping people safe from potential abuse and obtaining lawful consent to their care.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions 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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

Downshire House is a residential care home without nursing, providing accommodation and personal care for up to eight older people and younger adults living with a learning disability, autistic people, people living with mental health needs, dementia, sensory impairments and physical disabilities. At the time of our inspection there were eight people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The provider was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support

People’s care was not consistently person-centred and did not always promote people’s human rights. The service was not working within the principles of the Mental Capacity Act and the provider could not demonstrate that appropriate legal authorisations were in place to deprive people of their liberty.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

Recruitment procedures, staff supervision and training did not ensure enough suitably qualified staff were deployed to make sure people were always safe and received care that met their needs. The provider did not effectively use incidents and accidents to identify potential abuse and take preventative actions. Risks to people’s safety were not always mitigated. Unexplained injuries had not always been investigated to identify any potential causes so that strategies could be implemented to reduce the risk of reoccurrence. Partnership working with other relevant bodies to contribute to individual risk assessments and develop plans for safeguarding was poor.

Staff were able to describe how to communicate with people. However, care plans indicated people may benefit from additional communication tools which were not always used.

Right Care

Care and support was not always effectively planned and delivered in line with current evidence-based guidance and best practice. However, people experienced good continuity and consistency of care from a stable core staff team.

Staff engaged with other agencies to ensure people had access to the support they needed for their healthcare and wellbeing needs. The service made referrals and liaised with other healthcare professionals when the need arose.

Staff interacted with people with warmth and respect. However, when staff were task driven due to staffing levels, this compromised positive and meaningful interactions with people.

Right Culture

Quality assurance and performance management was not reliable and effective. Quality assurance processes had not effectively identified emerging risks to people and ensured they were managed safely.

The provider did not understand their responsibilities to inform people, or their representatives, when things went wrong. The provider had not conducted honest and transparent investigations to identify essential lessons to prevent further occurrences.

Staff supported people and their families to express their views and be actively involved in making decisions about their care, support and treatment as far as possible.

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 good (report published 14 February 2018).

Why we inspected

The inspection was prompted due to concerns received about the other services operated by the provider. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this report.

The provider has begun to take action to mitigate the risks identified, though it is too soon evaluate whether this has been effective.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the management and leadership of the service, the safe care and treatment of people, managing risks and protecting people from avoidable harm, consent to care, staffing levels, staff training, record keeping, quality assurance measures and failures to notify relevant authorities of notifiable incidents when required.

We issued Warning Notices to the provider regarding three breaches of regulation relating to good governance, safeguarding and consent to care. The provider is working with us with the support of the local authority care quality, safeguarding team and commissioners to address the issues raised.

Please see other action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

At the last inspection in 7 December 2015 the service was rated Good overall with Requires Improvement in Safe (No breach). We found that some fire doors were being propped open which had the potential to put people at risk in the event of a fire.

This unannounced inspection took place on 10 January 2018. At this inspection we found the service remained Good overall. Further steps had been taken to address the previous concerns and we found that improvements had been made. However, we found that the recruitment processes were not always sufficiently robust and had the potential to put people at risk of unsuitable staff. Therefore the service remains Requires Improvement in Safe.

Why the service is rated Good overall:

There is a registered manager running the service. 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’s safety was contributed to by staff who had been trained in safeguarding vulnerable adults and health and safety policies and procedures. Staff understood how to protect people and who to alert if they had any concerns. General risks and risks to individuals were identified and appropriate action was taken to reduce them.

There were enough staff on duty at all times to meet people’s diverse, individual needs safely. The service had a stable staff team. The service required improvements to its recruitment procedures. References were not always pursued from previous employers and full work histories were not always obtained. People were given their medicines safely, at the right times and in the right amounts by trained and competent staff.

The service remained effective. Staff were well-trained and able to meet people’s health and well-being needs. They were able to respond effectively to people’s current and changing needs. The service sought advice from and worked with health and other professionals to ensure they met people’s needs.

People were encouraged to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practise.

The service continued to be caring and responsive. The committed, attentive and knowledgeable staff team provided care with kindness and respect. Individualised care planning ensured people’s equality and diversity was respected. People were provided with a wide variety of activities, according to their needs, abilities, health and preferences.

The registered manager was well thought of and respected. The quality of care the service provided continued to be assessed, reviewed and improved, as necessary.

Downshire House is a care home which is registered to provide care (without nursing) for up to seven people with a learning disability. The home is a large detached building within a residential area close to Reading town centre. People have their own bedrooms and use of communal areas that included an enclosed private garden. The people living in the home needed care from staff at all times and have a range of care needs.

There is a full-time 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.

People’s safety had been placed at risk as wooden wedges were used to prop open doors, in particular where a dorgard had been fitted. A dorgard is a wireless fire door retainer that automatically closes on the sound of the alarm, delaying the spread of fire. The provider had taken immediate action on the day of our visit to ensure people’s safety was not compromised by removing the wedges and replacing dorgards that were defective.

The recruitment and selection process helped to ensure people were supported by staff of good character. There was a sufficient amount of qualified and trained staff to meet people’s needs safely. Staff knew how to recognise and report any concerns they had about the care and welfare of people to protect them from abuse.

People were provided with effective care from a dedicated staff team who had received support through supervision, staff meetings and training. Their care plans detailed how they wanted their needs to be met. Risk assessments identified risks associated with personal and specific behavioural and or health related issues. They helped to promote people’s independence whilst minimising the risks. Staff treated people with kindness and respect and had regular contact with people’s families to make sure they were fully informed about the care and support their relative received.

The service had taken the necessary action to ensure they were working in a way which recognised and maintained people’s rights. They understood the relevance of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and consent issues which related to the people in their care. The Mental Capacity Act 2005 legislation provides a legal framework that sets out how to act to support people who do not have capacity to make a specific decision. DoLS provide a lawful way to deprive someone of their liberty, provided it is in their own best interests or is necessary to keep them from harm.

Staff were supported to receive the training and development they needed to care for and support people’s individual needs. People received good quality care. The provider had an effective system to regularly assess and monitor the quality of service that people received. There were various formal methods used for assessing and improving the quality of care.

We spoke with two people who use the service about their experiences in the home. One person told us, "I like it here. I have everything I need." Another said, "Nice staff." We spent time observing how staff were interacting with people who live there. People were relaxed and comfortable in the presence of staff. It was clear from talking with staff that they knew the needs of each individual well and were mindful of people's particular preferences and wishes. Self-care was prompted with sensitivity and patience.

We saw detailed person-centred care plans had been developed to reflect the particular needs, wishes and interests of people at the home. They contained information about how people wished to spend their time and how they wanted to be supported. Any risks to people had been fully assessed and there were guidelines in place to manage risks identified.

We spoke with staff about safeguarding. They were knowledgeable about protecting people from abuse and exploitation. They said they had plenty of opportunities to undertake training to enhance their knowledge and skills

There were appropriate policies in place to effectively manage and respond to complaints or suggestions people made.

People using the service were complimentary about the home. One person said 'staff helped' and another person said 'everyone was kind'. People commented that the the food was 'good' and that they enjoyed the activities that took place.

Staff involved people using the service in the running of the home and acted upon their wishes and preferences.

Staff assessed peoples' needs and documented the approaches that were needed to promote peoples' wellbeing. People using the service were involved in the development of person-centred care plans. Staff worked in partnership with other agencies to ensure that peoples' needs could be met.

The home was clean and well maintained. People were able to personalise their rooms if they wished.

Staffing levels met the needs of the people using the service. Staff described a 'really nice atmosphere' and said that they were well supported.

Systems were in place to seek peoples' views and their suggestions were acted upon. Information was provided in different formats to promote peoples' inclusion in the quality assurance of the home.