Our inspection visit took place on 27 November, 3 and 5 December 2018. The inspection was unannounced for the first two days and announced for the third day. We went back to the service on the 19 December 2018 to check what actions the service had taken since the first day of our inspection visit.

We last carried out a focused inspection to this service on 12 July 2018 because we had concerns about the service. These included the departure of the registered manager, the clinical lead and one of the operational managers. We felt this would have a significant impact on the stability and safety of the service. There had been a sharp rise in medication errors. Our concerns were shared with the Local Authority and other health care professionals. We also received a number of whistle-blowers who raised concern about the safety of the service. Before the focussed inspection we met with the providers to seek assurances. We also requested a written action plan from the service stating how they would address the concerns and improve the service for people living there.

At our focussed inspection on 12 July 2018 some improvements had been made and a new manager appointed. We received positive feedback about their impact. There was a new clinical lead in post and a reduction in the use of agency staff. There had been no recent medication errors. Despite these improvements we found some shortfalls and three breaches of regulation. We had concerns about insufficient staffing, poor risk management and poor governance and oversight. We rated both key questions, safe and well -led as requires improvement.

Soon after our focussed inspection the registered manager left. The service recruited another manager but they failed to start. The service did not have a registered manager at the time of our most recent inspection. It is a condition on the homes registration to have a registered manager in post. 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.

Downham Grange is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate people with a nursing or residential care need including those people living with dementia. It is registered for 62 people. On the day of inspection there were 56 people living in the service. The service is divided up into three separate units, on the ground and first floor. The building is modern and lends itself to the needs of the people using the service.

At our inspection on 27 November, 3, 5 and 19 December 2018. We found three repeated breaches of regulation including insufficient deployment and skill mix of staff, poor oversight and governance and poor risk management. We identified three further breaches in relation to the care people received which was not person-centred care and found there was poor oversight of complaints and poor oversight of people dietary and hydration needs.

Management oversight of the service was shared between the service manager, interim manager and regional manager. The clinical lead was in post Monday to Friday and had oversight of the clinical care. Registered nurses led the nursing dementia floor and the nursing unit. The service was almost fully recruited to all staffing positions. Despite this we found there was poor oversight on shift with insufficient deployment of staff at busier times of the day and care being compromised at these times. Not all staff had the necessary skills or training for the job they were expected to do. Staff supervision and personal development was improving b

The inspection took place on the 12 July 2018 and was unannounced. We last inspected this service on 23 and 30 January 2017 and gave the service an overall rating of good, with a requires improvement for the key question Effective. Since that inspection there have been a number of significant changes to the service which have included both the registered manager and the clinical lead leaving. One of the operational managers with oversight of the service had also left. In the midst of so much change we had concerns raised about the stability and safety of the service from the local authority, health care professionals and from whistle blowers. Our response had been to meet and seek assurances from the service about what they are doing to secure good outcomes for people using the service. We also received a detailed and up to date action plan the service is working towards. However, despite these assurances we were still concerned that planned improvements were not happening quickly enough and we needed to satisfy ourselves that people were safe. For this reason, we brought forward an inspection called a focused inspection where we looked at two key questions Safe and Well-Led because no concerns had been raised about the other key questions. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection which is now rated requires improvement.

Downham Grange is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate people without a nursing need or people living with dementia. It is registered for 62 people. On the day of inspection there were 53 people using the service.

A condition of the home’s registration is there should be a registered manager in post. A manager was in post but not yet registered with CQC. 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.

In summary we found concerns about the service but recognized the service was on an upward trend having already made some improvements to the service. There was confidence about the manager and their ability to bring about positive change and there was a full complement of nursing staff but some vacant hours for care staff. However there had been a significant reduction in agency usage which helped reduce cost and improved continuity for people using the service. There was also a new clinical lead who had been in post three weeks. This helped strengthen the management team. The level of skill and experience of the staff team was a concern given that not all staff had a good knowledge of people’s needs.

We had concerns about staffing. We were not assured there was an adequate skill mix across the three separate units, the dementia unit, residential unit and nursing unit. The shifts were poorly organized without effective leadership and staff were not deployed sufficiently across the day. This meant people were not provided with the necessary support taking into account their wishes and preferences. We found lunch time on two of three units were poorly organised and did not help ensure people had enough to eat and drink. We also found the provision of activities did not effectively demonstrate how they met individual’s needs. We had concerns that people were not adequately monitored for their safety in communal areas and the risks of this had not considered.

The management of individual risks were adequately documented in people’s care plans and known by staff. However, information was hard to track

We carried out a comprehensive inspection of Downham Grange on 11 July 2016. Following this inspection we served two warning notices for breaches of two regulations of the Health and Social Care Act 2008 relating to good governance and the management of people’s medicines. In addition to this, we also found additional breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during that inspection. These breaches were in relation to person centred care, monitoring the quality and safety of the service and insufficient suitably qualified, competent and skilled staff to meet people’s needs safely.

We undertook an unannounced focused inspection on 7 November 2016 to check that our warning notices had been complied with. At that inspection, we found that the provider had taken sufficient action to achieve compliance with the warning notices.

We undertook this unannounced comprehensive inspection 23 and 30 January 2017 to look at all aspects of the service, and confirm that the service now met legal requirements. At this inspection, we found improvements had been made in the required areas and the provider was no longer in breach of the regulations.

You can read the report for previous inspections, by selecting the 'All reports' link for 'Downham Grange’ on our website at www.cqc.org.uk

Downham Grange is registered to provide accommodation for up to 62 older people who require nursing and personal care, some of whom may be living with dementia. On the days of our inspection, 51 people were living at the home.

There was a newly registered manager in post who had commenced employment at the home in October 2016. A registered manager is a person who has registered with the Care Quality Commission (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 is run.

During this inspection people said they felt safe and that staff treated them well. Safeguarding adults' procedures were in place and staff understood how to protect people from the risk of abuse. Risks associated with people's care were identified, assessed and recorded. There was a whistle-blowing procedure available and staff said they would use it if they needed to.

Policies and procedures were in place to guide staff with the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely by trained staff.

There were sufficient numbers of suitably qualified staff employed at the service. The provider’s recruitment process ensured they only employed staff deemed suitable to work with people in a care setting. Staff had completed an induction programme when they started work and they were up to date with the provider's mandatory training.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the registered manager was knowledgeable about when a request for a DoLS application would be required. Applications had been submitted appropriately to the relevant local authority.

Staff respected and maintained people’s privacy. People received care and support as required and people did not have to wait for long periods before having their care needs met. This meant that people’s dignity was respected and that their care needs delivered in a timely manner.

People’s assessed care and support needs were planned and met by staff who had a good understanding of how and when to provide people’s care whilst respecting their independence. Care records were detailed and up to date so that staff were provided with guidelines to care for people in the right way.

People were supported to access a range of health care professionals

We carried out an unannounced comprehensive inspection of this service on 11 July 2016. Four breaches of the legal requirements were found and two Warning Notices were issued in respect of these breaches. After the comprehensive inspection, we gave the provider until 31 August 2016 to meet the legal requirements in relation to this warning notice. We undertook this focused inspection on 7 November 2016 to check that they had undertaken changes to meet these requirements. This report only covers the findings in relation to that notice.

We have not changed the overall rating for this service as a result of this inspection, which was only to follow up our enforcement action. The service remains rated as requires improvement. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Downham Grange on our website at www.cqc.org.uk

Downham Grange provides accommodation and support to a maximum of 62 older people, some of whom are living with dementia. The home provides a mixture of nursing and residential care.

At the time of this inspection, the homes registered manager had recently resigned and was no longer working at the home. The provider had recently recruited a new manager for the home, who had been employed for three weeks. They told us that they were applying to become the registered manager for the home. 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 and associated Regulations about how the service is run.

At the previous comprehensive inspection, effective monitoring systems were not in place to ensure quality and safe care. This had resulted in people receiving poor care and being at risk of harm. We found that medicines had not been managed safely and people did not receive them as the prescriber intended.

Since our last inspection, the provider had deployed a number of staff to focus on improving the quality and safety of care provided to people. This included a regional operations manager to oversee the improvements required and take responsibility for the implementation of these. At this inspection we saw that there were effective systems in place that had been developed since our last visit. These were to monitor the quality and safety of people living at the home, and to reduce the risk of harm and poor care. The regional operations manager had identified where improvements had been needed and actions had been undertaken to achieve this. The regional operations manager had, as a result of this also identified where they would like to make future improvements and a plan was in place for this.

The Warning Notices we issued were complied with.

This inspection was unannounced and took place on 11 July 2016.

During our inspection of the home in January 2016, we found that the provider was in breach of seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. These were in respect of sufficient staffing, safe care and treatment, treating people with dignity and respect, the need for consent, providing person centred care, statutory notifications and good governance.

At this inspection, although we found that some improvements had been made we found further and continued concerns. The provider is in breach of Regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we told the provider to take at the back of the full version of this report.

Following the inspection in January 2016, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

Downham Grange is a service that provides accommodation and care to a maximum of 62 older people, some of whom may be living with dementia. On the day of our inspection, there were 46 people living at the home.

There was a registered manager in post. 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.

We found that there were continuing issues regarding the governance and quality monitoring of the service. The provider's quality monitoring did not always identify shortfalls in the provision of care to people, and when it did, did not identify actions that needed to be taken. The registered manager did not have a full understanding of their responsibilities and had not always taken the required actions. We have told the provider that they need to make improvements in the way the service is led and monitored.

Medicines were not always managed safely. On the day of our inspection, there was an avoidable delay in people receiving their medicines on time. There was a lack of guidance about how medicines for occasional use, to assist people who were distressed or anxious were used.

Records of when people received their medicines were incomplete and the registered managers systems to check this was not effective. Peoples preferences about how they liked to take their medicines were not documented, and any allergies and sensitivity’s to medicines were wrongly documented. There were numerical discrepancies of medicines and systems to account for them were not being used accurately.

Not all staff had completed training to support them in recognising and responding to suspicions that people might be at risk of harm. However, most knew what was expected of them and how they should report any concerns. The registered manager did not always identify and take action to manage situations that placed people at risk.

Not all staff had received the training they needed in order to meet people's needs. Training that the provider had identified as mandatory had not been completed by all staff.

People did not always receive the care and support they needed to eat their meals in a pleasant and timely way. Staff did not always know what assistance people needed, or support people in an appropriate way.

People received support from staff who were mainly kind and caring. However, people were not always treated with dignity and respect because staff were task focussed and care took place in a manner that was hurried with little or no interaction.

Improvements had been made to identify peoples preferences about the way they wanted their care delivered. The way in which these were recorded and presented had also improved which meant staff found them easier to use. Interests, hobbies and backgrounds were not always taken int

The inspection took place on 8 and 12 January 2016 and was unannounced.

Downham Grange provides accommodation and care to a maximum of 62 older people, some of whom may be living with dementia. It is able to deliver nursing care to people using the service. When our inspection started, there were 58 people using the service.

There was a registered manager in post. 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.

There were shortfalls in the safety of the service because not enough suitable and competent staff were always properly deployed. People sometimes experienced significant delays before staff were available to assist them with the care they required. Risks to individuals were assessed but staff were not always available to address these. We have told the provider that they need to make improvements to ensure people's safety.

Medicines were not always managed safely. Whilst the majority of people received their medicines at the appropriate time, there was a lack of guidance about how medicines for occasional use, to assist people who were distressed or anxious, were to be used. Insulin administration was not always consistent and there was a lack of guidance for nursing staff to support them with this. There was an audit process in place. However, this was partially compromised as balances in stock at the beginning of each month were not always clearly recorded. We have told the provider they need to make improvements in this area to ensure that people receive safe care and treatment.

Not all staff had completed training to support them in recognising and responding to suspicions that people might be being abused. However, most knew what was expected of them and how they should report any concerns to contribute to people's safety.

The service people received was not always effective. Significant numbers of staff had not been properly trained to understand how they should support people who could not make decisions for themselves. There were inconsistencies in the way people's capacity to make decisions was assessed to demonstrate that their rights were protected. Staff were unclear who was subject to any authorised restrictions on their freedom and the manager was unable to clarify this at inspection. We have told the provider that they need to make improvements to ensure consent to care and treatment is properly and lawfully obtained.

Mandatory staff training and induction was not always completed promptly so that staff had consistent underpinning knowledge about their roles and how to support people well. The provider had identified this as an area needing to improve and had a plan to address shortfalls.

People did not always receive prompt and appropriate assistance to eat their meals and drink enough. The mealtime experience was not always as pleasant as it could be in encouraging people to eat. Staff took action to ensure people's health needs were referred for professional advice where necessary.

People received support from staff who were largely kind and compassionate. However, they were not always available to intervene promptly when people needed support and sometimes people's dignity and privacy was compromised. We have told the provider they need to make improvements in this area.

People's needs and preferences about the way they wanted their care delivered were not always acted upon. Their interests, hobbies and backgrounds were not always taken into account. There was a lack of activities to meet people's preferences. We have told the provider that they need to make improvements in the way the service responds to people’s needs and wishes. The manager was recruiting staff specifically to assist with activities.

Downham Grange is a modern and purpose built nursing home for up to 62 older people. There were 42 people living at the home at the time of our inspection.

There was no registered manager in place at the time of our inspection, but an interim manager had been appointed, pending the recruitment of a permanent 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 and associated Regulations about how the service is run.’

At our previous inspection on 8 May 2014 we asked the provider to take action to make improvements in relation to how people were cared for, the number of staff on duty, how staff were recruited, and how the quality of the service was monitored. This action had been taken and we noted significant improvements in all these areas during this inspection.

We received many positive comments about the home from people who lived there, their relatives and visiting health care professionals. People told us that staff treated them in a way that they liked and there were enough of them around to meet their needs in a timely way. They stated that they received good quality care which had maintained and, in some cases, improved their health and well-being. Family members told us staff were good at keeping them informed of events that affected their relative: something which they greatly appreciated.

People lived in a safe and well maintained environment. Medicines were stored correctly and records showed that people had received them as prescribed. Staff had received appropriate training for their role and had also received training in the Mental Capacity Act 2005. We saw that appropriate applications to deprive people of their liberty had been made so that people who could not make decisions for themselves were protected.

People’s needs were clearly recorded in their plans of care so that staff had the information they needed to provide care in a consistent way. Care plans were regularly reviewed to ensure they accurately reflected people’s current needs.

Effective quality assurance systems were in place to monitor the service and people’s views were sought and used to improve it. It was clear that this home had made good improvements since our last inspection and the interim manager was bringing about much needed change.

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?

Below is a summary of what we found. It is based on our observations during the inspection, speaking with people who used the service; the staff supporting them and from looking at a range of records.

SAFE

We found that medicines were managed well and that people received their medication safely, and as prescribed by their GP. Equipment at the home was regularly maintained and serviced to ensure its safety for people. Each person had a personal evacuation plan in place to that they could be moved effectively in the event of an emergency.

However we found that the home’s recruitment practices were not robust and some staff had been employed with unsuitable references. Although staff had received recent training in the Mental Capacity Act, we found their knowledge of its practical application was limited and they were unable to identify when a person might need safeguards in place to protect their liberty.

We saw that a number of staff had long, and sometimes painted, nails. This not only compromised good hand hygiene, but also posed a risk of injury to people. We saw staff carrying soiled laundry in their arms, rather than putting it in laundry bins to reduce the spread of infection. Not all night staff had received relevant training in first aid to ensure they could deal with a medical emergency if required.

EFFECTIVE

We found that people’s health was regularly monitored to identify changes to their needs and that they were supported to see a range of health care professionals to maintain their well-being. People’s needs had been regularly reviewed by staff. However, health care professionals we spoke felt that staff did not always have the relevant skills to look after nursing patients appropriately. The monitoring of people’s fluid intake was poor, as were observation checks of their well-being at night.

Activities at the home for people to enjoy were limited and were not provided on a daily basis to ensure people were stimulated and entertained.

CARING

We observed positive interaction between staff and people using the service on the day of our inspection. Most people told us that staff treated them in a way that they liked, and that their decisions were respected by them. Relatives we spoke with reported the staff were caring and respectful toward their family member and spoke to them appropriately. The also told us that staff were good at keeping them up to date about what was happening with their family member. One relative stated, “They always ring if mum has a funny turn, they’re very caring that way”. Another stated, “The staff seem to genuinely love my mother, she can be awkward at times but they take it in their stride”

However we witnessed several instances where staff just walked into people’s bedroom without knocking, or asking if it was alright for them to enter. On one occasion this was when we were having a confidential conversation with someone about staff’s behaviour towards them. During our inspection one relative told us that her husband had overheard two members of staff arguing outside his door, which he had found inappropriate and inconsiderate.

RESPONSIVE

We noted many aspects of the home’s environment that were responsive to the needs of people with dementia. There was dementia friendly signage throughout the home to help people identify their bedroom and key locations such as toilets and bathrooms. Corridor walls were decorated with reminiscence objects to create an interesting and stimulating environment for people We received particularly positive comments about the home’s administrator who was described as efficient, helpful and who responded to people’s requests quickly and efficiently.

People were involved in the assessment and planning for their end of life care, and were able to make choices and decisions about their preferred options. However they were not actively involved in reviewing their care plans so that they could contribute to decisions about their care and welfare.

Staffing levels at the home were not enough to ensure that people’s needs were met in a timely way. It was not clear how staffing levels were assessed and monitored to ensure they were sufficient to meet people’s needs.

WELL-LED

Prior to our inspection we had received a number of concerns from visiting health care professionals about the leadership in the home and its lack of responsiveness when they had raised their concerns. We received mixed views from staff about the leadership of the home, some felt well supported by the management team but others felt that their concerns, especially around staffing levels, had not been listened to. Poor morale had been raised as an issue in the latest staff survey and also during our inspection.

Many of the themes such as poor staffing levels, a lack of activities and relatives not being involved in care planning that people who lived at the home and their relatives had raised in July 2013 still remained an area of concern during our visit. The manager had not been effective in addressing these issues or in bringing in the improvements needed.

The manager conducted a number of monthly audits to assess the service, but these had not identified many of the shortfalls we found during our inspection. The stability of the home’s staffing was a concern. At the time of our inspection the home was without a clinical lead nurse and a number of staff had left or had been dismissed.

People living in the home and a visitor we spoke with made positive comments about the standard and quality of the support and care that was being provided. We saw that care plans were kept up to date, this meant that the information on care plans was current and reflected the choices people had made.

We found that the needs and welfare of people living in the home were being met. Members of staff, people living in the home and a visitor told us that at times there was a need for more staff to be on duty. One regular visitor to the home said that this was often the case at meal times when people may need some assistance.

People living in the home told us they felt cared for and that staff were available when they needed any assistance or care. During this inspection we found a calm environment with a staff team on duty that knew and understood the individual needs of people living in the home.

People who used the service had the right level of information to make a decision about their care. People we spoke with told us that choices were provided by staff before undertaking any care and support. One person told us; “They listen to me when I ask for specific assistance.”

People's health and welfare was maintained with appointments being made with healthcare professionals, as was necessary. We saw that care plans were current and had been updated regularly. This meant that people could be assured that staff would provide the appropriate assistance.

We saw there were menu options for people at each meal time and that the dining experience was a calm and social event. Records showed us that staff monitored the nutrition of people and ensured their continued health was maintained.

The building at Downham Grange had been purpose built and we saw that the last stages of the build were currently in progress. The building had been fully risk assessed and the plans ensured the continued safety of people living in the home while the building work was being undertaken. All bed rooms now have an en-suite bathroom and people have a choice of which type of bathroom they use.

We spoke with three members of staff and reviewed four staff files. We found there were appropriate checks completed before any new members of staff started working in the home.

The people we spoke with told us that they were happy living at Downham Grange. They were satisfied with the support they received and said it met their needs. The three family members we spoke with told us that they thought people living in the home received good care. Staff understood people’s health needs and ensured they were referred to health care professionals in a timely way. We found that people were supported to maintain their independence. They were treated as individuals and their privacy was respected.

People told us they felt safe and no-one we spoke with had any concerns about the way they were treated. One person commented, “The staff are all nice; I don’t feel uncomfortable with anyone.” Staff received training to help them to recognise and respond to any suspected abuse.

Staff received regular training in a range of topics relating to the health, safety and welfare of the people using the service. One person told us, “I don’t know what training the staff have to do but the end result is good.” Staff told us that senior staff supported them to carry out their role.

People were consulted about things that were happening in the home. They, their family and friends had opportunities to comment about the service they received and make suggestions for improvements. Staff and visiting professionals were also asked for their views about how the home was run.

People with whom we spoke during our visit on 08 June 2011 told us that they were happy living at Downham Grange and that they knew how to raise concerns with the staff or the manager. They told us that they felt happy to do so.

One person commented “All the girls [staff] are very kind.” Others said they “Wouldn’t change anything.” and “We have lovely carers and are pretty well off.”

People told us about the activities provided. One person told us that she is able to change her library books frequently and has plenty of choice. People also told us that they are able to request library books. One person told us that they attend a church service once a month. A hairdresser visits weekly and people told us that they liked having their hair done.

People told us that a chiropodist visits the home regularly to attend to people’s feet and people who use the service can ask for their name to be added to the list for a visit.

People with whom we spoke also told us that residents’ meetings are held two-monthly and that activities and food are frequently discussed. One person said “You can discuss anything you want to”. Another person told us that they had raised a concern that the food was always cold because it was served on cold plates. They told us that this has since been addressed.

We asked people about the food provided at Downham Grange and received a mixed response. One person said “They cook it too long” Another said “There are too many cooks; the cleaner cooks and the carers cook.” Several people commented that the meat was tough and that this was sometimes the case. Conversely one person said “the food is very good” and people told us that they have sufficient menu choice.