This inspection took place on the 27 and 28 June 2018 and was unannounced.

Downs House 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.

Downs House accommodates up to 49 older people, some of whom may be living with dementia in one adapted building. At the time of this inspection there were 39 people living in the home.

A registered manager was 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.

Managers and staff understood and acted on their responsibility to protect people from abuse. Staff supported people to manage risks to promote their safety. There were sufficient staff available to meet people’s needs.

The home provided a clean and comfortable environment for people. Procedures were in place and followed to manage the prevention and control of infections. People’s medicines were managed safely.

The provider and registered manager had worked with others to ensure that lessons were learnt when things went wrong. Improvements had been made in response to safety incidents to prevent a reoccurrence.

People were supported to have choice and control and staff supported them in the least restrictive way possible; However not all of the processes in the service supported this practice. Improvement was required to ensure the use of equipment which can restrict people’s freedom of movement and constitute a restraint, was assessed in line with the Mental Capacity Act (2005).

Not all of the protected characteristics of the Equality Act 2010 were considered as part of the needs assessment or person-centred care planning. We have made a recommendation about this.

People were supported by staff who were trained and supported to meet their needs effectively. People’s nutrition and hydration needs were known and met.

People told us staff provided respectful, dignified and compassionate care. Personal care was delivered in private and people’s decisions about their care were respected.

People’s care plans were person centred and people received care in line with their assessed needs and preferences. People were supported to participate in a range of activities to meet their needs for social activity and stimulation.

People’s complaints were investigated and responded to. People were aware of the complaints procedures and were confident the manager and staff would listen and act on complaints.

People were supported at the end of their life by staff who provided, sensitive, appropriate and compassionate care for people and their families. Plans were in place to improve end of life care planning and training for staff.

There were effective systems in place to monitor and improve the safety and quality of the service people received. Feedback from people, their families and staff was used to drive improvements to the service. The registered manager led by example and was committed to promoting a positive culture where the needs of people were prioritised and staff were valued.

The inspection took place on 25 and 26 February 2016 and was unannounced.

Downs House provides accommodation and care for up to 37 older people, some of whom may also be living with dementia. At the time of the inspection, work was underway to complete an extension to the home. The extension, when completed, will provide 12 extra bedrooms with ensuite wet rooms, a new kitchen and an orangery. There were 33 people using the service at the time of the inspection and one bedroom was not in use due to the building work.

Downs House has 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.

People said they felt safe. Staff had received safeguarding training and were able to explain how to protect people from abuse and how to report suspected abuse.

People’s individual risks were appropriately assessed and care plans were in place to mitigate known risks. Staff were knowledgeable about risks to people and what actions needed to be taken to keep people safe.

There were sufficient staff on duty. People’s needs were met whether they were in the communal areas or being cared for in bed.

Staff recruitment and induction practices were safe. Relevant checks were carried out to ensure that suitable staff were recruited.

Medicines were stored and administered safely. Records in relation to medicines were accurate and staff had received training in medicines administration, and had their competency checked regularly.

Staff had received appropriate training to meet people’s needs. Records showed that staff had received training in key areas such as infection control, fire training, moving and handling, food hygiene and first aid. Staff were supported to study for health and social care vocational qualifications. Staff told us they felt supported in their role.

Staff were knowledgeable about people’s needs and how to support them. Staff said they knew about people’s needs from handovers, care plans, risk assessments, people themselves and their families. We saw that staff interacted with people appropriately and kindly, appearing to know them well as individuals, and treating them accordingly.

People were asked for their consent before care or treatment was provided and the provider acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA). People made their own decisions where they had the capacity to do this, and their decisions were respected.

People were supported to have sufficient to eat and drink and to maintain a balanced diet. Drinks were readily available throughout the day and staff encouraged people to drink. For lunch a main meal was offered, with alternatives available. The chef was knowledgeable about people’s individual requirements such as those people who required a pureed diet, a soft diet or a diabetic diet. We saw that staff maintained a presence in the dining room during lunch, checking that everyone was managing and offering support if needed.

People were supported to maintain good health through access to ongoing health support. Records showed that district nurses, speech and language therapists and the GP had been involved in people’s care and referrals were made where appropriate.

Staff were kind and patient with people, using gentle persuasion and encouragement to support them. They took time to listen to people and understand how they were feeling. People’s dignity was respected. People were supported to be as independent as possible.

People were involved in decisions about their care and were offered choices in all aspects of their daily life. Where they had capacity, people had signed their care plans showing that they agreed with the plan of care.

Staff

We visited this service on Monday 18 August 2014 to follow up one area of non-compliance from our previous inspection in May 2014.

During our visit we spoke with the registered manager, the deputy manager and three members of staff. We reviewed records of staff meetings and supervision sessions and observed staff working in the home. We found the provider had ensured adequate staffing structures and support was in place.

We carried out a routine inspection of this home on Tuesday 22 April 2014. At the time of our visit there were 32 people living at the home. On the day of our visit we spoke with the registered provider, the registered manager, the deputy manager, the cook and four members of care staff. We spoke with six people who lived at the home.

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 caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found-

Is the service caring?

People told us they were supported by kind and attentive staff. Staff treated people as individuals and provided care which was in line with their agreed plan of care. People told us staff were kind and responsive to their needs at all times. We saw that people’s needs were supported in a calm, dignified and respectful way. This meant people were cared for in a kind and respectful manner.

Is the service responsive?

People’s needs were assessed and reviewed regularly to ensure their needs were met. People and their representatives were encouraged to participate in care planning and review. The registered manager or deputy manager regularly spoke with people and their representatives to ensure their needs were being met. This meant that people were able to express their views of the care they received and have them acted upon.

Is the service safe?

People told us they felt safe in the home and when being cared for by staff. People were cared for by staff who had the appropriate skills and experience to ensure their safety and welfare. Staff had a good awareness of the needs of people who lived at the home. This meant people received care which ensured their safety and welfare.

Is the service effective?

We saw people received care which was individualised and planned in line with their needs. People told us they received the care they needed to maintain their independence and dignity.

Is the service well-led?

People told us the registered manager and provider for this service were very approachable. Staff told us they received adequate support from the management. However, staff told us there was a lack of clarity in staff roles which had led to low staff morale. Staff told us they had reported their concerns, however this had not improved. This meant that staff were not supported to raise concerns and have them dealt with. We have asked the provider to inform us of actions they will be taking to resolve this matter.

We visited this home on 11 September 2013 and there were 33 people living at the home. During our inspection we spoke with the proprietor, the new registered manager, three staff members, six people who live at this home and two visitors.

At our last inspection in March 2013 we had identified concerns in; care and welfare of people who use the service, management of medicines, supporting workers and the quality assessment of this service. The provider had sent us an action plan detailing how they would work to improve these areas.

At this inspection we reviewed the progress the provider and new manager had made in taking action to ensure compliance in the areas of concern or where improvements had been requested. We found that improvements had been made in all of these areas.

We saw that the home was clean and well maintained. Care was provided over three floors with single occupancy rooms available. Access to many areas of the home was via stairs and there were two lifts available for use.

People were able to personalise their rooms with their own possessions and could access their rooms whenever they chose. Few people chose to remain in their rooms throughout the day, as the communal lounge area was the hub of activity during the day. Quieter areas were available for people to use if they chose.

We saw that staff treated people in a kind and gentle manner respecting their dignity at all times.

We directly observed care within the service so as to help us determine what it was like for people living at Downs House. We found that staff interactions with people who live at the home were positive and staff were noted to have a good understanding of people's care and support needs. People told us that they liked living at Downs House and found staff to be kind and caring. Relatives spoken with told us that they were very happy with the care and support provided for their member of family and that they were always kept informed of what was happening.

However our findings also showed that as a result of non-compliance with the regulations or part of a regulation, improvements were required in relating to the service's care planning documentation, medicines management, staff training, staff supervision and appraisal. In addition we found that the service's quality assurance systems were ineffective as they provided little evidence as to how information was consistently monitored to identify risks and areas for improvement.