What the CQC found at Donwell House

People received their medicines on time and medicines were stored correctly. Staff checks were used to monitor medicines practice.

“People received the medicines they needed when they were due; medicines were stored correctly so they remained safe to use.” from the report

People and relatives described staff as kind and caring. Inspectors saw staff responding promptly and supporting dignity, communication and independence.

“People received good care from kind and caring staff.” from the report

There were enough staff to respond to people's needs, recruitment checks were completed and staff had the training they needed.

“There were sufficient staff deployed to meet people's needs quickly.” from the report

The new manager was open about the home's problems and had started action on meals, kitchen hygiene, care plans and quality checks.

“The manager was open and transparent about the improvements the home needed to make to provide good quality care.” from the report

People had opportunities to join activities and access the local community. Previous complaints had been investigated and resolved.

“There were opportunities for people to participate in activities; people chose whether to take part and staff respected their decision.” from the report

Care plans did not contain enough personalised information to guide staff, including how to support people when they were distressed. CQC said this placed people at risk of harm and found a breach.

“Care plans lack personalised information to guide staff about how people should be cared for.” from the report

The home's governance systems had not driven sustained improvement. New quality meetings and checks had started but were not yet fully embedded, and this was a breach.

“Quality assurance systems were not effective in monitoring the service and promoting sustained improvement in the quality and safety of people's care.” from the report

The manager said meal quality and kitchen hygiene had previously been unacceptable. During the inspection, one lunch had processed food, no fresh vegetables and no choice, although action was taken that day.

“During lunch people were served with a meal which consisted of processed food with no fresh vegetables.” from the report

Mental capacity assessments and best-interests decisions were not always recorded for restrictions placed on people, such as the use of bedrails.

“Assessments and best interests decisions had not always been recorded for other restrictions placed on people.” from the report

The home had been without a registered manager for an extended period and had employed three managers in two years. The overall rating had remained Requires Improvement for three inspections.

“The new manager was also the third manager employed in the last two years.” from the report