CQC report explained · a residential care home
What the CQC found at Downhurst Residential Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Downhurst Residential Home Limited is rated Requires Improvement and placed in special measures; medicines, safeguarding and management systems were not reliable enough.
This was an unannounced focused inspection on 6 June 2023. Inspectors checked whether the provider had acted on its previous improvement plan. They spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files and staff supervision records.
There had been improvements in risk assessments, care planning and activities. Relatives said people were safe and well cared for. Inspectors also found enough staff, suitable recruitment checks and good infection control arrangements.
However, some medicines were not given as prescribed, medicines were sometimes unavailable, and records were not always accurate. A possible safeguarding incident was not referred to the local authority. The provider's audits did not reliably identify these problems or ensure lessons were learned.
The overall rating remained Requires Improvement. Safe improved from Inadequate to Requires Improvement, Responsive improved to Good, and Well-led fell from Requires Improvement to Inadequate. Effective and Caring were not inspected, so their previous ratings were used in the overall rating.
Improved care planning
Care plans included current support needs, preferences, communication needs and risk information. Staff could access them electronically.
“People's care plans reflected their support needs and identified how they wished their care needs to be provided.” from the report
Activities
The range of activities had improved, with an activities coordinator arranging exercises, singing, puzzles, hand massages and gardening-related activities.
“We saw the activities coordinator spending time with people in the lounge singing, supporting people with chair-based exercises, hand massages and completing puzzles.” from the report
People felt safe and welcomed
People and relatives said they felt safe and were happy with the care. Relatives also said they were welcomed when visiting.
“People we spoke with said they felt safe living at the home.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment, safe visiting arrangements and the home's ability to manage infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines were not always safe
seriousSome medicines were given differently from the prescriber's directions. Medicines were also sometimes missing, and handwritten records did not always contain complete instructions.
“This meant people did not always receive medicines as prescribed.” from the report
Safeguarding procedure not followed
seriousAn incident between two people was not recognised as a possible safeguarding concern and was not referred to the local authority for investigation.
“This placed people at risk of harm.” from the report
Weak quality checks
seriousAudits did not identify important problems with medicines, safeguarding, incidents or falls. This meant leaders did not have a dependable picture of risks and needed improvements.
“The provider had not implemented a robust process to monitor the quality of the care being provided.” from the report
Improvements were not sustained
needs fixingThe provider had remained in breach of regulations 12 and 17 since April 2021, and the improvement work had not produced consistent compliance.
“The provider had not made and sustained improvements to the service to change the rating of the location following inspections.” from the report
- 01What checks are now in place to make sure every medicine is given exactly as prescribed and that medicines do not run out?
- 02How will you identify and report incidents that may be safeguarding concerns to the local authority?
- 03What changes have you made to ensure lessons are recorded after falls, accidents and incidents?
- 04How will your audits check every relevant fall, medicines issue and safeguarding concern rather than only selected examples?
- 05What action plan was sent to the CQC, and what progress has been made since the warning notice?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 October 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Downhurst is rated Requires Improvement and placed in special measures; inspectors found unsafe medicines and risk management despite kind care and some improvement.
This was an unannounced follow-up inspection on 17 and 18 October 2022. Inspectors spoke with people, relatives and staff. They reviewed care plans, medicines records, recruitment records and staff supervision records.
The main concerns were about safety. Some health risks were not assessed or managed properly. Medicines were not always given as prescribed, and records did not always show what people had received. Care plans also did not always reflect people's current needs, including support with eating.
There were positive findings too. The ratings for Effective and Caring improved to Good. The overall rating is Requires Improvement, but the home was placed in special measures because it had been rated Inadequate in at least one key question at two consecutive comprehensive inspections.
Kind and respectful care
People and relatives said staff were kind, caring and respectful. Inspectors observed care being provided in a caring way.
“We observed care workers provided support in a kind and caring manner and understood the needs of people which supported the feedback received from people living at the home and relatives.” from the report
Healthcare support
People were supported to access healthcare and other services when their needs changed.
“People were supported to access healthcare and other services if there was a change to their care needs and to enable them to live a healthier life.” from the report
Recruitment checks
The provider had checks in place when recruiting staff, including references, right-to-work evidence and a DBS check.
“The provider had a robust recruitment procedure which meant they had checks in place to ensure new staff had the required skills for the role.” from the report
Clean environment
Inspectors found the home clean and tidy. Staff used protective equipment in line with the guidance in place at the time.
“We found the home was clean, tidy and free from any malodours as regular cleaning was carried out.” from the report
Unmanaged risks
seriousSome medical conditions, choking risks and repositioning needs did not have clear risk assessments or instructions. This could leave staff without the guidance needed to keep people safe.
“We found no evidence that people had been harmed. However, the provider had not ensured that risks were always identified, monitored and mitigated.” from the report
Medicines not always given correctly
seriousInspectors found examples of medicines being given at the wrong frequency and records showing medicines had been given by staff when they had not. Audits had not found these problems.
“During this inspection we again identified concerns in relation to the administration and recording of medicines.” from the report
Care plans not kept up to date
seriousSome care plans did not reflect changes in people's needs, personal care preferences or mobility. One person's care plan did not give guidance for oral care.
“The provider had not always ensured care plans included information which recorded the person's current care needs and the preferences of the person and that these were appropriately implemented.” from the report
Mealtime support
seriousOne person who needed encouragement and supervision with eating was not supported appropriately during lunch and did not eat the meal.
“Our observations confirmed that the person's care plan around the support they needed at mealtimes, was not appropriately implemented so the person could maintain their levels of nutrition.” from the report
Activities not consistent
needs fixingSome people said there were not enough activities. Inspectors found activities were not always planned, structured or clearly matched to people's interests.
“Some people felt there were not enough organised activities to engage in.” from the report
Weak quality checks
seriousManagement audits and care plan reviews did not reliably identify missing information, medicine problems or gaps in care records.
“The monthly care plan reviews carried out by the registered manager did not always enable them to identify where information required updating following a change in a person's care needs or where information was missing.” from the report
- 01What has changed to make sure every person's medicines are given exactly as prescribed and recorded accurately?
- 02How do you check that care plans are updated promptly after a hospital discharge or any change in needs?
- 03What specific instructions are now in place for people at risk of choking, poor nutrition, pressure ulcers or other health risks?
- 04How will you make sure people receive the mealtime support recorded in their care plans?
- 05What is the current activities timetable, and how are activities matched to each person's interests and abilities?
This was an unannounced follow-up inspection checking action from the previous inspection, and it considered all five key questions as well as infection prevention and control. This explanation was written from the published report of 17 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Downhurst Residential Home Limited
8 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
Read what inspectors found at Downhurst Residential Home Limited →
- December 2022Requires improvementup from InadequateSafe: InadequateResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Downhurst Residential Home Limited →
- July 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: Requires improvement
- July 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Ealing
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 77 can care for a couple. 11 years' experience on average.
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.