CQC report explained · a residential care home
What the CQC found at Downs House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found kind care, but medicines, safety risks, staff training and oversight were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 27 and 28 July 2022 and reviewed information until 18 August 2022. They spoke with people, relatives and staff, and checked care plans, medicines records, recruitment files, audits and safety records.
The home had enough staff and followed recruitment checks. Staff were caring and people were treated with dignity. However, medicines were not always managed safely, some building and fire risks were not dealt with promptly, and many staff were overdue important training.
Inspectors also found problems with consent decisions under the Mental Capacity Act. Audits and other checks did not reliably identify or fix risks. The overall rating changed from Good in 2018 to Requires Improvement. The Safe, Effective and Well-led ratings were all Requires Improvement.
Kind and respectful staff
Inspectors saw people being supported in a kind and caring way. People were treated with dignity and respect.
“The staff were caring and supportive to people who used the service” from the report
Enough staff and safe recruitment
Inspectors found enough staff to meet people's needs during the inspection. Recruitment checks, including DBS checks, were completed as required.
“During our inspection there were enough staff in place to meet people's needs.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infections, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Healthcare support
People were supported to use a range of health services, and changes in their health were referred to appropriate professionals.
“People were supported to access services to maintain and improve their health” from the report
Suitable surroundings
The home was spacious and light, with accessible gardens, different lounge areas and a coffee bar for people and relatives.
“There was a coffee bar in the dining room that provided a social area where people and their relatives could get drinks and snacks.” from the report
Medicines were not always safe
seriousMedicines records and instructions were incomplete or inconsistent. Some medicines were stored outside recommended temperatures, and some staff gave medicines without the proper training.
“We found that medicines were not always managed safely which placed people at risk of harm.” from the report
Premises and fire risks
seriousInspectors found an unsafe second-floor window, unalarmed fire doors, blocked escape routes and hazardous substances or storage areas that were not secured. Some issues were only addressed after inspectors raised them.
“This put people at risk of avoidable harm.” from the report
Consent decisions
seriousThe home did not always complete decision-specific mental capacity assessments and best-interest decisions, including for bed rails, dietary decisions and sensor alarms.
“The provider did not always ensure that decision specific mental capacity assessments and best interest decisions were carried out in relation to bed rails.” from the report
Weak audits and oversight
seriousAudits of medicines, training, care plans and risk assessments did not reliably find problems. Fire safety records were incomplete or missing, and call bells were not routinely checked.
“The processes in place to monitor the quality and safety of the service were not robust.” from the report
Malnutrition planning
needs fixingPeople at risk of malnutrition had been assessed, but care plans did not always say clearly what staff should do if someone ate too little or how often risks should be reviewed.
“There was not always a clear plan for managing that risk, such as prompts for staff to offer regular snacks” from the report
- 01What has been done to make medicines records, PRN instructions, allergy plans and medicine storage temperatures safe and accurate?
- 02Which fire safety, window, hazardous storage and call bell problems have been fixed, and how are they now checked?
- 03How many staff are currently overdue training in medicines, dementia, the Mental Capacity Act, safeguarding and fire safety?
- 04How are mental capacity assessments and best-interest decisions recorded for bed rails, sensor alarms and dietary choices?
- 05What actions are in the provider's improvement plan, and how will families be told about progress?
This was an unannounced focused inspection of Safe, Effective and Well-led, with infection control considered under Safe; Caring and Responsive were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 1 October 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.
What inspectors found, March 2021
Inspected but not rated; inspectors found good COVID-19 arrangements but several infection-control measures were not always consistent.
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic. Inspectors visited the home on 16 February 2021 and carried out a follow-up review of information on 2 March 2021.
Inspectors found good arrangements for social distancing, testing, safe admissions, vaccination access, personal protective equipment, and staying in touch with relatives. The home had also created a screened visiting area.
However, staff had not received updated formal training on personal protective equipment and infection control. Visitor testing and other safety checks were not always consistent. The visiting room was not always cleaned between visits, and some policies did not fully describe the safeguards being used.
The home was inspected but not rated. This means the inspection looked at a specific area and did not give a new overall quality rating.
Safer layout
The home had reviewed its communal areas to support social distancing and had placed personal protective equipment stations around the building.
“This included review of communal areas to support social distancing and implementing personal protective equipment stations throughout the home.” from the report
Safe admissions
Inspectors found information showing that the home had measures for testing and isolation when people newly entered or returned to the home.
“We reviewed information which provided assurances that the provider understood and implemented national guidance to support safe admissions to the home.” from the report
Testing and vaccination access
People and staff had access to regular COVID-19 testing, and staff could access the vaccination programme.
“People and staff were supported appropriately to have access to regular testing in line with national guidelines and staff were able to access the COVID-19 vaccination programme.” from the report
Contact with relatives
The home provided a screened visiting area and helped people keep in touch by telephone or online calls.
“The provider had adapted an area of the home to facilitate screened visits for people and their loved ones.” from the report
Visitor safety checks
needs fixingVisitor safety arrangements were not always applied consistently. This included the use of lateral flow testing devices.
“We found measures for visitors at the home were not always robust or consistently implemented.” from the report
Cleaning between visits
needs fixingThe visitors room was not always cleaned between visits, and staff guidance about cleaning it was not always clear.
“For example, there had been occasions where the visitors room had not cleaned between visits.” from the report
Policy detail
needs fixingSome infection-control policies did not consistently record the safeguards being used in practice, including arrangements for the home minibus.
“However, we found these did not always consistently include information on the measures that had been implemented in practice to keep people and staff safe.” from the report
- 01What updated formal training have staff received on PPE and infection prevention and control?
- 02How are lateral flow tests and other safety checks now carried out for visitors?
- 03How is the visitors room cleaned between every visit, and how is this checked?
- 04Have the infection-control policies been updated to reflect the safeguards used in practice, including for the home minibus?
- 05What evidence can you show that the immediate actions mentioned in the report have been maintained?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 18 March 2021 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.
Every inspection of Downs House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- September 2018Goodstayed GoodSafe: GoodEffective: Requires improvementWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 16 February 2011.
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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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 £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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