CQC report explained · a nursing home
What the CQC found at Downshaw Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2022
Inspected but not rated; inspectors found good infection-control practice and no current detrimental impact from workforce pressures.
This was an announced, targeted inspection on 17 February 2022. It focused on infection prevention and control during the COVID-19 pandemic, and on whether staffing pressures were affecting care.
Inspectors found policies for managing COVID-19 risks, enough personal protective equipment, correct use of PPE, regular testing and screening for visitors. They were assured that the home was managing infection risks, admissions and visits safely.
The home had adapted its layout so people and relatives could interact safely. Staff had good working relationships with healthcare professionals, and inspectors found that workforce pressures were not currently harming the service.
The service was inspected but not rated. This visit did not provide an overall quality rating or ratings for the other four areas of care.
Infection control
The home had arrangements to manage COVID-19 risks and outbreaks. Inspectors found enough PPE and observed it being used correctly.
“There were enough stocks of personal protective equipment (PPE). We observed staff and management were using PPE correctly and there were procedures in place to support staff with its use.” from the report
Testing and visitor checks
People living in the home, staff and visitors were included in regular testing. Visitors were screened before entry.
“The provider had implemented a regular programme of COVID-19 testing for people in the home, staff, and visitors.” from the report
Working with health professionals
The home had established links with relevant healthcare professionals, and this support continued during the pandemic.
“Staff had established good working relationships with relevant healthcare professionals and their support continued during the pandemic.” from the report
Staffing pressures
Inspectors found that workforce pressures were not having a detrimental effect on care at the time of the inspection.
“Workforce pressures were not currently having a detrimental impact on the delivery of the service.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection-control arrangements are in place now, including testing, PPE and outbreak management?
- 02How are visitors currently screened, and how are visits being facilitated?
- 03How do you check that staffing pressures are not affecting people’s care?
- 04How are staff supported to use PPE correctly?
- 05How do you work with healthcare professionals when people need support during an infection outbreak?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the report does not provide ratings for the other areas. This explanation was written from the published report of 1 March 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 2020
Downshaw Lodge was rated Good; inspectors found safe, kind and personalised care, with improvements since the last inspection.
This was an unannounced inspection on 9 and 10 January 2020. Inspectors spoke with people living in the home, relatives and staff. They observed care, checked the building and reviewed care, medicine, staffing and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found medicines were managed safely, staff were trained, the home was clean, and people were protected from abuse and avoidable harm.
People were treated with kindness and respect. Their care plans included their individual needs, communication and preferences. Activities were available, complaints were dealt with, and staff worked with health and social care professionals.
The previous inspection rated the home Requires Improvement and found two breaches of regulations. The provider made improvements, and inspectors found the home was no longer in breach of those regulations.
Safe medicines
Inspectors found that medicines were securely stored, given by trained staff and recorded accurately. There were also checks on medicine stocks and storage conditions.
“Medicines were safely stored and administered by trained staff.” from the report
Kind and respectful care
Staff knew people well and supported them with complex needs. Inspectors saw positive interactions and found that privacy, dignity and independence were promoted.
“Staff were kind and caring. We saw positive interactions between staff and the people they were supporting.” from the report
Personalised support
Care plans included people's health, social, communication and personal preferences. Staff understood people's likes, dislikes and individual ways of communicating.
“People's care plans were personalised.” from the report
Improved management
The home had improved since the previous inspection. Managers used audits, checks and feedback to identify and address areas for improvement.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.” from the report
End of life plans still developing
needs fixingEnd of life care plans were in place, but inspectors said they could be more personal. The manager said work on this was still ongoing.
“We discussed with the registered manager about how these could be more person-centred and work on this area was ongoing.” from the report
Views about staffing differed
minorPeople, relatives and staff generally said staffing was sufficient, but this was not everyone's view. Inspectors observed staff responding quickly to people's needs.
“The feedback from people, relatives and staff was that there was generally enough staff, although not everyone agreed.” from the report
- 01What has been done to make end of life care plans more person-centred since the inspection?
- 02How do you check that staffing levels are enough throughout the day and night?
- 03How are people's preferred activities and community trips planned and reviewed?
- 04How do you check that as-needed and covert medicines are still appropriate for each person?
- 05How do audits and feedback from relatives lead to changes in the home?
This was an unannounced planned inspection covering all five CQC areas, including the building and the care provided. This explanation was written from the published report of 6 March 2020 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 Downshaw Lodge
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017
Registered with the Care Quality Commission on 10 July 2017.
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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