CQC report explained · a residential care home
What the CQC found at Downshire House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected by staff who understood safeguarding, medicines and assessed risks. However, one staff risk assessment lacked enough information, and the old digital incident system had not been fully decommissioned.
- Effective?
- Good
- Staff had the skills and training to meet people's complex needs. Care plans, consent records, mental capacity assessments, medicines reviews and health support had improved.
- Caring?
- Requires improvement
- This question was not inspected during this visit. The report describes people receiving kind and compassionate care that respected their privacy and dignity.
- Responsive?
- Requires improvement
- This question was not inspected during this visit. The report says support plans reflected people's needs and promoted their wellbeing and enjoyment of life.
- Well-led?
- Good
- The management team had improved oversight, quality checks, incident reviews and staff support. The manager and area manager were visible, approachable and focused on learning and improvement.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found major progress from inadequate, but some safety systems still needed tightening, and special measures had ended.
This was a focused inspection on 14 June 2023. It checked Safe, Effective and Well-led, including whether earlier legal requirements and warning notices had been addressed. Inspectors spoke with people, staff and professionals, observed care, and reviewed care records, incident records, medicines records and quality checks.
The home had improved in several important areas. People were supported by staff who knew them well, understood safeguarding, and promoted choice and independence. Medicines, consent, staff training, care plans and management oversight had all improved. Effective and Well-led were rated Good.
Safe was rated Requires Improvement because some safety systems were not yet fully reliable. A risk assessment linked to an adverse DBS check lacked enough information, and an old digital incident system had not been fully closed down. The overall rating improved from Inadequate to Requires Improvement, and the home was no longer in special measures.
Kind, respectful care
People were treated with kindness and their privacy, dignity and individual needs were respected.
“People received kind and compassionate care from staff who protected and respected their privacy and dignity.” from the report
Improved medicines support
Medicines plans had been reviewed, staff competency was checked, and clear protocols were in place for as-needed and emergency medicines.
“People's medicines administration records (MARs) showed they received their medicines as prescribed.” from the report
Skilled staff
Staff had received relevant training, supervision and competency checks for people's complex needs, including positive behaviour support and reducing restrictive practice.
“At this inspection we found staff had the required skills and knowledge to support people according to their needs.” from the report
Good management oversight
The management team had established stronger quality monitoring and understood its responsibilities to report significant events.
“Governance was becoming embedded within the service and the management team operated an effective monitoring and assessment system.” from the report
Recruitment risk assessment
needs fixingOne risk assessment relating to a staff member with an adverse DBS check did not explain the concern or why continued employment was appropriate. The area manager took immediate action to address this.
“The document did not contain sufficient information to explain the circumstances of concern or the continued employment of the staff member.” from the report
Two incident recording systems
needs fixingThe home had introduced a paper system, but the old digital system had not been fully closed down. This created a risk that incidents might not be reviewed if the manager was absent.
“However, we found the digital system had not been fully decommissioned and staff were still recording entries.” from the report
- 01How have you fully closed the old digital incident recording system, and how do you make sure every incident is reviewed when the manager is absent?
- 02How do you quality-check risk assessments for staff who have an adverse DBS check?
- 03What evidence can you show that staff remain competent to administer medicines and support people with epilepsy or other complex needs?
- 04How will you maintain the improvements that led to the previous warning notices being met?
- 05When were the Caring and Responsive questions last inspected, and what were their ratings?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit and their previous ratings carried forward. This explanation was written from the published report of 12 August 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, May 2023
Rated Inadequate and still in special measures; inspectors found that safeguarding training and lawful consent arrangements were not yet reliable.
This was an unannounced targeted inspection on 31 March 2023. It followed two warning notices from the previous inspection about protecting people from abuse and getting lawful consent for care.
Some improvements had been made. Safeguarding incidents were being reported when required, and legal authorisations for people deprived of their liberty were in place. However, the provider had not fully met either warning notice.
Inspectors found that some staff had not completed safeguarding, restrictive practice or Mental Capacity Act training. Care records did not properly record consent, best-interest decisions or people's involvement in decisions. The overall rating remained Inadequate, and the home remained in special measures.
Safeguarding reports
The home had improved how it reported safeguarding incidents. This gave relevant authorities better oversight of action taken to protect people.
“At this inspection we found the deputy manager had appropriately reported incidents where required, which enabled relevant authorities to ensure the provider had taken necessary action to protect people from avoidable harm.” from the report
Liberty safeguards tracking
Legal authorisations were in place, and the home was tracking when applications needed to be made or renewed.
“The deputy manager effectively operated a DoLS tracking system which ensured future applications were submitted well before current authorisations expired.” from the report
Some specialist training
The deputy manager and a team leader had completed enhanced training in safeguarding, reducing restrictive practices and the Mental Capacity Act.
“Since our last inspection the deputy manager and a designated team leader had completed enhanced training in relation to the MCA.” from the report
Safeguarding training gaps
seriousEight of 22 staff had not completed safeguarding training at a level suitable for their role. The provider could not be assured that all staff could recognise and report different types of abuse.
“The provider had failed to ensure all staff had completed relevant safeguarding training.” from the report
Restrictive practice training gaps
seriousNine of 22 staff had not completed required training on restraint and other restrictive practices. This meant the provider could not be assured that any restraint would be necessary, proportionate and lawful.
“The provider had failed to ensure all staff had completed required training that is relevant to their role and at a suitable level” from the report
Consent records incomplete
seriousThe records did not contain decision-specific mental capacity assessments, consent records or best-interest decisions for important areas such as medicines, community access and personal care.
“There were no mental capacity assessments or best interest decisions recorded detailing key decisions, for example those relating to people's medicines, accessing the community and personal care.” from the report
Poor monitoring of restrictive interventions
needs fixingRestrictive interventions were not consistently reviewed, monitored or followed by reflective discussions. This reduced the home's ability to identify learning and reduce restrictive practice.
“There was poor or absent monitoring on the use of restrictive interventions.” from the report
- 01How many staff have now completed safeguarding training, and what level of training did each role require?
- 02How many staff have completed training on restraint and restrictive practices, and how is this checked before they support residents?
- 03Have all residents had decision-specific mental capacity assessments and best-interest decisions recorded for medicines, personal care and community access?
- 04How are residents and their representatives involved in care decisions, and where is that involvement recorded?
- 05How are restrictive interventions reviewed after they happen, and what changes have been made to reduce their use?
This was a targeted inspection of specific parts of Safe and Effective following warning notices; it did not assess the whole of either key question or Caring, Responsive or Well-led, so the existing overall Inadequate rating carried over. This explanation was written from the published report of 6 May 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.
Every inspection of Downshire House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- May 2023Inadequatestayed InadequateSafe: Inspected but not ratedEffective: Inspected but not rated
- December 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- February 2018Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 16 August 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 £1,010 to £1,270 a week. 86 can care for a couple. 12 years' experience on average.
“The quality of life that she's given my parents has been priceless. The peace of mind she's given my sisters and I, through a very difficult time, has been invaluable.”
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