CQC report explained · a nursing home
What the CQC found at Downsvale Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines arrangements and appropriate safety checks. They did find that staff did not always follow mask-wearing guidance.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The provider's checks were not robust enough to ensure staff always wore masks in line with guidance. Other leadership arrangements were clear, with regular supervision, handovers and care audits.
What inspectors found, July 2021
Downsvale Nursing Home was rated Good overall; inspectors found safe, kind care, but leadership and mask checks required improvement.
This was an unannounced focused inspection on 12 May 2021. Inspectors looked at Safe and Well-led because concerns had been raised about staffing, culture, training, medicines and recruitment. They spoke with people, relatives, staff and professionals, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines arrangements and regular checks of the building and equipment. People and relatives said they felt safe and received kind care.
Well-led was rated Requires Improvement. Staff did not always wear face masks as required when close to people, and quality checks had not reliably identified this. The provider sent an action plan after the inspection, including more PPE checks and infection control training.
The overall rating stayed Good, as the other three questions were not inspected and their previous ratings were carried forward. The previous overall rating was also Good, published on 31 May 2018.
Enough staff
Inspectors found enough staff to meet people's needs. Call bells were answered quickly during the visit.
“We observed there were sufficient staff to support people during meal times and we observed call bells being answered quickly.” from the report
Safe medicines
Medicines were recorded with important information such as photographs, allergies and guidance for medicines given when needed. Staff competency checks were completed.
“People received their medicines on time and were supported to administer medication independently if they wished to do so.” from the report
Kind care
People and relatives described staff as kind and said they felt safe and supported.
“People told us they felt safe and staff were kind and caring towards them.” from the report
Risk management
The home had care plans and risk assessments for issues including falls, choking and pressure areas. Staff worked with health professionals when risks were identified.
“Staff had completed risk assessments to identify and manage risks.” from the report
Mask wearing
seriousSeveral staff members were not wearing masks in line with infection control guidance when close to people. The provider sent an action plan after the inspection.
“We observed several members of staff who were not wearing masks in accordance with guidelines.” from the report
Quality checks
needs fixingThe audits did not reliably identify whether staff were following mask guidance. The provider said it would increase PPE checks and provide further infection control training.
“Audits were not robust enough to ensure staff were always wearing face masks in line with guidelines.” from the report
- 01Have all staff completed the planned infection prevention and control training?
- 02How do you now check that staff wear face masks correctly when close to residents?
- 03What evidence can you show that your increased PPE checks are working?
- 04When will Caring, Effective and Responsive be reviewed again in a comprehensive inspection?
- 05How are you checking that the action plan from this inspection has been completed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 July 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.
What inspectors found, October 2020
Downsvale Nursing Home was rated Good overall; inspectors found safe, caring management but identified security and medicine trolley issues that were addressed after the visit.
This was an announced targeted inspection on 2 September 2020. Inspectors looked at specific concerns about safety, staffing, infection control, accidents, staff competence, the home's culture and its management systems. They spoke with six people, two relatives and eight staff, and reviewed care, medicines, recruitment and management records.
People told inspectors they felt safe and received timely attention. Staffing levels were considered sufficient, recruitment checks were completed, and staff understood people's risks and safeguarding duties. Infection control arrangements were also found to be satisfactory, including the use of protective equipment and measures to reduce infection risks.
Inspectors found that one ground-floor window did not have a restrictor, the home had security concerns that could allow people to leave unnoticed, and one medicine trolley was not stored according to best practice. The manager sent evidence after the inspection showing these shortfalls had been addressed.
The overall rating remained Good, the same as at the previous inspection in 2018. Safe and Well-led were inspected but not re-rated, and the other three areas were not assessed during this targeted visit.
Sufficient staffing
People received help in a timely way. Staff were available at meals, checked people's drinks and the home used agency staff to cover rota gaps.
“Where people required assistance, we observed staff attended in a timely manner.” from the report
People felt safe
Staff knew people's individual risks and had guidance to reduce them. Safeguarding concerns were reported and investigated with the appropriate authorities.
“People felt safe and were known well by staff who were able to describe people's individual needs and risks.” from the report
Infection control
The home was clean and inspectors found no concerns in its infection prevention and control assessment. Protective equipment, testing and visitor safety measures were in place.
“As part of this inspection we carried out an infection prevention and control assessment which did not identify any concerns about the service.” from the report
Supportive management
Staff said communication was good and that they felt supported and listened to. The manager used audits and reviewed accidents and incidents.
“A second told us, "I always feel listened to and supported.” from the report
Staff training and checks
Recruitment records included applications, health declarations, references and DBS checks. Staff competency was checked and nurses received refresher training.
“Staff competency was checked to help ensure they provided safe care and followed good practices.” from the report
Security and medicine trolley storage
seriousInspectors found security concerns that could allow people to leave unnoticed. One ground-floor window lacked a restrictor, and one medicine trolley was not stored according to best practice. The manager provided evidence that these issues had been addressed after the inspection.
“We also identified one ground floor window which did not have window restrictors and as such could enable people to leave unobserved.” from the report
- 01What changes were made to the ground-floor window and the home's security after the inspection?
- 02How is the storage of medicine trolleys checked now, and what evidence can you show that this issue has been resolved?
- 03How often are staffing levels reviewed, and how do you maintain consistency when agency staff are used?
- 04How are staff competencies checked after training, particularly for medicines and moving and handling?
- 05When is the next comprehensive inspection expected to review Effective, Caring and Responsive care?
This was a targeted inspection of selected parts of Safe and Well-led; the overall Good rating carried over from the previous inspection and the other key questions were not assessed. This explanation was written from the published report of 13 October 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 Downsvale Nursing Home
5 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- July 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2020Goodstayed GoodSafe: Inspected but not ratedWell-led: Inspected but not rated
- May 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- May 2012
Registered with the Care Quality Commission on 1 May 2012.
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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