The inspection took place on 11 October 2018 and was unannounced. This meant the provider and staff did not know we would be visiting.

Donwell House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. At the time of our inspection 41 people were living at the service. The service comprised of four units, two residential care units and two nursing units.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection of this service in June 2018. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Donwell House on our website at www.cqc.org.uk.

The service had introduced a number of supporting documents to ensure a safe environment was maintained. The registered manager had reviewed people’s care records and identified risks had detailed risk assessments in place.

People’s medicines continued to be managed safely. Enough staff were deployed to meet the care and support needs of the people living at Donwell House. The provider collated and analysed safeguarding concerns and accidents and incidents to identify any trends or patterns. Lessons learnt was cascaded to all the provider’s services to drive improvement.

People were encouraged to maintain links with the local community. The service supported people to access activities in the local community including visiting places and shopping.

The provider had implemented additional governance systems to monitor the quality and safety of the service. The service regularly consulted with people living at the service, relatives and staff.

The registered manager had a good oversight of the running of the service and was knowledgeable about people’s care and support needs.

This inspection took place on 29 May 2018 and was unannounced. This meant the provider did not know we would be visiting. The home was aware we were returning on 31 May and 11 June 2018.

Donwell House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. At the time of our inspection 44 people were living at the home. The home is made up of four units, two residential care units and two nursing units. The home had recently had a change in directorship.

A registered manager was in place. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 6 and 7 April 2017, the service was rated requires improvement. At this inspection we found the service remained rated as requires improvement.

The home did not always ensure that people had a safe environment. Items which posed a risk of harm to people were easily accessible.

Identified risks had not always been mitigated against. Medicines records we viewed were accurate and up to date. People received their medicines in their preferred way. PRN (as required medicines) protocols were not always in place or lacked detail. Protocols for the administration of covert medicines were not followed.

A robust recruitment and selection process in place. There were sufficient staff deployed in the home to meet the needs of people. The home had systems in place to ensure people were protected from abuse. Staff had completed a range of training and received regular supervisions.

Personal emergency evacuation plans (PEEP's) were in place to ensure people were able to evacuate the premises in an emergency.

Staff respected people's privacy and promoted their independence. People and their relatives were involved in decisions about their care and support. People’s confidential and sensitive records were not always protected.

Menus were not always accessible to enable people to make an informed choice. People were supported to have a balanced diet. Kitchen staff catered for people’s preferences.

Care plans contained limited information and did not always reflect people's needs and preferences. Some information was inaccurate.

We saw evidence in care plans of cooperation between care staff and healthcare professionals including occupational therapists and GPs. Follow up advice was not always sought in a timely manner.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The home had activity staff on duty each day, including evenings and weekends, to support with activities. People were supported to supported to maintain links to their local community and to take part in various activities. Relatives and visitors were made welcome in the home.

People were provided with information on how to make a complaint. The registered manager promoted an open culture within the home.

Quality assurance systems were not always effective. However, the new director had a strong commitment to drive improvement within the home and had introduced new quality assurance processes.

This inspection took place on 6 April 2017 and was unannounced. A second day of inspection took place on 7 April 2017 and was announced.

Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. There are two wings at Donwell House; one wing is made up of two residential care units. The other wing has two nursing units.

At the time of the inspection there were 46 people using the service, many of whom were living with a dementia. 28 people had been assessed as needing nursing care.

During an inspection in March 2016 we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 specifically Regulations 7, 9, 12, 13, 14, 17 and 18. Donwell House was rated inadequate overall and placed into special measures.

We last inspected Donwell House on the 17 and 18 October 2016 and found the provider had breached a number of regulations we inspected against. Specifically we found evidence of continued breaches of regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found the provider to be in breach of regulation 10. Donwell House was continued to be rated inadequate and remained in special measures

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A registered manager was registered with the Care Quality Commission at the time of the inspection. They had been in post since 3 October 2016 and registered since 28 March 2017.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found improvements had been made. This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Governance and quality assurance systems had been introduced and had been effective in driving improvements. In order to ensure consistent good practice over time the systems and processes that had been introduced needed to be embedded.

Risk assessments in relation to the premises did not include dates or signatures so we were unable to make a judgement as to the timeliness of these documents. Risk assessments in relation to people, such as mobility, skin integrity and choking were in place and identified control measures to minimise risk. One person who had a diagnosis of epilepsy did not have a protocol in place to guide staff as to the action to take should the person experience a seizure.

Care plans had improved since the last inspection, however we found one had not been updated following a change in need; another person’s contained inconsistencies in relation to their nutritional needs and another person’s lacked detail in relation to support with mobility.

Some mental capacity assessments were not decision specific and we did not see any capacity assessments or best interest decision in relation to the use of wheelchair lap belts. For other restrictions, such as bed rails, these were in place and detailed risk assessments had been completed to inform decision making. We have made a recommendation about the principles of the Mental Capacity Act 2005.

Staff training had improved however some staff were yet to attend training in moving and handling, safeguarding, mental capacity and deprivation of libe

This inspection took place on 17 October 2016 and was unannounced. A second day of inspection took place on 18 October 2016 and was announced.

Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. There are two wings at Donwell House; one wing is made up of two residential care units. The other wing has two nursing units.

At the time of the inspection there were 53 people using the service, many of whom were living with a dementia. 29 people had been assessed as needing nursing care.

We last inspected Donwell House on the 9, 10 and 14 March 2016 and found the provider had breached a number of regulations we inspected against. Specifically the provider had breached Regulations 7, 9, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered manager had failed to demonstrate the necessary competence, skills and experience to manage the carrying on of a regulated activity. The provider did not do everything that was reasonably practicable to make sure people using the service received personalised care and treatment that was appropriate, met their needs and reflected their preferences. Care and treatment was not provided in a safe way. Assessment planning and delivery of care was not based on appropriate risk assessment. Not everything was done to reasonably and practicably mitigate risks. Medicines were not managed in a proper and safe way. Policies and procedures were not followed appropriately. People were not being protected from neglect and improper treatment. Systems and processes were not established and operated effectively to prevent abuse, neglect and improper treatment of people. The nutrition and hydration needs of service users was not being met. A variety of nutritious, appetising food was not available to meet people’s needs. Up to date assessments for nutrition and hydration needs were not being followed. Systems and processes were not established and operated effectively to ensure compliance. Systems did not assess, monitor and improve the quality and safety of the service. They did not assess, monitor and mitigate risks. Accurate, complete and contemporaneous records of care and treatment were not maintained. Feedback was sought but not acted upon to improve quality. The provider did not ensure audit and governance systems were effective. Staff did not have appropriate training to enable them to carry out the duties they were employed to perform. Staff had not received regular appraisals of their performance.

During this inspection we found evidence of continued breaches of regulation. Specifically regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found the provider to be in breach of regulation 10. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A registered manager was not registered with the Care Quality Commission at the time of the inspection. A manager was in post but they had only started the role on 3 October 2016.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Premises safety was a concern. There were duplicate fire zones and room numbers within the building. The actions identified from a fire risk assessment completed in April 2016 had not been rectified, this included action in relation to an inadequate fire detection system and inadequate training for the evacuation of people. A service user evacuation register was out of date and the fire log book contained 29 personal emergency evacuation plans (PEEPs) wh

This inspection took place on 9, 10 and 14 March 2016 and was unannounced. We inspected Donwell House in May 2014 and found it was not meeting all legal requirements we inspected against. We re-inspected in September 2014 and found improvements had been made.

Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. There are two wings at Donwell House; one wing is made up of two residential care units. The other wing has two nursing units.

At the time of the inspection there were 57 people using the service; 30 of whom needed nursing care.

A registered manager was registered with the Care Quality Commission (CQC) at the time of the inspection.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were not managed in a safe way. Protocols were in place for ‘as and when required’ medicines however they did not contain specific instructions for staff to follow in relation to dosage, time between medicine administration and indicators that a person may need their medicine.

The recording of transdermal patch applications was not robust, nor was the recording in relation to topical medicine applications, such as prescribed creams.

Risk assessments were completed but did not effectively assess and mitigate the risks to the health, safety and welfare of people. Some risks had not been assessed.

People were not safeguarded from the risks of receiving improper care and treatment because care plans and risk assessments were not sufficiently accurate and up to date to ensure care and treatment was appropriate to their needs.

Care plans were not sufficiently detailed, accurate or up to date to ensure people received person centred care and treatment appropriate to their needs.

People were unhappy with the variety of meals offered to them and they said meals were not appetising.

Staff were not effectively following care plans in relation to monitoring people’s nutrition and hydration needs; specifically with regards to monitoring people’s weight.

Emergency plans were in place, however personal emergency evacuation plans and the service user evacuation register did not contain accurate information in relation to people’s needs and the equipment they needed or used, such as oxygen therapy.

Quality assurance and governance procedures were not operated effectively to assess, monitor and improve the quality and safety of the service. Identified actions were not followed up and re-audits were not completed to ensure improvements had been made.

Feedback from people and their relatives was sought but it was not fully acted upon to improve the quality of the service people received.

Staff had not attended refresher training in practical moving and handling skills, nor had they attended care planning and risk assessment training.

A high number of staff had not received an annual appraisal.

Safeguarding alerts and concerns and accidents and incidents were recorded and reported to the appropriate professionals. Analysis was completed for any trends and lessons learnt were discussed.

A dependency tool was used to assess the number of staff needed to provide care and support for people. The registered manager was increasing staff levels based on the outcome of this tool.

Safe recruitment procedures were in place, which included disclosure and barring service checks.

Compliance with the completion of ELearning was high and all staff had regular supervision with their line manager. Staff told us they felt well supported.

Applications to deprive people of their liberty, known as deprivation of liberty safeguards (DoLS) had been submitted to the supervising body and where they had been authori

The provider had made progress since our last inspection to ensure that the quality and accuracy of care records had improved. Staff now had access to accurate and up to date records to enable them to provide appropriate care for each person.

We carried out an early morning visit following concerns made known to the Care Quality Commission (CQC) about shortage of staff at night and how staff were getting people dressed and out of bed early in the morning. We arrived on site at 7.10am and saw seven people out of a total of 48 were up out of bed. We spoke with some people and one person told us “How she always gets up at 6.30am in the morning”. Staff members were seen to interact well with people and knew them by their first name. We observed care interventions being carried out for those people who were more dependent and heard how staff spoke to people in a pleasant and respected manner. We saw on the morning of our visit, there were sufficient qualified, skilled and experienced staff to meet people’s needs.

People’s assessed needs were addressed and incorporated along with an individual’s wishes and preferences about how their care should be given. Risks to people who used the service, and risks to staff, were being assessed and appropriate actions taken to reduce possible harm. A resident we spoke with confirmed he was satisfied with the care he received and had no concerns. A visiting relative we spoke with said she liked the care staff and how they made her mother feel at ease. No one we spoke with had needed to use the complaint process. Care records were up to date and showed people and their families had been involved in their development. People told us; "everything is provided for" and "the staff are good and friendly".

This review was carried out to check improvements made to the service's procedures about medicines management and we had received some concerning information from two anonymous sources telling us of instances of poor care of people's needs. We did not speak directly with users of the service on this occasion. At both of our previous visits on July 04 and October 05 2012 we spoke to staff and people who use the service. Visitors commented positively about the staff who work at the home. One person said, “The staff are very good they are all very caring in looking after people.”

People we spoke with told us they were happy with the care they received and liked living at Donwell House. One relative we spoke with told us”The staff here are a life saver” and “My mum has been in hospital recently and we were so pleased when she returned to Donwell House”. Another relative told us “She and her family were overwhelmed by how well their mother was cared for by the members of staff and they just know what my mum likes to wear”. We spoke with a small group of people who were sitting in the lounge. They told us they were very happy with the service and told us about how much they appreciated the staff and the manager. However we found the service did not fully protect people against the risks associated with the unsafe use and management of medication and also the recording, handling and use of medicines.

We spoke to one person who used the service about their medicines at this visit. The person confirmed that care workers gave them the right amount of support and help with their medicines.

People we spoke with told us they were happy with the care they received and liked living at Donwell House. A visitor we spoke with confirmed they were satisfied with the care their relative received and had no concerns. One person who lived at Donwell House told us, “I love it here. They’re all very friendly”. A relative said she was very happy with the home and she was always made to feel very welcome. A visitor we spoke with confirmed they were satisfied with the care their relative received and had no concerns.

Another visitor, when asked about the care being given to their relative, said “The staff asked about my relatives likes and dislikes and how she likes her tea”.

We spoke with a small group of people who were sitting in the lounge. They told us they were very happy with the service and told us about how much they appreciated the staff and the manager. They told us the food was nice and they served generous portions.

We found that members of staff were kind and patient in their approach. People looked well cared for and at ease with the members of staff caring for them.

Those people who were able to speak with us told us they were happy with the care provided. One person said “the girls are very kind to us.” And another said “they look after me really well.”

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found.

The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report. This is a summary of what we found:

Is the service safe?

Where staff had identified a potential risk, either during the initial assessment or after admission, a risk assessment had been completed to ensure people remained safe. We found the provider assessed people, using recognised tools, against a range of potential risks. For example, the risks of poor nutrition, skin damage and falls.

The provider had systems in place to ensure people received their medication safely and in a timely manner, by trained and competent staff.

The provider had appropriate recruitment and selection processes in place to ensure new staff were suitable to work with the people who used the service. This included checking applicants did not have any criminal convictions that may prevent them from working with vulnerable people and asking for references from previous employers.

Is the service effective?

Information gathered during the initial assessment of people's needs was used to develop detailed care plans. We found care plans clearly identified people’s needs and potential risks and specific aims and objectives for people to aim for. For example, for one person the aim was to provide support with personal hygiene in a respectful and dignified manner.

We spoke with four people who used the service. They told us they received good care. People’s comments included: “I get everything I need”; “I get good care”; and, “I think it is great here.” People told us that staff sometimes came to chat but they were very busy. We spoke with four family members. They said they were satisfied with their relative’s care. Some family members said they had not seen their relative’s care plans and felt people could have more one to one time with staff. Their comments included: “The nurses are good”; “The care is pretty good”; and, “My relative gets good care, I am very happy.”

From our observations we saw that staff followed the guidance within people’s care plans. For example, we observed staff transferring people from their wheelchair using the specialist equipment and techniques described in their care plans.

Is the service caring?

People’s care records showed that staff had completed a social profile and a ‘This is my life booklet.’ These documents contained detailed information about people’s life histories, such as previous employment, religion and beliefs, favourite memories and likes and dislikes. This meant staff had access to detailed information to help them better understand people’s needs.

We observed care being delivered throughout our inspection and undertook specific observations over a lunch time and in the lounge area. We found that staff interacted positively with people and were attentive, gentle and kind. We observed people for 40 minutes and saw that people had very little interaction with staff. We saw that this improved significantly following intervention from the manager when staff then spent one to one time with people chatting and offering manicures.

Is the service responsive?

People had regular input from various professionals appropriate to their needs, such as dietitians, speech and language therapists, specialist nurses and GPs.

Care plans were evaluated each month to ensure they remained up to date and reflected people’s current needs. We saw examples within people’s care records of action taken to respond to people’s changing needs, such as referring them to various health professionals for advice and guidance, including specialist nurses, speech and language therapists and dietitians.

Is the service well-led?

The manager reviewed staffing levels to ensure there were enough staff to meet people’s needs. We saw the review included an analysis of people’s dependency levels. These were compared to previous reviews, which highlighted how dependencies within the home were changing over time. The analysis also considered other factors such as accidents/incidents, safeguarding alerts, complaints, skin damage and weight loss.

We found the provider consulted with people who used the service, relatives and professionals to gather their views about the service provided at Donwell House. We viewed the completed questionnaires from the most recent consultation with residents and relatives. Most of the people who responded gave positive comments about the service. Comments included: “I am happy living here”; I am happy at the moment”; and, “No complaints at all.” We found that the findings from the consultation had been analysed and an action plan developed.

The provider had an effective system of quality audits in place to identify gaps in care records, including medication records, and take appropriate action to address these gaps. However, we found there was an on-going problem with the quality of certain records.

People and family members said they were happy with the care and they did not raise any concerns with us. They commented: “I would feel comfortable talking to all of the staff”; “I have been here six weeks and I have loved every minute of it”; “I have no concerns”; and, “We have had a very positive experience.”