Downsvale Nursing Home 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. Downsvale Nursing Home is registered to provide accommodation for persons who require nursing or personal care for up to 35 people and personal care. There were 26 people living at the service at the time of our inspection.

There was a registered manager in post. 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. The registered manager was at the home during the time of our inspection.

We last carried out a comprehensive inspection of Downsvale Nursing Home in December 2016 where we found the registered provider was in breach of 3 regulations. These related to activities, mental capacity assessments and quality assurance. Following this inspection the registered provider sent us an action plan of how they would address these issues.

The inspection took place on 26 April 2018 and was unannounced. During this inspection we found that the concerns raised at our previous inspection had been addressed.

Accidents and incidents were recorded and an analysis of why accidents or incidents had occurred or what action could be taken to prevent further accidents had been developed. There were enough staff to meet the needs of the people and for people to take part in meaningful activities. Robust recruitment procedures were completed to ensure staff were safe to work at the service. People felt safe living at the home. Staff understood their responsibilities around protecting people from harm. The provider had identified risks to people’s health and safety with them, and put guidelines in place for staff to minimise the risk. Infection control processes were in place that helped to reduce the risk of infection. People received their medicines as prescribed by their GP.

Staff understood the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that decisions were made in the least restrictive way. Where there were restrictions in place, staff had followed the legal requirements to make sure that this was done in the person’s best interest. People’s nutritional needs were assessed and individual dietary needs were met. People had involvement from external healthcare professionals and staff supported them to remain healthy. Staff received appropriate training and had opportunities to meet with their line manager regularly that helped them to provide effective care to people. The environment was suitable for people living with dementia.

People’s care and support was delivered in line with their care plans. People’s privacy and dignity was respected. Staff were knowledgeable about the people they cared for and were aware of people’s individual needs and how to meet them. People were supported with their religious beliefs and were able to practice their faith.

Documentation that enabled staff to support people and to record the care they had received was up to date and reviewed on a regular basis. People would receive end of life care that was in line with their needs and preferences and staff had received training in regard to this. Care plans included people’s requests about their end of life wishes that included if they wanted to remain at the home or be admitted to hospital.

Complaints were addressed within the stated timescales to the satisfaction of complainants. A complaints procedure was available to people, relatives and visitors.

The provider and staff undertook quality assurance audits to monitor the standard of service provided to people. An

The service is registered for 35 people. At the time of the inspection there were 28 people living in the home. People had a range of needs. Some were living with dementia; others required nursing care to manage pressure areas and end of life care whilst other people required minimal assistance.

There was a new manager in post. The new manager started in post in October 2016. They were not yet registered with CQC, however they had submitted the relevant paperwork and an interview with CQC was pending. 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

At the last inspection on 27 and 29 April 2016 we told the provider to take action to make improvements in the management of medicines, and reducing the risks of harm to people and staffing deployment. Whilst some improvements had been made, there was still some work to be done. We told the provider to put systems in place to monitor, review and improve the quality of care, to ensure that it was personalised and responsive. We also told the provider to ensure that processes were in place to ensure that people’s rights were protected if they lacked mental capacity. Whilst some improvements had been made, there was still some work to be done. We told the provider that they needed to make improvements in promoting people’s dignity and respect, safe recruitment of staff, equipment to be safe and safeguarding to be reported to the appropriate authorities. These actions have been completed.

Some people’s rights were not always protected because the manager did not always act in accordance with the Mental Capacity Act 2005 (MCA). Where people were assessed to lack capacity to make some decisions, mental capacity assessment and best interest meetings had not always been undertaken. Relatives had made decisions regarding people’s care and the manager had not always ensured that they had the legal right to do so. This is a continued breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what we told the provider to do at the back of the report. Staff were heard to ask peoples consent before they provided care.

Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People told us that they wanted to do more activities. There were some activities on offer, improvements could be made.

There were some systems in place to monitor, evaluate and improve the quality of care provided. However, improvements could be made as they had not always identified areas of improvement.

People told us that they had enjoyed the food. People had sufficient to eat, but improvements could be made regarding the fluid intake of people. We have made a recommendation. People were seen to be offered choice of what they would like to eat and drink.

People’s medicines were now administered, stored and disposed of safely. Staff were trained in the safe administration of medicines and kept relevant records that were accurate. For people who needed PRN (as required medicine) medicine, there were some guidelines in place.

The manager had oversight of incidents and accidents and ensured that actions had been taken to reduce the risks of them occurring again.

There were inconsistencies to how risks to people were managed. There were risk assessments in place to maintain people’s skin integrity, to reduce the risk of falls and to ensure people’s weights were maintained. However, some risk assessments lacked detail to tell staff how to keep people safe. We have made a recommendation in relation to this.

People had personal emergency evacuation

This was an unannounced inspection and took place of 27 and 29 April 2016.

The service is registered for 35 people. At the time of the inspection there were 31 people living in the service. People had a range of needs. Some were living with dementia; others required nursing care to manage pressure areas and end of life care whilst other people required minimal assistance.

The service had a registered manager. 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.

People were not always protected from harm. Risks to people had not always been assessed and therefore put them at risk of harm. For example, one person had a pressure sore and there was no risk management plans in place.

Care equipment that was provided was not always safe for use. One person had a bed rail, yet they managed to sustain an injury to their head as a result of poorly fitting bed rails. Hoists, commodes and wheelchairs were not always cleaned.

The registered manager and provider had not always identified when there was a safe guarding concern. One staff member had been “quite rough” with a person and this was not reported as a safe guarding concern.

There was not always enough staff on duty to meet people’s needs. People told us that they had to wait for staff when they needed something. Half of the staff we spoke to said they felt rushed and they would like to spend more time with people.

People did not always have their medicines administered safely. One person had not received a medicine for six days. Medicines were not always stored and disposed of safely.

Robust recruitment practises were not in place to ensure that staff were safe to work with people. References and applications were not always in place for staff, the registered manager had not ensured staff were of good character.

People’s human rights could have been affected because the requirements of the Mental Capacity Act were not always followed. For people who lacked capacity to make decisions about their care, mental capacity assessments and best interests decisions had not occurred.

People did not always receive effective care. The registered manager had not always ensured that staff had the knowledge; skills and regular supervision to enable to them care for people safely and effectively.

People had sufficient food and fluids. Some people told us that they could not always reach their drinks when they were in their beds. People said they liked the food.

People were not always involved in the care. Some relatives were involved, but others had not been. People and relatives said that the staff were kind and caring. People’s privacy and dignity was not always respected. Staff did not knock on people’s doors and waited until they were told to enter.

People did not always receive personalised care. Three people, who were newly admitted, did not have their needs assessed, this meant that staff would not know how to support people. People’s preferences and wishes were not always recorded in their care plans.

There was an activities programme in place; people said they enjoyed the activities.

People and their relatives knew how to make a complaint. Complaints had been responded to in line with the service’s policy.

The service was not well led. There was not a robust system in place to monitor and review the incident and accidents.

There was not a robust process in place to monitor and evaluate the care provided to drive improvements. Record keeping was inconsistent and records were not stored securely.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken im

The last inspection report recorded some shortfalls under outcome 10 (regulation 15) and set a compliance action. At this inspection we reviewed the actions the providers had taken in response to the compliance action. We found that the providers had taken action to address the shortfalls that we had identified at the last inspection and the compliance action was closed.

We therefore found that People who used the service, staff and visitors protected against the risks of unsafe or unsuitable premises.

People who used the service told us the food was good, the staff were nice, they were offered choices of food and they could have a snack or a drink at any time.

People also told us they liked their rooms, and they were warm enough. They said that they had no complaints but knew how to make one if they did.

One person told us the home was like a home from home, and if they had any concerns they would tell the manager, as they intended to do that day about a minor issue. They also told us that if they had a problem they would not have stayed at Downsvale for so many years.

Another person told us one of their windows did not open and the other one was wonky.

We saw that people were supported to eat and drink sufficient amounts to meet their needs.

We found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

We saw that people were given support to make a comment or complaint where they needed assistance and had their comments or complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint.