The inspection was carried out on 14 September 2017 and was unannounced. The last inspection took place on 23 February 2017 to follow up a breach of regulation 17 in respect of shortfalls with risk assessment and care plan documentation identified at the comprehensive inspection carried out in June 2015. At the February 2017 inspection we found although there had been improvements with record keeping, further work was needed and we judged the provider had not fully met the breach of regulation. At our inspection on 14 September 2017, we found the provider had met the breach of regulation.

Ealing Eventide Homes Limited - Downhurst is a service which provides accommodation and personal care for up to 26 older people who have a range of needs, including dementia. At the time of inspection there were 25 people using the service.

The service is required to have a registered manager in post, and there was a registered manager for this service. 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 being managed and people received their medicines as prescribed. Guidance for the crushing of medicines was not always being followed. We have made a recommendation.

Staff recruitment procedures were followed to ensure only suitable staff were employed by the provider. There were enough staff available to meet people’s needs and temporary staff were accessed to cover staff absence. Systems were in place to safeguard people from the risk of abuse and staff understood the action to take if they had any concerns. People were encouraged to express any concerns, however minor, so they could be addressed. There was a complaints procedure in place and people and relatives felt confident to speak with staff about any issues they might have.

Individual risk assessments were comprehensive and care plans evidenced the action to be taken to minimise each risk. People’s risk and care records were monitored by the registered manager and action was taken promptly to address any shortfalls identified with any of the documentation. Risk assessments were in place for premises, equipment and safe working practices and these were reviewed annually to keep the information current.

The service was clean and fresh throughout and infection control procedures were being followed. Systems and equipment in use in the service were being maintained and were serviced at the correct intervals to keep them in good working order.

Staff received training in a variety of topics to provide them with the skills and knowledge to care for people effectively. Staff were encouraged to undertake and had obtained recognised qualifications in health and social care.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA). People’s mental capacity had been assessed. For some people DoLS were in place to ensure that their freedom was not unduly restricted. Staff understood people’s needs and always acted in their best interests.

People’s dietary needs and preferences were identified and met and there was a wide range of meals available. People’s nutritional needs and status were assessed and monitored. People’s healthcare needs were identified and they received input from healthcare professionals when required.

People, relatives and healthcare professionals were happy with the care and support being provided at the service. People, and where appropriate their relatives, had been consulted about care needs and the care plans had been drawn up with their input. Care records were very person centred and up to date and changes in peoples’ needs and care were identified and included in the care plans.

Staff demonstra

This unannounced inspection took place on 21 February 2017. The last inspection of the service took place on 15, 16 and 17 June 2015. We rated the service as Good overall but identified one breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as the registered person did not always maintain an accurate record in respect of each person. This may have placed people at risk of unsafe or inappropriate care.

At the inspection of 21 February 2017 we checked care records to see if risks had been assessed and care plans reviewed to reflect the findings of the risk assessments. We found the provider had taken action. There had been improvements in reflecting the risk assessment findings in the care plans, however further improvements and monitoring of the care records were required. Therefore we have made a new requirement for this finding.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Ealing Eventide Homes Limited – Downhurst’ on our website at www.cqc.org.uk.

Ealing Eventide Homes Limited - Downhurst is a service which provides accommodation for up to 26 older people who have a range of needs, including dementia.

The service is required to have a registered manager in post, and there is a registered manager for this service. 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.

Improvements had been made with the risk assessments and associated care records, however further improvements were required to ensure all the records accurately reflected changes in people’s needs.

The processes in place for monitoring and reviewing the care documentation were not robust and shortfalls were not always being identified and addressed in a timely way.

The majority of risk assessments and care records had been completed and these were comprehensive and reflected any changes in people’s needs.

This was a follow up inspection to check that the essential standard of quality and safety regarding the management of medicines was being met.

At this inspection we did not speak to any people who lived in the home. We looked at the storage and record keeping of medicines. We saw that medicines were stored appropriately and good record keeping provided us with the evidence that people were receiving their medicines as prescribed.

We spoke with seven people using the service and five staff.

People expressed their satisfaction with the service and the care they were receiving. They said staff were helpful and looked after them well. One person said, “staff are very kind”. Satisfaction surveys had been carried out and comments from people using the service included, “the staff are nice and helpful. I am very happy here.”

Surveys completed by relatives contained comments such as, “A very warm and caring environment, with lovely staff”, “Really lovely, calm and happy atmosphere. Interesting activities for residents and annual events to include families. Staff always pleasant and good relations between residents and staff” and “a caring environment well run, providing a comfortable home for residents.”

Systems were in place for the management of medicines, however these were not always effective and shortfalls were identified, which could place people at risk of unsafe care.

Action had been taken to address shortfalls with the environment identified at the last inspection.

Staff had received training and supervision to provide them with the knowledge and skills to care for people effectively.

Systems were in place for the auditing and monitoring of equipment, systems and safe working practices, and action was taken to address any shortfalls identified.

During our visit we spoke to five people who use the service. One person said “..I enjoy living here..”. People told us that they received good support from the staff and that the staff had a caring approach towards the people who use the service.

People told us about the different activities they got involved in throughout the week, such as playing bingo, exercises, receiving Mass and seeing their family. The activity timetable showed that the service provided different activities throughout the week.

People said they felt safe with the staff, and that they had the right skills and experience to support them with their needs.

In the report we have highlighted areas where the provider was failing to meet the required standards. During our inspection visit we found that fire exits were obstructed. There were uncovered hot water pipes with exposed hot surfaces. The environment was not safe for people who used the service.

The inspection was carried out on 15, 16 and 17 June 2015 and the first day was unannounced. The last inspection took place on 11 July 2013 and the provider was compliant with the regulations we checked.

Ealing Eventide Homes Limited - Downhurst is a service which provides accommodation for up to 26 older people who have a range of needs, including dementia. At the time of inspection there were 23 people using the service.

The service is required to have a registered manager in post, and there is a registered manager for this service. 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 happy with the service and we received positive feedback from people, relatives and visiting healthcare professionals, who felt the service was well run and people’s changing needs were being identified and met.

Although staff understood the risks to individuals and the care and support they needed to minimise these, risk assessments and associated care plans had not always been accurately completed to reflect these.

Staff recruitment procedures were in place and were being followed to ensure suitable staff were being employed at the service.

Staff understood safeguarding and whistleblowing procedures and were clear about the process to follow to report any suspicions of abuse. Complaints procedures were in place and people and relatives said they would feel able to raise any issues so they could be addressed.

Overall medicines were being well managed and people were receiving their medicines as prescribed.

Staff supported people in a professional, gentle and friendly manner, showing respect for their privacy and dignity. Staff received regular training and updates and had a good understanding of people’s individual choices and needs and how to meet them.

We found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA). DoLS are in place to ensure that people’s freedom is not unduly restricted.

Care records reflected people’s needs, interests and wishes. Staff demonstrated a good understanding of people’s changing needs and procedures were in place to ensure information was passed on between staff, so they were kept up to date.

The registered manager and deputy manager alongside the managing director provided good leadership for the service and championed the provision of person-centred care.

Systems were in place for monitoring the service and these were effective so action could be taken promptly to address any issues identified.